Gastroesophageal Reflux Following Gastric Operation R. D. Henderson, M.B., F.R.C.S.(C) ABSTRACT The combination of previous gastric operation and gastroesophageal reflux produces major difficulties in obtaining effective symptomatic relief. Seventy patients were studied by history, radiology, endoscopy, and esophageal manometry before surgical reflux control. Twenty-eight had had vagotomy and pyloroplasty; 4, vagotomy and gastroenterostomy; 11, Billroth I gastrectomy; and 27, Billroth I1 gastrectomy. In all patients reflux control was accomplished by hernia repair, and in 14 patients bile diversion was added for control of bile gastritis. A variety of reflux control operations were used. However, the most effective results were achieved with total fundoplication gastroplasty, and in this group of 22 patients there has been no anatomical recurrence and no reflux. The partial fundoplication gastroplasty (Belsey type) was ineffective in reflux control and should not be used in patients who have had a previous gastric procedure. Reflux control and, when necessary, bile diversion give effective relief to patients with bile gastritis and esophageal reflux following gastric operation.
The incidence of gastroesophageal reflux is increased following gastric operation [16]. Reasons for this increase are not clearly delineated, but it may be secondary to mechanical disruption of the phrenoesophageal ligament and supporting structures or secondary to altered neurogenic and hormonal responses in the gastroesophageal junction [4, 5, 12, 14, 151. Bile gastritis has been reported as a complication of gastric procedures. It occurs most frequently following Billroth I1 resections, but is also reported after Billroth I resections or vagotomy and drainage [l].The incidence of bile From the Departments of Surgery, Women’s College Hospital and the University of Toronto, Toronto, Ont, Canada. Presented at the Fourteenth Annual Meeting of The Society of Thoracic Surgeons, Jan 23-25, 1978, Orlando, FL. Address reprint requests to Dr. Henderson, Women’s College Hospital, 76 Grenville St, Toronto, Ont, Canada M5S 1B2.
gastritis has not been cleariy established, and since patients with this condition may be asymptomatic, it is difficult to do. When gastroesophageal reflux is also present, the refluxed bolus contains bile. These patients have bile esophagitis in association with bile gastritis [2]. Patients with intractable symptoms of bile gastritis and bile esophagitis undergo operation to achieve bile diversion, surgical correction of gastroesophageal reflux, or a combination of both procedures. When bile diversion by Roux-en-Y anastomosis is used, some authors have advocated the addition of vagotomy to further reduce gastric acidity and avoid stoma1 ulceration [ 2 , 3 , 6,131. Each of these operations has been recommended as the correct operative approach, based on the quality of results reported. Controversy remains concerning the best surgical approach for patients with combined bile gastritis and bile esophagitis. In the present study, 70 patients who had undergone previous gastric operation and had intractable reflux symptoms were evaluated before a further procedure. This operative procedure was tailored to fit the findings of the preoperative investigations. All patients had an antireflux procedure, and bile diversion was added only in those with endoscopic evidence of moderate to severe bile gastritis. Materials and Methods Seventy patients who had had a previous gastric procedure and then experienced symptomatic gastroesophageal reflux were reviewed. Twenty-eight had undergone vagotomy and pyloroplasty; 4, vagotomy and gastroenterostomy; 11, Billroth I gastrectomy; and 27, Billroth I1 gastrectomy. For the purpose of evaluation, symptomatic and preoperative investigative comparison is made with 100 consecutive patients who had not had previous gastric operations but who required surgical correction of
563 0003-4975/78/0026-0610$01.25@ 1978 by R. D. Henderson
564 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
Table 2 . Reflux Symptoms: Comparison between ZOO Consecutive Patients with Reflux and 70 Patients with Reflux and Previous Gastric Operation
Symptoms
Consecutive Patients (N = 100)
Patients with Billroth I; Previous Gastric Vagotomy and Operation Drainage (N = 70) (N = 43)
Duration of symptoms Heartburn Reflux Reflux and aspiration Hiccup Burping Water brash Nausea Vomiting Dysphagia (total) Cricopharyngeal Aspiration Gastroesophageal Regurgitation Peptic stricture
5.1 yr 100% 84 '/o 21% 33 Yo 68'/o 23 Yo 62% 37% 84'/o 58'/o 28 O/O 68% 31 yo 2 o/o
7.7 yr 100% 83.1% 43.6o/' 18.3'/o 59.1'/o 31yo 74.3% 63.5'/o 78.8% 47.1% 23.9% 67'/o 35.2 '/o 5.7%
Billroth I1 (N = 27)
2 Y' 100% 88.3'/o 44.1 yo 20.9 '/o 60.4% 23.2%
8.5 yr 100% 78.5'/o 42.8% 14.8% 59.2% 44.4%
58.1 '/o 72'/o 46.5% 30.2'/o 62.8O/O 32.5'/o 4.6%
74 '/o 92.6% 48.1% 14.2'/o 77.7% 40.7% 7.2%
operated on between May, 1971, and March, 1977, and the 100 consecutive patients (without previous gastric operation) requiring a reflux procedure and operated on within a 16-month period up to March, 1977. Certain features of patient history are of note (Table 1).The majority of symptoms occurred with equal frequency in those patients with uncomplicated reflux, those with a Billroth I gastrectomy or vagotomy and drainage, and those with a previous Billroth I1 gastrectomy. Dysphagia was more common in patients who had had a Billroth I1 gastrectomy, and vomiting was more frequent and severe in all patients who had undergone previous gastric operation, particularly in those who had had a Billroth I1 gastrectomy. Endoscopic and radiological methods were sed to determine the presence of ulcerative esophagitis and stricture formation. The incidence of these lesions was higher in the patients who had had a previous gastric operation (Table 2 ) . Manometric findings in both the patients with uncomplicated reflux and those with a previous gastric operation were similar. Both Results groups had a reduction in sphincteric tone and Symptom comparison was made between the an increased percentage of lower esophageal 70 patients with a previous gastric procedure disordered motor activity [ill. Previous hiatal
gastroesophageal reflux. All patients were studied before operation by history, radiology, endoscopy, and esophageal manometry, and these findings were compared. The 70 patients who had had a previous gastric procedure were considered to have the potential of bile reflux. These patients had reflux correction by one of four techniques: standard Belsey hernia repair without esophageal lengthening; standard Belsey repair with the esophagus lengthened by circumferential myotomy; gastroplasty with partial fundoplication (Belsey type); or gastroplasty with total fundoplication (Nissen type). In patients who had undergone a Billroth I1 gastrectomy or vagotomy and gastroenterostomy and had severe bile gastritis, a low enteroenterostomy or Roux-en-Y anastomosis was added for bile diversion. In follow-up evaluation, a proportion of patients with partial fundoplication gastroplasty had failure of reflux correction and were converted to a total fundoplication gastroplasty [81.
565
Henderson: Gastroesophageal Reflux after Gastric Operation
Table 2 . Endoscopic and Manometric Comparisons Factor
100 Consecutive Patients
70 with Previous Gastric Operation
Peptic stricture Ulcerative esophagitis Tone: gastroesophageal junction Percent DMA Previous hiatal hernia repair
2% 12% 11.3 cm H,O 44.7% 21Yo
5.7% 15.7% 11 cm H,O 52.6% 49.8%
DMA
=
Controls (N = 9)
18.8 cm H,O 8.3%
disordered motor activity.
