Gastric
Emptying After Fundoplication With and Without Proximal Gastric
Glyn
G. Jamieson, MS, FRACS, FACS;
Guy J.
Fifty-four patients having antireflux surgery (20 fundoplication alone [group 1] and 34 fundoplication with proximal gastric vagotomy [group 2]) had their gastric emptying assessed preoperatively and postoperatively. At 3 years after operation, in group 1, the emptying of a solid meal was significantly accelerated. In contrast, no such acceleration in solid emptying was observed in group 2. Liquid emptying was significantly accelerated in both groups of patients postoperatively. No consistent relationship was found between symptomatic outcome and gastric emptying in either group of patients. We conclude that proximal vagotomy interferes with reflex pathways that are involved in the acceleration of solid gastric emptying after fundoplication. \s=b\
(Arch Surg. 1991;126:1414-1417)
used
has been the frequently oper¬ Fundopl i c ati o n of gastroesophageal surgical works which the flux disease. The most treatment
ation in the
re¬
is not
way in
operation completely understood, although there are undoubtedly several mechanisms. For example, reduction of the angle of His, restoration of a length of mtra-abdominal esophagus, a one-way valve effect, an increase in lower sphincter tone, and prevention of the effects of gastric distention in trigger¬ ing transient lower-sphincter relaxations, may all play a role.! It has been reported that 6 months after a fundoplica¬ tion, solid and liquid gastric emptying are accelerated compared with preoperative emptying, and this may be a further mechanism by which fundoplication achieves its success.2 The addition of a proximal gastric vagotomy to fundoplication has been advocated because it reduces the major injurious component of refluxate, ie, acid, and aids in a technically more exact fundoplication.3"5 This study describes a consecutive group of patients who were operated on for gastroesophageal reflux disease whose gastric emptying was investigated preoperatively, and again postoperatively, during a 3-year period. Oper¬ ations carried out on the patients were either a fundopli¬ cation alone (group 1) or a fundoplication with proximal gastric vagotomy (group 2). Accepted for publication May 5, 1991. From the Departments of Surgery, The University of Adelaide (Drs Jamieson and Maddern) and Royal Adelaide Hospital (Miss Myers), South Australia. Reprint requests to Department of Adelaide, GPO Box 498,
Jamieson).
of
Surgery,
The
University
Adelaide, South Australia
5001 (Dr
Vagotomy
Maddern PhD, FRACS; Jennifer C.
Myers
PATIENTS AND METHODS Patients and Operative Techniques The patients were derived from those referred to our unit for the
surgical management of gastroesophageal reflux disease. The in¬ vestigations that patients underwent included esophageal manometry, endoscopy, 24-hour pH studies, and gastric emptying studies. The gastric emptying studies were repeated at 6 months and 3 years postoperatively. Where reflux symptoms had recurred after sur¬ gery, pH studies were conducted to confirm the recurrence. The fundoplication technique involved the furtdus and upper part of the body of the stomach being mobilized and wrapped around the lower 4 to 5 cm of the esophagus. The wrap thus used
anterior and posterior walls of the stomach.6 The anterior vagus nerve was included in the wrap, but the posterior vagus nerve was excluded. In those patients in whom proximal gastric vagotomy was undertaken, dissection of the lesser curvature extended from the antral corpus junction at the "crow's foot" to the esophagus, which was mobilized for approximately 5 cm from the gastroesophageal junction.7 No selection was involved in the type of operation carried out. Proximal gastric vagotomy and fundoplication became our rou¬ tine technique for antireflux surgery during the review period. Thus, initially all patients had a fundoplication, and later all patients had a fundoplication and a proximal gastric vagotomy.
Assessment of Reflux Disease and Symptomatic Outcome Reflux disease was assessed by routine esophageal manometry with pH studies and endoscopy. If endoscopy did not show un¬ equivocal evidence of reflux disease (ie, erosions or ulcération), 24hour pH studies were undertaken, and only those patients showing a pH of less than 4 for more than 7% of the 24-hour period were classified as suffering from gastroesophageal reflux disease.8 Patients with achalasia, scleroderma, diabetes, and peptic ul¬ cer disease were excluded from the study. Patients were catego¬ rized into the following four grades postoperatively: 1, no symptoms or minor symptoms; 2, moderate symptoms but not detracting from the outcome of surgery in the patient's view; 3, marked symptoms, either reflux or other symptoms; and 4, symptoms as bad as or worse than preoperative symptoms.
Measurement of Gastric Emptying This test has been reported previously.9,10 Briefly, it consists of a simultaneous measurement of gastric emptying using a solid meal of cooked ground beef, and a liquid meal of 10% dextrose in water, each of the meals being labeled with a different isotope. After an overnight fast, the test is performed with the patient seated in front of a scintillation camera. The solid meal is eaten during a 5-minute period, and the dextrose solution is then drunk. Time zero is defined as the time of meal completion and the study is continued for at least 2 hours. Data are corrected for patient move¬ ment, radionuclide decay, computer scatter, and gamma ray
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/01/2015
100
100
o
L
o 6
Preoperative (n=20)
3y
mo
Postoperative (n=20)
.
Preoperative (n=34)
Postoperative
6
mo
Postoperative (n=34)
(n=20)
3y
Postoperative (n=11)
Fig 1.—This shows the solid gastric emptying from the total stomach before, and 6 months and 3 years after, either a fundoplication (group 1, left) or a combined highly selective vagotomy and fundoplication (group 2, right). The short horizontal bars are the median values. In group 1, the median values at 6 months and 3 years are significantly (P
Emptying After Fundoplication With and Without Proximal Gastric
Glyn
G. Jamieson, MS, FRACS, FACS;
Guy J.