Table 3 . Gastritis in Patients with Previous Gastric Operation
Gastritis
Vagotomy and Pyloroplasty (N = 28)
Vagotomy and Gastroenterostomy (N = 4)
Billroth I (N = 11)
(N= 27)
Normal to mild Moderate Severe
23 5 0
1 1 2
8 3 0
11 4 12
hernia repair had been performed in 21 patients (21%) in the uncomplicated reflux group and in 35 patients (49.8%) in the group with previous gastric operation. Endoscopy was used for assessment of bile gastritis. The findings were classified as normal to mild, moderate, and severe gastritis. The incidence of severe bile gastritis was highest in those with a previous Billroth I1 gastrectomy, but also occurred in 2 patients with a previous vagotomy and gastroenterostomy. Moderate gastritis was present in a proportion of all groups studied (Table 3). The method of surgical correction of reflux in those patients who had had a previous gastric procedure has changed during the six years of the present study. In the early years, esophageal lengthening was carried out either by gastroplasty and partial fundoplication or by circumferential esophageal myotomy and Belsey fundoplication. Esophageal lengthening was used in those with previous hernia repair or in those with esophageal shortening from panmural esophagitis. A standard Belsery hernia repair was the alternative method of hernia reduction and fixation. Because of ineffective reflux control with gastroplasty and partial fundoplication, a new
Billroth I1
operative technique was developed and has been used with increasing frequency for two and a half years. This approach uses a gastroplasty and total fundoplication of the Nissen type [8] (Fig 1).The total fundoplication gastroplasty is now used in all patients requiring reflux correction. Some patients with severe continuing reflux following partial fundoplication gastroplasty were converted to a total fundoplication. Bile diversion by low enteroenterostomy or by Roux-en-Y anastomosis was performed only in those patients with a previous Billroth I1 gastrectomy or vagotomy and gastroenterostomy who had severe gastritis. In these patients bile diversion was combined with an antireflux procedure.
Operative Results Nine patients were treated by a transthoracic Belsey fundoplication and 7 by Belsey fundoplication and circumferential myotomy. Forty-two patients had a gastroplasty and partial fundoplication; 10 required conversion to a total fundoplication because of continued severe reflux. Twelve patients had a total fundoplication gastroplasty as the primary method of reflux control (Table 4).
566 The Annals of Thoracic Surgery Vol 26
I
No 6 December 1978
2cm E
Fig I . T h e technique of preparing a gastroplasty tube has been described previously [8]. The stomach fundus is mobilized into the chest and the f a t pad is removed. (A) Posterior crural sutures are placed. (B) The gastroplasty tube ( G )is cut over a 60F Maloney bougie and closed in with t w o layers of continuous suture. T h e
gastroplasty tube is 5 cm in length. ( C ) The fundus of the stomach is sewn back to the gastroplasty tube and distal2 cm of esophagus ( E ) w i t hinterruptedmattresssutures. (D) The fundus is n o w completely wrapped, very loosely, with completion of fundoplication (TF)over a distance of 3 to 31/2 cm.
Table 4. Results of Surgical Correctiorr Procedure
Stage I ( Ole)
Standard Belsey (N = TI) 57 Belsey and circumferential myotomy (N = 7) 71.4 50 Partial fundoplication gastroplasty ( N = 42) 100 Total fundoplication gastroplasty (N = 12) Conversion from partial to total 100 fundoplication gastroplasty (N = 10) “Two patients were lost to follow-up.
Stage IIIB
Stage I1
Stage IIIA
( O/O )
(
)
( O/O )
28.6 28.5 2.3 0 0
0 0 47.6 0 0
14.3 0 0 0 0
567
Henderson: Gastroesophageal Reflux after Gastric Operation
Two patients with a transthoracic Belsey fundoplication were lost to follow-up. In the remaining patients, average follow-up for those with the standard Belsey operation was 52.5 months; with the Belsey plus circumferential myotomy, 33.3 months; with partial fundoplication gastroplasty, 46.7 months, and with conversion to a total fundoplication gastroplasty, 12.4 months; and with total fundoplication gastroplasty, 18.3 months. Adequate follow-up includes continued clinical evaluation and radiological studies with particular attention to reflux. There was no operative mortality. A localized esophageal fistula developed in 1patient, but it closed spontaneously in two weeks following tube drainage. Results for the 70 patients who had undergone previous gastric operation were categorized as follows: Asymptomatic or with mild residual symptoms; no radiological recurrence and no reflux Stage 11: Minor symptoms; radiological reflux and no radiological recurrence Stage IIIA: Major reflux symptoms; radiological reflux and no radiological recurrence Stage IIIB: Radiological recurrence
Stage I:
With standard Belsey fundoplication, Stage I results were achieved in 4 patients (57%); Stage I1 results in 2 patients (28.6%); and Stage IIIB results in 1 patient (14.3%) (see Table 4). With circumferential myotomy and Belsey repair, Stage I results were obtained in 5 patients (71.4O/0) and Stage I1 results in 2 (28.5%). There were no anatomical recurrences. Gastroplasty combined with partial fundoplication was the most common procedure in the early period of this study. The results obtained were unsatisfactory: Stage 1 in 21 patients (50%); Stage I1 in 1 patient (2.3%); and Stage IIIA in 20 patients (47.6%). Because of failure of this method, 12 patients were treated by total fundoplication gastroplasty and an additional 10 were converted from partial to total fundoplication. All 22 patients obtained total reflux control and were categorized as Stage I.
Bile diversion was added in 12 patients with a Billroth I1 gastrectomy and in 2 patients with vagotomy and gastroenterostomy. Only 7 patients have had follow-up endoscopy to assess the effect of diversion on the gastric mucosa. Of these 7 patients, 6 had an improvement in endoscopic gastritis and 1 was unchanged. Reflux correction was by partial fundoplication gastroplasty in 11 patients, total fundoplication gastroplasty in 2, and standard Belsey repair in 1. Three patients with a partial fundoplication gastroplasty have continued symptomatic reflux (Stage IIIA) and 1 has radiological reflux without symptoms (Stage 11). All other patients have good clinical improvement.
Comment Comparing the symptomatology of patients who had had a previous gastric operation and reflux with the symptoms in those patients with reflux demonstrated the only major difference to lie in the incidence of vomiting. Vomiting is a common symptom in patients with gastroesophageal reflux. However, it becomes more common and frequently more severe in those with associated bile gastritis. Vomiting occurred more often in patients with a Billroth I1 gastrectomy versus a Billroth I gastrectomy or vagotomy and drainage (74% versus 58.1%) (see Table 1). The same statistics were obtained by comparing the incidence of vomiting with the presence or absence of moderate or severe gastritis (mild gastritis and vomiting, 58%; moderate or severe gastritis and vomiting, 74%). In those patients with reflux and no previous operative procedure, vomiting occurred in only 37%. Vomiting has been described as a major symptom of bile gastritis [l] and of gastroesophageal reflux [71. The present study demonstrates that when both disorders are combined, vomiting is even more severe. Dysphagia also was more common in those with bile gastritis, but this difference was not as striking and may be a reflection of the severity of reflux. In experimental animals it is possible to produce more severe esophagitis with bile than with hydrochloric acid, and the most severe esophagitis resulted from the combination of
568 The Annals of Thoracic Surgery Vol 26
No 6 December 1978
Table 5. Risk Factors in Partial Fundoplication Gastroplasty Factor Reflux uncomplicated Peptic stricture Previous hiatal hernia Scleroderma Previous gastric operation
Total
Stages I, I1 (%)
Stages IIIA, IIIB (%)
28 27 31 7 42
97 70 70 57 50
3 30 30 43 50
135
70
30
No. of Patients
bile and acid [lo]. In the present study, the incidence of ulcerative esophagitis and stricture was higher in those patients who had had previous gastric operation than in those who had not (21.4% versus 14%) (see Table 2). Despite these endoscopic changes, there were no significant differences between the tone of the high-pressure zone and the percentage of disordered motor activity in the lower esophagus. One very important difference between the patient groups studied was the incidence of failed previous attempts at reflux correction. This was much higher in patients with previous gastric operation (49.8% versus 21%). This high incidence of recurrent reflux may well reflect the difficulty in obtaining effective reflux control in patients who have had previous gastric operation. Certainly in the present study, the partial fundoplication gastroplasty was ineffective in reflux control.
increases with peptic stricture and in the presence of a previous hernia repair; is still higher with scleroderma; and is highest with previous gastric operation (see Table 5). In the total group of patients who had undergone a previous gastric procedure, the incidence of Stage I11 results using a partial fundoplication gastroplasty was 50%. In those with gastric operation but no previous esophageal procedure, the incidence of Stage I11 results was 42.1%, and in those who had had a previous hiatal hernia procedure as well, Stage I11 results occurred in 59.1%. These results are in sharp contrast with the results of total fundoplication gastroplasty. Follow-up information was available on 22 of these patients, and none showed evidence of reflux or anatomical recurrence. Bile diversion by low enteroenterostomy or Roux-en-Y anastomosis was used only in those patients with severe bile gastritis who underSurgical Reflux Control went Billroth I1 gastrectomy or vagotomy and In a previous report, the results obtained with gastroenterostomy. Follow-up endoscopy was the partial fundoplication gastroplasty were available for only half of these patients, but 6 analyzed and several factors were shown to out of 7 did show resolution of the gastritis. In evaluating the results of operation, good predispose to continued reflux [8].The major factors are ulcerative esophagitis or stricture, symptomatic relief has been found in patients previous operation for hiatal hernia, who have effective reflux control. It is not posscleroderma, previous esophageal myotomy, sible to determine whether bile gastritis is imand previous gastric procedure (Table 5). If portant in the production of symptoms because none of these are present and the hernia is for each patient with severe gastritis, bile diotherwise uncomplicated, the partial fundopli- version was added to the procedure. cation gastroplasty is reliable in reflux control The major therapeutic problem is how to oband produces a very low incidence of anatom- tain effective reflux control. That 49.89'0 of the ical recurrence. In the present study, in a group patients in this series had had at least one preof 28 patients with an uncomplicated hernia, 1 vious attempt at reflux control helps emphasize had continued radiological reflux and none had this point. The problem has been resolved by radiological recurrence of the hernia. When risk the use of total fundoplication gastroplasty. factors are present, the incidence of poor results Although the available statistics confirm that
569 Henderson: Gastroesophageal Reflux after Gastric Operation
y+++iJ/
NEUROGE N IC HORMONAL
REFLUX PRESSURE
ESOPHAGUS
Fig 2 . In the normal esophagus, increased intraperitoneal pressure and selective increases of gastric pressure do not cause reflux because of the counterbalancing effects of the intraabdominal esophagus, sphincteric tone, and the neurogenic (N) and hormonal (H) reflux mechanisms. (9' = intraperitoneal pressure; D = diaphragm; T, = gastroesophageal sphincteric pressure.)
total fundoplication is more effective in reflux control, it is necessary to evaluate the factors involved and see if reasons for this difference can be determined. Under normal circumstances, several factors are involved in reflux control, and the difficulty lies in deciding the importance of each aspect of control (Fig 2). When the distal esophagus and high-pressure zone are subdiaphragmatic, the factors preventing reflux are the intraabdominal segment of esophagus, the high-pressure zone, and possible neurogenic and hormonal influences from the stomach [ 9 ] . Two types of reflux pressure have to be counterbalanced: diffuse increases in intraperitoneal pressure and selective gastric pressure increases such as may occur after eating or with increased gastric motor activity [lo]. Increases in intraperitoneal pressure act on both the stomach and the intraabdominal segment of esophagus and, therefore, are counterbalancing. The tone of the high-pressure zone remains as a pressure barrier supplemented by its pressure increases from neurogenic and hormonal reflexes. When gastric pressure is selectively increased, reflux is prevented by the tone of this zone and its neurological and hormonal reflexes. The gastroplasty tube has been shown to markedly reduce the incidence of anatomical hernia recurrence, but has not proved effective
in reflux control. The measurable tone of the gastroplasty tube is very low [81 and is unlikely to be a factor in reflux control. At present, the neurogenic and hormonal responsiveness of the gastroplasty tube is unknown. When the gastroplasty patient is exposed to intraperitoneal pressure increases, reflux control is achieved by counterbalancing pressure increases from extrinsic compression on both the gastroplasty tube and the high-pressure zone. In this situation, the gastroplasty tube seems theoretically to add to the competence mechanism. When selective gastric pressure increases occur, there are no counterbalancing effects and the low-tone gastroplasty tube is no longer an effective pressure barrier. If the high-pressure zone is low toned and if it is no longer responsive to neurogenic or hormonal influences because of preexisting disease or surgical damage, then reflux is likely to occur. In this situation, the type of fundoplication is critical. With a partial fundoplication (240-degree wrap), selective gastric pressure increases are partially but not completely transmitted around the gastroplasty tube and high-pressure zone. Using the total fundoplication gastroplasty (360-degree wrap), reflux is controlled by effective transmission of gastric pressure to either the gastroplasty tube or the high-pressure zone, or to both structures (Figs 3, 4). In the patients reviewed here, many highrisk factors were present, including a low-tone high-pressure zone, previous esophageal operation, esophageal shortening from ulceration and stricture, and previous gastric operation. Under these conditions, the tone of the highpressure zone and its responsiveness to neurogenic and hormonal stimuli are inevitably reduced. Partial fundoplication gastroplasty is ineffective. In patients with major esophageal disease and a previous gastric procedure, total fundoplication with gastroplasty is the most effective surgical method of obtaining reflux control. When effective reflux control is achieved, there is good symptomatic relief. The combination of a previous gastric procedure and gastroesophageal reflux produces major difficulties in efforts to provide effective
570 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
NEUROGENIC/ HORMONAL
)\ \
REFLUX
GASTROPLASTY TG
--I\
-
Fig 3 . The gastroplasty tube has a low intrinsic tone and assists in preventing reflux w h e n intraperitoneal pressure ("P) increases but is ineffective in the presence of selective gastric pressure increases. The partial fundoplication does not transmit total gastric pressure to the gastroplasty tube. Therefore, increases in gastric pressure may result in reflux. (T(;= gastroplasty tubal tone; T, = sphincteric tone; D = diaphragm; R + R , = transmission of gastric pressure b y the fundoplication; X = loss of pressure transmission due to the incomplete fundoplication.)
symptomatic relief. Seventy patients with this combination were studied by history, radiology, endoscopy, and esophageal manometry, before surgical reflux control. Vomiting was frequent, and there was also a high incidence of
Fig 4 . Again, the gastroplasty tube does not b y itself prevent reflux w h e n there are selective increases in gastric pressure. W i t h the addition of total fundoplication, gastric pressure is totally transmitted around the gastroplasty tube, and reflux control is effective. (T, = gastroplasty tubal pressure; Ts = sphincteric pressure; D = diaphragm; "I' = intraperitoneal pressure; R R , = transmission of gastric pressure b y the fundoplication .)