Fifty-four patients having antireflux surgery (20 fundoplication alone [group 1] and 34 fundoplication with proximal gastric vagotomy [group 2]) had their gastric emptying assessed preoperatively and postoperatively. At 3 years after operation, in group 1, the emptying of a solid meal was significantly accelerated. In contrast, no such acceleration in solid emptying was observed in group 2. Liquid emptying was significantly accelerated in both groups of patients postoperatively. No consistent relationship was found between symptomatic outcome and gastric emptying in either group of patients. We conclude that proximal vagotomy interferes with reflex pathways that are involved in the acceleration of solid gastric emptying after fundoplication. \s=b\
(Arch Surg. 1991;126:1414-1417)
used
has been the frequently oper¬ Fundopl i c ati o n of gastroesophageal surgical works which the flux disease. The most treatment
ation in the
re¬
is not
way in
operation completely understood, although there are undoubtedly several mechanisms. For example, reduction of the angle of His, restoration of a length of mtra-abdominal esophagus, a one-way valve effect, an increase in lower sphincter tone, and prevention of the effects of gastric distention in trigger¬ ing transient lower-sphincter relaxations, may all play a role.! It has been reported that 6 months after a fundoplica¬ tion, solid and liquid gastric emptying are accelerated compared with preoperative emptying, and this may be a further mechanism by which fundoplication achieves its success.2 The addition of a proximal gastric vagotomy to fundoplication has been advocated because it reduces the major injurious component of refluxate, ie, acid, and aids in a technically more exact fundoplication.3"5 This study describes a consecutive group of patients who were operated on for gastroesophageal reflux disease whose gastric emptying was investigated preoperatively, and again postoperatively, during a 3-year period. Oper¬ ations carried out on the patients were either a fundopli¬ cation alone (group 1) or a fundoplication with proximal gastric vagotomy (group 2). Accepted for publication May 5, 1991. From the Departments of Surgery, The University of Adelaide (Drs Jamieson and Maddern) and Royal Adelaide Hospital (Miss Myers), South Australia. Reprint requests to Department of Adelaide, GPO Box 498,
Jamieson).
of
Surgery,
The
University
Adelaide, South Australia
5001 (Dr
Vagotomy
Maddern PhD, FRACS; Jennifer C.
Myers
PATIENTS AND METHODS Patients and Operative Techniques The patients were derived from those referred to our unit for the
surgical management of gastroesophageal reflux disease. The in¬ vestigations that patients underwent included esophageal manometry, endoscopy, 24-hour pH studies, and gastric emptying studies. The gastric emptying studies were repeated at 6 months and 3 years postoperatively. Where reflux symptoms had recurred after sur¬ gery, pH studies were conducted to confirm the recurrence. The fundoplication technique involved the furtdus and upper part of the body of the stomach being mobilized and wrapped around the lower 4 to 5 cm of the esophagus. The wrap thus used
anterior and posterior walls of the stomach.6 The anterior vagus nerve was included in the wrap, but the posterior vagus nerve was excluded. In those patients in whom proximal gastric vagotomy was undertaken, dissection of the lesser curvature extended from the antral corpus junction at the "crow's foot" to the esophagus, which was mobilized for approximately 5 cm from the gastroesophageal junction.7 No selection was involved in the type of operation carried out. Proximal gastric vagotomy and fundoplication became our rou¬ tine technique for antireflux surgery during the review period. Thus, initially all patients had a fundoplication, and later all patients had a fundoplication and a proximal gastric vagotomy.
Assessment of Reflux Disease and Symptomatic Outcome Reflux disease was assessed by routine esophageal manometry with pH studies and endoscopy. If endoscopy did not show un¬ equivocal evidence of reflux disease (ie, erosions or ulcération), 24hour pH studies were undertaken, and only those patients showing a pH of less than 4 for more than 7% of the 24-hour period were classified as suffering from gastroesophageal reflux disease.8 Patients with achalasia, scleroderma, diabetes, and peptic ul¬ cer disease were excluded from the study. Patients were catego¬ rized into the following four grades postoperatively: 1, no symptoms or minor symptoms; 2, moderate symptoms but not detracting from the outcome of surgery in the patient's view; 3, marked symptoms, either reflux or other symptoms; and 4, symptoms as bad as or worse than preoperative symptoms.
Measurement of Gastric Emptying This test has been reported previously.9,10 Briefly, it consists of a simultaneous measurement of gastric emptying using a solid meal of cooked ground beef, and a liquid meal of 10% dextrose in water, each of the meals being labeled with a different isotope. After an overnight fast, the test is performed with the patient seated in front of a scintillation camera. The solid meal is eaten during a 5-minute period, and the dextrose solution is then drunk. Time zero is defined as the time of meal completion and the study is continued for at least 2 hours. Data are corrected for patient move¬ ment, radionuclide decay, computer scatter, and gamma ray
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/01/2015
100
100
o
L
o 6
Preoperative (n=20)
3y
mo
Postoperative (n=20)
.
Preoperative (n=34)
Postoperative
6
mo
Postoperative (n=34)
(n=20)
3y
Postoperative (n=11)
Fig 1.—This shows the solid gastric emptying from the total stomach before, and 6 months and 3 years after, either a fundoplication (group 1, left) or a combined highly selective vagotomy and fundoplication (group 2, right). The short horizontal bars are the median values. In group 1, the median values at 6 months and 3 years are significantly (P