+
dysphagia and of endoscopic ulcerative esophagitis and stricture. Almost half of these patients had undergone a previous hiatal hernia procedure that had failed to correct reflux. A variety of surgical approaches for reflux control were used in the early stages of this study, including standard Belsey repair, Belsey repair plus esophageal lengthening by circumferential myotomy, and partial fundoplication gastroplasty. Because ineffective reflux control was obtained using these methods, a total fundoplication gastroplasty was used and none of the 22 patients treated in this manner have had reflux recurrence. Bile diversion was reserved for patients with severe bile gastritis. These patients have progressed satisfactorily, and part of their symptom relief is probably related to the diversion. In those who had follow-up endoscopy, most showed effective resolution of gastritis. The combination of total fundoplication gastroplasty and bile diversion, when necessary, is an effective surgical approach to the patient with bile reflux.
4
GASTROPLASTY TG
/
\TS
571 Henderson: Gastroesophageal Reflux after Gastric Operation
References Wickbom G, et al: A 1. Bushkin FL, Deford JW,
clinical evaluation of postoperative alkaline reflux gastritis. Am Surg 41238, 1975 2. Bushkin FL, Woodward AR: Alkaline reflux esophagitis. Major Probl Clin Surg 29:64, 1976 3. Capper WM, Butler TJ, Kilby JP: Reversal of non-Addisonian achlorhydria by a Roux-en-Y loop. Gut 8:612, 1967 4. Castell DO, Harris LD: Hormonal control of gastroesophageal sphincter strength. N Engl J Med 282:886, 1970 5. Cohen S, Lipshutz W: Hormonal regulation of human lower esophageal sphincter competence; interaction of gastrin and secretin. J Clin Invest 50:449, 1971 6. Coppinger WR, Job H, De Lauro JE, et al: Surgical treatment of reflux gastritis and esophagitis. Arch Surg 106:463, 1973 7. Henderson RD: Motor Disorders of the Esophagus. Baltimore, Williams & Wilkins, 1976, P 48 8. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:206, 1977 9. Henderson RD: The gastroplasty tube as a method of reflux control. Can J Surg 21:264, 1978 10. Henderson RD, Magashe FL, Jeejeebhoy KN, et al: Synergism of acid and bile salts in the production of experimental esophagitis. Can J Surg 16:12, 1973 11. Henderson RD, Pearson FG: Preoperative assessment of esophageal pathology. J Thorac Cardiovasc Surg 72:512, 1976 12. Henderson RD, Rodney K: Tone of the gastroesophageal junction; its response to abdominal compression and to swallowing. Can J Surg 14:328, 1971 13. Himal HS: Alkaline gastritis and alkaline esophagitis: a review. Can J Surg 20:403, 1977 14. Ingelfinger FJ: The sphincter that is a sphinx. N Engl J Med 284:1095, 1971 15. Lind JF, Warrian WG, Warkling WJ: Responses of the gastroesophageal junctional zone to increases in abdominal pressure. Can J Surg 9:32, 1966 16. Windsor CWO: Gastroesophageal reflux after partial gastrectomy. Br Med J 2:1233, 1964
Discussion (St. Louis, MO): I was pleased that Dr. Henderson provided me with a copy of the manuscript before the meeting because I found the abstract somewhat confusing and the title of the paper perhaps a little misleading. It suggests that gastric resection per se produces reflux, which, I think, is not the case. Esophageal reflux after a gastric operation means DR. THOMAS B . FERGUSON
to me one of two things: either the patient had a preexisting hiatal hernia that was not repaired at the time of gastric operation or a hiatal hernia was created at the time of gastric operation by mobilization and destruction of the supporting ligaments around the cardioesophageal junction. That preexisting hernia was a factor in Dr. Henderson’s series is suggested by the fact that 50% of the patients had had a “previous hiatal hernia repair.” The paper does not elaborate on these operations, nor is there laboratory or roentgenographic data as to the efficacy of the repairs done before gastrectomy. The second cause for reflux-disruption of the phrenoesophageal ligament-may result from abdominal vagectomy, just as hernia with reflux has been reported after laparotomy for a Heller myotomy to correct achalasia. In fact, 28 of the 70 patients in the present series, or 40%’ had vagectomy. I have no experience with this group of patients, but I polled the gastric surgeons at Barnes Hospital who tell me that in their combined experience the incidence of reflux, bile or otherwise, after a gastric resection is almost nil unless the patient has had an associated hiatal hernia that was not corrected. It would be interesting to know the population base from which these 70 patients were derived. Also, in the experience of the Barnes surgeons the incidence of bile gastritis and esophagitis is very low. They agree that when either does occur, enteroenterostomy is not a good procedure and recommend an isoperistaltic jejunal loop combined with a Nissen fundoplication. On the positive side, Dr. Henderson’s study does point out that when symptomatic reflux is present in association with a previous gastric operation, control of the reflux is more difficult than when uncomplicated hiatal hernia is present. His method of dealing with the problem, namely, gastroplasty combined with Nissen fundoplication, seems from his data to be the most effective method of control. DR. NICHOLAS J . DEMOS (Jersey City, NJ): Out of a group of more than 50 patients having hiatal hemioplasty, 7 who underwent subtotal gastrectomy required an antireflux operation. Our simple gastroplasty combined with total fundoplication is anatomically frugal and avoids a major reduction of the small gastric remnant. We divide neither the stomach nor the short gastric vessels. We simply staple the fundus to prolong the esophagus and obviate extensive esophageal dissection and its complications. A few sutures at the rim of the plicated fundus anchor the organ under the diaphragm. No sutures are made in the fragile esophageal wall at any time. In the very rare instance of an irreducible cardia, our stapling is done lower down in the fundus, which easily achieves an infradiaphragmatic position for the plicated fundus.
572 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
We have not needed additional procedures to enlarge the gastric reservoir, which looks adequate after the frugal fundoplication that we perform. DR. MARK BURTON ORRINGER (Ann Arbor, MI): I would like to commend Dr. Henderson for his outstanding results in this very difficult group of patients. In our hands, the combination of the Collis gastroplasty and Belsey hiatal hernia repair has been associated with a 16% incidence of recurrent reflux symptomatically and almost a 30”/0 incidence of recurrent reflux with pH reflux testing. Therefore we now use the Collis gastroplasty in combination with a 360-degree Nissen fundoplication and have documented much better early reflux control. 1 want now to focus on the real problem under discussion-not the best means of controlling reflux, but rather how to manage the patient with severe epigastric and chest pain, early satiety, regurgitation, vomiting, and weight loss following a prior gastric operation. Gastroesophageal reflux may often be present, but precise documentation of the associated esophageal and gastric pathophysiology is essential in planning a rational program of management. If gastric analysis shows continued acid production after vagotomy or gastric resection, a transthoracic completion vagotomy in addition to an antireflux operation is needed. If there is bile in the stomach at endoscopy or as proved by high sodium concentration in the gastric aspirate, bile gastritis may be the major problem even though there may be no clear evidence of inflammation of the stomach. In this instance, diversion of bile from the stomach may be quite adequate therapy. A Collis-Belsey or Collis-Nissen operation can certainly be performed when there is only a small gastric remnant, and control of reflux can be achieved. But if there is gastric irritation by bile, continued abdominal pain and early satiety may remain incapacitating and require the addition of a later biliary diversion procedure. This added procedure was necessary in 4 of our 12 patients with this condition who were treated with either a Collis-Belsey or Collis-Nissen operation. Finally, the pain in 2 of our postgastrectomy patients was not from reflux esophagitis or bile gastritis, but rather from esophageal spasm that required esophagomyotomy for relief. I would ask Dr. Henderson, then, if he does not think additional diagnostic measures-specifically, gastric analysis, gastroscopy, and a histamine stimulation test-might be indicated to differentiate the patient with peptic esophagitis from the one in whom bile reflux esophagitis or gastritis or a combination of these is occurring. In our experience, this differentiation is of paramount importance in planning successful operative treatment.
DR. JOEL COOPER (Toronto, Ont, Canada): 1, too, congratulate Dr. Henderson on approaching a difficult and very complicated subject. 1 had the good fortune
to train with Mr. Belsey, as did my colleague Dr. Pearson, and 1 was a colleague of Dr. Henderson’s for four years when he was with our division at the Toronto General Hospital. I want to emphasize a point he has already made, namely, that his operation differs in an essential way from the Belsey Mark IV repair. The Belsey repair employs three mattress sutures that incorporate esophagus, stomach, and diaphragm and hold these structures in a fixed relationship. Dr. Henderson’s repair does not utilize these three sutures. Therefore, I think it inappropriate for Dr. Henderson to describe his own, “Henderson,” repair as a Belsey or a modified Belsey repair. Furthermore, it is particularly inappropriate to use the unsatisfactory results obtained with his repair to indict the Belsey Mark IV repair. The differences between the Henderson repair and the Belsey repair are evident in the results. Manometrically, Dr. Henderson has reported that sphincter pressures at one year following operation in his group of Collis-Henderson repairs are belozu the preoperative values. In our series of Collis-Belsey repairs, the sphincter pressures average 2% times the preoperative values, even at one year following operation. Clinically, Dr. Henderson has found an incidence of 25% of recurrent, troublesome symptoms following the Henderson-Collis combination. However, in 214 patients who had a Collis-Belsey repair for complicated problems and who have been followed from two to thirteen years with 96% seen during 1977 for evaluation, only 5% have symptomatic recurrence. Therefore, 1 would ask Dr. Henderson to what he attributes the unsatisfactory results when he adds the Collis gastroplasty to his own repair, particularly since he seems satisfied with the results of his own repair-recurrence of only 3%. If he traces the unsatisfactory results to the Collis gastroplasty, why does he now add that procedure to the Nissen repair? DR. HENDERSON: 1 have been in this argument before, and the topics covered are very familiar. With reference to Dr. Cooper’s remarks, there are some points that are very important. First, the method 1 have used for doing the Belsey or partial fundoplication gastroplasty is identical to that used by Dr. Pearson except for the addition of sutures from the fundus of the stomach to the diaphragm. This does not in any way alter the amount of gastroplasty tube wrapped by stomach and is not associated with a higher incidence of anatomical recurrence. Knowing these facts, 1 am surprised Dr. Cooper considers the point important. Second, the repair done by Dr. Pearson is not a Belsey Mark 1V repair. It incorporates three rows of sutures from gastroplasty to stomach and is clearly a variation of the Belsey technique. This point is displayed in Dr. Pearson’s movie on the Belsey gastroplasty. Third, Dr. Orringer has used an absolutely standard Belsey Mark IV technique and is reporting a
573
Henderson: Gastroesophageal Reflux after Gastric Operation
30% incidence of continued reflux. Further, Dr. Pearson was reporting 6.5% bad results last year. He continues to have about the same percentage of bad results but recognizes that 13% of patients have reflux. In my experience, when radiological reflux develops in a large number of patients, additional major symptoms occur. The final point 1 would like to make is that using the standard Belsey repair, Dr. DeMeester has documented a 50% incidence of gastroesophageal reflux in follow-up; 20% of these patients were symptomatic. We have to accept that the Belsey type of partial fundoplication is associated with a high incidence of continued reflux. Mr. Belsey himself does not believe
that his wrap-around has anything to d o with reflux control. Dr. Ferguson’s remarks were very pertinent. He questions whether or not a previous gastric operation produces reflux. Windsor published a paper in 1964 indicating that in 50% of patients who had previously undergone a gastric procedure, reflux does develop. Finally, I want to emphasize that many of the patients in my study are extremely ill. Indeed, many are in the salvage group who were true gastric cripples following a radical Billroth I1 resection. In this type of patient, effective reflux control coupled with bile diversion has produced a very satisfactory result.
Notice from the Editor and the Editorial Board The Editor and members of the Editorial Board are grateful for the assistance given in the review of certain manuscripts during the past year by the following persons: Ralph D. Alley, M.D. Albany, NY
Paul Knight, M.D. Ann Arbor, MI
John A. Penner, M.D. Ann Arbor, MI
Douglas M. Behrendt, M.D. Ann Arbor, MI
Nicholas T. Kouchoukos, M.D. Birmingham, AL
Bertram W. Pitt, M.D. Ann Arbor, MI
David G. Bjoraker, M.D. Ann Arbor, MI
Hiram T. Langston, M.D. Chicago, IL
Amnon Rosenthal, M.D. Ann Arbor, MI
Lawrence I. Bonchek, M.D. Milwaukee, WI
Sidney Levitsky, M.D. Chicago, IL
Stuart S. Sagel, M.D. St. Louis, MO
Allan Brown, M.D. Ann Arbor, MI
Keith G. Lieding, M.D. Ann Arbor, MI
Arthur B. Simon, M.D. Ann Arbor, MI
James F. Brymer, M.D. Ann Arbor, MI
Peter Mansfield, M.D. Seattle, WA
Nicholas P. D. Smyth, M.D. Washington, DC
Richard J. Cleveland, M.D. Boston, MA
James McKenzie, M.D. Piscataway, NY
James E. Stanley, M.D. Ann Arbor, MI
Peter J. Cohen, M.D. Ann Arbor, MI
Hassan Najafi, M.D. Chicago, IL
Albert Starr, M.D. Portland, O R
Arnold G. Coran, M.D. Ann Arbor, MI
John C. Norman, M.D. Houston, TX
Panagiotis N. Symbas, M.D. Atlanta, GA
W. Sterling Edwards, M.D. Albuquerque, NM
Mark B. Orringer, M.D. Ann Arbor, MI
John R. Thornbury, M.D. Ann Arbor, MI
C. Frederick Kittle, M.D. Chicago, IL
F. Griffith Pearson, M.D. Toronto, Ont, Canada
Harold C. Urschel, Jr., M.D. Dallas, TX
The incidence of gastroesophageal reflux is increased following gastric operation [16]. Reasons for this increase are not clearly delineated, but it may be secondary to mechanical disruption of the phrenoesophageal ligament and supporting structures or secondary to altered neurogenic and hormonal responses in the gastroesophageal junction [4, 5, 12, 14, 151. Bile gastritis has been reported as a complication of gastric procedures. It occurs most frequently following Billroth I1 resections, but is also reported after Billroth I resections or vagotomy and drainage [l].The incidence of bile From the Departments of Surgery, Women’s College Hospital and the University of Toronto, Toronto, Ont, Canada. Presented at the Fourteenth Annual Meeting of The Society of Thoracic Surgeons, Jan 23-25, 1978, Orlando, FL. Address reprint requests to Dr. Henderson, Women’s College Hospital, 76 Grenville St, Toronto, Ont, Canada M5S 1B2.
gastritis has not been cleariy established, and since patients with this condition may be asymptomatic, it is difficult to do. When gastroesophageal reflux is also present, the refluxed bolus contains bile. These patients have bile esophagitis in association with bile gastritis [2]. Patients with intractable symptoms of bile gastritis and bile esophagitis undergo operation to achieve bile diversion, surgical correction of gastroesophageal reflux, or a combination of both procedures. When bile diversion by Roux-en-Y anastomosis is used, some authors have advocated the addition of vagotomy to further reduce gastric acidity and avoid stoma1 ulceration [ 2 , 3 , 6,131. Each of these operations has been recommended as the correct operative approach, based on the quality of results reported. Controversy remains concerning the best surgical approach for patients with combined bile gastritis and bile esophagitis. In the present study, 70 patients who had undergone previous gastric operation and had intractable reflux symptoms were evaluated before a further procedure. This operative procedure was tailored to fit the findings of the preoperative investigations. All patients had an antireflux procedure, and bile diversion was added only in those with endoscopic evidence of moderate to severe bile gastritis. Materials and Methods Seventy patients who had had a previous gastric procedure and then experienced symptomatic gastroesophageal reflux were reviewed. Twenty-eight had undergone vagotomy and pyloroplasty; 4, vagotomy and gastroenterostomy; 11, Billroth I gastrectomy; and 27, Billroth I1 gastrectomy. For the purpose of evaluation, symptomatic and preoperative investigative comparison is made with 100 consecutive patients who had not had previous gastric operations but who required surgical correction of
563 0003-4975/78/0026-0610$01.25@ 1978 by R. D. Henderson
564 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
Table 2 . Reflux Symptoms: Comparison between ZOO Consecutive Patients with Reflux and 70 Patients with Reflux and Previous Gastric Operation
Symptoms
Consecutive Patients (N = 100)
Patients with Billroth I; Previous Gastric Vagotomy and Operation Drainage (N = 70) (N = 43)
Duration of symptoms Heartburn Reflux Reflux and aspiration Hiccup Burping Water brash Nausea Vomiting Dysphagia (total) Cricopharyngeal Aspiration Gastroesophageal Regurgitation Peptic stricture
5.1 yr 100% 84 '/o 21% 33 Yo 68'/o 23 Yo 62% 37% 84'/o 58'/o 28 O/O 68% 31 yo 2 o/o
7.7 yr 100% 83.1% 43.6o/' 18.3'/o 59.1'/o 31yo 74.3% 63.5'/o 78.8% 47.1% 23.9% 67'/o 35.2 '/o 5.7%
Billroth I1 (N = 27)
2 Y' 100% 88.3'/o 44.1 yo 20.9 '/o 60.4% 23.2%
8.5 yr 100% 78.5'/o 42.8% 14.8% 59.2% 44.4%
58.1 '/o 72'/o 46.5% 30.2'/o 62.8O/O 32.5'/o 4.6%
74 '/o 92.6% 48.1% 14.2'/o 77.7% 40.7% 7.2%
operated on between May, 1971, and March, 1977, and the 100 consecutive patients (without previous gastric operation) requiring a reflux procedure and operated on within a 16-month period up to March, 1977. Certain features of patient history are of note (Table 1).The majority of symptoms occurred with equal frequency in those patients with uncomplicated reflux, those with a Billroth I gastrectomy or vagotomy and drainage, and those with a previous Billroth I1 gastrectomy. Dysphagia was more common in patients who had had a Billroth I1 gastrectomy, and vomiting was more frequent and severe in all patients who had undergone previous gastric operation, particularly in those who had had a Billroth I1 gastrectomy. Endoscopic and radiological methods were sed to determine the presence of ulcerative esophagitis and stricture formation. The incidence of these lesions was higher in the patients who had had a previous gastric operation (Table 2 ) . Manometric findings in both the patients with uncomplicated reflux and those with a previous gastric operation were similar. Both Results groups had a reduction in sphincteric tone and Symptom comparison was made between the an increased percentage of lower esophageal 70 patients with a previous gastric procedure disordered motor activity [ill. Previous hiatal
gastroesophageal reflux. All patients were studied before operation by history, radiology, endoscopy, and esophageal manometry, and these findings were compared. The 70 patients who had had a previous gastric procedure were considered to have the potential of bile reflux. These patients had reflux correction by one of four techniques: standard Belsey hernia repair without esophageal lengthening; standard Belsey repair with the esophagus lengthened by circumferential myotomy; gastroplasty with partial fundoplication (Belsey type); or gastroplasty with total fundoplication (Nissen type). In patients who had undergone a Billroth I1 gastrectomy or vagotomy and gastroenterostomy and had severe bile gastritis, a low enteroenterostomy or Roux-en-Y anastomosis was added for bile diversion. In follow-up evaluation, a proportion of patients with partial fundoplication gastroplasty had failure of reflux correction and were converted to a total fundoplication gastroplasty [81.
565
Henderson: Gastroesophageal Reflux after Gastric Operation
Table 2 . Endoscopic and Manometric Comparisons Factor
100 Consecutive Patients
70 with Previous Gastric Operation
Peptic stricture Ulcerative esophagitis Tone: gastroesophageal junction Percent DMA Previous hiatal hernia repair
2% 12% 11.3 cm H,O 44.7% 21Yo
5.7% 15.7% 11 cm H,O 52.6% 49.8%
DMA
=
Controls (N = 9)
18.8 cm H,O 8.3%
disordered motor activity.
Table 3 . Gastritis in Patients with Previous Gastric Operation
Gastritis
Vagotomy and Pyloroplasty (N = 28)
Vagotomy and Gastroenterostomy (N = 4)
Billroth I (N = 11)
(N= 27)
Normal to mild Moderate Severe
23 5 0
1 1 2
8 3 0
11 4 12
hernia repair had been performed in 21 patients (21%) in the uncomplicated reflux group and in 35 patients (49.8%) in the group with previous gastric operation. Endoscopy was used for assessment of bile gastritis. The findings were classified as normal to mild, moderate, and severe gastritis. The incidence of severe bile gastritis was highest in those with a previous Billroth I1 gastrectomy, but also occurred in 2 patients with a previous vagotomy and gastroenterostomy. Moderate gastritis was present in a proportion of all groups studied (Table 3). The method of surgical correction of reflux in those patients who had had a previous gastric procedure has changed during the six years of the present study. In the early years, esophageal lengthening was carried out either by gastroplasty and partial fundoplication or by circumferential esophageal myotomy and Belsey fundoplication. Esophageal lengthening was used in those with previous hernia repair or in those with esophageal shortening from panmural esophagitis. A standard Belsery hernia repair was the alternative method of hernia reduction and fixation. Because of ineffective reflux control with gastroplasty and partial fundoplication, a new
Billroth I1
operative technique was developed and has been used with increasing frequency for two and a half years. This approach uses a gastroplasty and total fundoplication of the Nissen type [8] (Fig 1).The total fundoplication gastroplasty is now used in all patients requiring reflux correction. Some patients with severe continuing reflux following partial fundoplication gastroplasty were converted to a total fundoplication. Bile diversion by low enteroenterostomy or by Roux-en-Y anastomosis was performed only in those patients with a previous Billroth I1 gastrectomy or vagotomy and gastroenterostomy who had severe gastritis. In these patients bile diversion was combined with an antireflux procedure.
Operative Results Nine patients were treated by a transthoracic Belsey fundoplication and 7 by Belsey fundoplication and circumferential myotomy. Forty-two patients had a gastroplasty and partial fundoplication; 10 required conversion to a total fundoplication because of continued severe reflux. Twelve patients had a total fundoplication gastroplasty as the primary method of reflux control (Table 4).
566 The Annals of Thoracic Surgery Vol 26
I
No 6 December 1978
2cm E
Fig I . T h e technique of preparing a gastroplasty tube has been described previously [8]. The stomach fundus is mobilized into the chest and the f a t pad is removed. (A) Posterior crural sutures are placed. (B) The gastroplasty tube ( G )is cut over a 60F Maloney bougie and closed in with t w o layers of continuous suture. T h e
gastroplasty tube is 5 cm in length. ( C ) The fundus of the stomach is sewn back to the gastroplasty tube and distal2 cm of esophagus ( E ) w i t hinterruptedmattresssutures. (D) The fundus is n o w completely wrapped, very loosely, with completion of fundoplication (TF)over a distance of 3 to 31/2 cm.
Table 4. Results of Surgical Correctiorr Procedure
Stage I ( Ole)
Standard Belsey (N = TI) 57 Belsey and circumferential myotomy (N = 7) 71.4 50 Partial fundoplication gastroplasty ( N = 42) 100 Total fundoplication gastroplasty (N = 12) Conversion from partial to total 100 fundoplication gastroplasty (N = 10) “Two patients were lost to follow-up.
Stage IIIB
Stage I1
Stage IIIA
( O/O )
(
)
( O/O )
28.6 28.5 2.3 0 0
0 0 47.6 0 0
14.3 0 0 0 0
567
Henderson: Gastroesophageal Reflux after Gastric Operation
Two patients with a transthoracic Belsey fundoplication were lost to follow-up. In the remaining patients, average follow-up for those with the standard Belsey operation was 52.5 months; with the Belsey plus circumferential myotomy, 33.3 months; with partial fundoplication gastroplasty, 46.7 months, and with conversion to a total fundoplication gastroplasty, 12.4 months; and with total fundoplication gastroplasty, 18.3 months. Adequate follow-up includes continued clinical evaluation and radiological studies with particular attention to reflux. There was no operative mortality. A localized esophageal fistula developed in 1patient, but it closed spontaneously in two weeks following tube drainage. Results for the 70 patients who had undergone previous gastric operation were categorized as follows: Asymptomatic or with mild residual symptoms; no radiological recurrence and no reflux Stage 11: Minor symptoms; radiological reflux and no radiological recurrence Stage IIIA: Major reflux symptoms; radiological reflux and no radiological recurrence Stage IIIB: Radiological recurrence
Stage I:
With standard Belsey fundoplication, Stage I results were achieved in 4 patients (57%); Stage I1 results in 2 patients (28.6%); and Stage IIIB results in 1 patient (14.3%) (see Table 4). With circumferential myotomy and Belsey repair, Stage I results were obtained in 5 patients (71.4O/0) and Stage I1 results in 2 (28.5%). There were no anatomical recurrences. Gastroplasty combined with partial fundoplication was the most common procedure in the early period of this study. The results obtained were unsatisfactory: Stage 1 in 21 patients (50%); Stage I1 in 1 patient (2.3%); and Stage IIIA in 20 patients (47.6%). Because of failure of this method, 12 patients were treated by total fundoplication gastroplasty and an additional 10 were converted from partial to total fundoplication. All 22 patients obtained total reflux control and were categorized as Stage I.
Bile diversion was added in 12 patients with a Billroth I1 gastrectomy and in 2 patients with vagotomy and gastroenterostomy. Only 7 patients have had follow-up endoscopy to assess the effect of diversion on the gastric mucosa. Of these 7 patients, 6 had an improvement in endoscopic gastritis and 1 was unchanged. Reflux correction was by partial fundoplication gastroplasty in 11 patients, total fundoplication gastroplasty in 2, and standard Belsey repair in 1. Three patients with a partial fundoplication gastroplasty have continued symptomatic reflux (Stage IIIA) and 1 has radiological reflux without symptoms (Stage 11). All other patients have good clinical improvement.
Comment Comparing the symptomatology of patients who had had a previous gastric operation and reflux with the symptoms in those patients with reflux demonstrated the only major difference to lie in the incidence of vomiting. Vomiting is a common symptom in patients with gastroesophageal reflux. However, it becomes more common and frequently more severe in those with associated bile gastritis. Vomiting occurred more often in patients with a Billroth I1 gastrectomy versus a Billroth I gastrectomy or vagotomy and drainage (74% versus 58.1%) (see Table 1). The same statistics were obtained by comparing the incidence of vomiting with the presence or absence of moderate or severe gastritis (mild gastritis and vomiting, 58%; moderate or severe gastritis and vomiting, 74%). In those patients with reflux and no previous operative procedure, vomiting occurred in only 37%. Vomiting has been described as a major symptom of bile gastritis [l] and of gastroesophageal reflux [71. The present study demonstrates that when both disorders are combined, vomiting is even more severe. Dysphagia also was more common in those with bile gastritis, but this difference was not as striking and may be a reflection of the severity of reflux. In experimental animals it is possible to produce more severe esophagitis with bile than with hydrochloric acid, and the most severe esophagitis resulted from the combination of
568 The Annals of Thoracic Surgery Vol 26
No 6 December 1978
Table 5. Risk Factors in Partial Fundoplication Gastroplasty Factor Reflux uncomplicated Peptic stricture Previous hiatal hernia Scleroderma Previous gastric operation
Total
Stages I, I1 (%)
Stages IIIA, IIIB (%)
28 27 31 7 42
97 70 70 57 50
3 30 30 43 50
135
70
30
No. of Patients
bile and acid [lo]. In the present study, the incidence of ulcerative esophagitis and stricture was higher in those patients who had had previous gastric operation than in those who had not (21.4% versus 14%) (see Table 2). Despite these endoscopic changes, there were no significant differences between the tone of the high-pressure zone and the percentage of disordered motor activity in the lower esophagus. One very important difference between the patient groups studied was the incidence of failed previous attempts at reflux correction. This was much higher in patients with previous gastric operation (49.8% versus 21%). This high incidence of recurrent reflux may well reflect the difficulty in obtaining effective reflux control in patients who have had previous gastric operation. Certainly in the present study, the partial fundoplication gastroplasty was ineffective in reflux control.
increases with peptic stricture and in the presence of a previous hernia repair; is still higher with scleroderma; and is highest with previous gastric operation (see Table 5). In the total group of patients who had undergone a previous gastric procedure, the incidence of Stage I11 results using a partial fundoplication gastroplasty was 50%. In those with gastric operation but no previous esophageal procedure, the incidence of Stage I11 results was 42.1%, and in those who had had a previous hiatal hernia procedure as well, Stage I11 results occurred in 59.1%. These results are in sharp contrast with the results of total fundoplication gastroplasty. Follow-up information was available on 22 of these patients, and none showed evidence of reflux or anatomical recurrence. Bile diversion by low enteroenterostomy or Roux-en-Y anastomosis was used only in those patients with severe bile gastritis who underSurgical Reflux Control went Billroth I1 gastrectomy or vagotomy and In a previous report, the results obtained with gastroenterostomy. Follow-up endoscopy was the partial fundoplication gastroplasty were available for only half of these patients, but 6 analyzed and several factors were shown to out of 7 did show resolution of the gastritis. In evaluating the results of operation, good predispose to continued reflux [8].The major factors are ulcerative esophagitis or stricture, symptomatic relief has been found in patients previous operation for hiatal hernia, who have effective reflux control. It is not posscleroderma, previous esophageal myotomy, sible to determine whether bile gastritis is imand previous gastric procedure (Table 5). If portant in the production of symptoms because none of these are present and the hernia is for each patient with severe gastritis, bile diotherwise uncomplicated, the partial fundopli- version was added to the procedure. cation gastroplasty is reliable in reflux control The major therapeutic problem is how to oband produces a very low incidence of anatom- tain effective reflux control. That 49.89'0 of the ical recurrence. In the present study, in a group patients in this series had had at least one preof 28 patients with an uncomplicated hernia, 1 vious attempt at reflux control helps emphasize had continued radiological reflux and none had this point. The problem has been resolved by radiological recurrence of the hernia. When risk the use of total fundoplication gastroplasty. factors are present, the incidence of poor results Although the available statistics confirm that
569 Henderson: Gastroesophageal Reflux after Gastric Operation
y+++iJ/
NEUROGE N IC HORMONAL
REFLUX PRESSURE
ESOPHAGUS
Fig 2 . In the normal esophagus, increased intraperitoneal pressure and selective increases of gastric pressure do not cause reflux because of the counterbalancing effects of the intraabdominal esophagus, sphincteric tone, and the neurogenic (N) and hormonal (H) reflux mechanisms. (9' = intraperitoneal pressure; D = diaphragm; T, = gastroesophageal sphincteric pressure.)
total fundoplication is more effective in reflux control, it is necessary to evaluate the factors involved and see if reasons for this difference can be determined. Under normal circumstances, several factors are involved in reflux control, and the difficulty lies in deciding the importance of each aspect of control (Fig 2). When the distal esophagus and high-pressure zone are subdiaphragmatic, the factors preventing reflux are the intraabdominal segment of esophagus, the high-pressure zone, and possible neurogenic and hormonal influences from the stomach [ 9 ] . Two types of reflux pressure have to be counterbalanced: diffuse increases in intraperitoneal pressure and selective gastric pressure increases such as may occur after eating or with increased gastric motor activity [lo]. Increases in intraperitoneal pressure act on both the stomach and the intraabdominal segment of esophagus and, therefore, are counterbalancing. The tone of the high-pressure zone remains as a pressure barrier supplemented by its pressure increases from neurogenic and hormonal reflexes. When gastric pressure is selectively increased, reflux is prevented by the tone of this zone and its neurological and hormonal reflexes. The gastroplasty tube has been shown to markedly reduce the incidence of anatomical hernia recurrence, but has not proved effective
in reflux control. The measurable tone of the gastroplasty tube is very low [81 and is unlikely to be a factor in reflux control. At present, the neurogenic and hormonal responsiveness of the gastroplasty tube is unknown. When the gastroplasty patient is exposed to intraperitoneal pressure increases, reflux control is achieved by counterbalancing pressure increases from extrinsic compression on both the gastroplasty tube and the high-pressure zone. In this situation, the gastroplasty tube seems theoretically to add to the competence mechanism. When selective gastric pressure increases occur, there are no counterbalancing effects and the low-tone gastroplasty tube is no longer an effective pressure barrier. If the high-pressure zone is low toned and if it is no longer responsive to neurogenic or hormonal influences because of preexisting disease or surgical damage, then reflux is likely to occur. In this situation, the type of fundoplication is critical. With a partial fundoplication (240-degree wrap), selective gastric pressure increases are partially but not completely transmitted around the gastroplasty tube and high-pressure zone. Using the total fundoplication gastroplasty (360-degree wrap), reflux is controlled by effective transmission of gastric pressure to either the gastroplasty tube or the high-pressure zone, or to both structures (Figs 3, 4). In the patients reviewed here, many highrisk factors were present, including a low-tone high-pressure zone, previous esophageal operation, esophageal shortening from ulceration and stricture, and previous gastric operation. Under these conditions, the tone of the highpressure zone and its responsiveness to neurogenic and hormonal stimuli are inevitably reduced. Partial fundoplication gastroplasty is ineffective. In patients with major esophageal disease and a previous gastric procedure, total fundoplication with gastroplasty is the most effective surgical method of obtaining reflux control. When effective reflux control is achieved, there is good symptomatic relief. The combination of a previous gastric procedure and gastroesophageal reflux produces major difficulties in efforts to provide effective
570 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
NEUROGENIC/ HORMONAL
)\ \
REFLUX
GASTROPLASTY TG
--I\
-
Fig 3 . The gastroplasty tube has a low intrinsic tone and assists in preventing reflux w h e n intraperitoneal pressure ("P) increases but is ineffective in the presence of selective gastric pressure increases. The partial fundoplication does not transmit total gastric pressure to the gastroplasty tube. Therefore, increases in gastric pressure may result in reflux. (T(;= gastroplasty tubal tone; T, = sphincteric tone; D = diaphragm; R + R , = transmission of gastric pressure b y the fundoplication; X = loss of pressure transmission due to the incomplete fundoplication.)
symptomatic relief. Seventy patients with this combination were studied by history, radiology, endoscopy, and esophageal manometry, before surgical reflux control. Vomiting was frequent, and there was also a high incidence of
Fig 4 . Again, the gastroplasty tube does not b y itself prevent reflux w h e n there are selective increases in gastric pressure. W i t h the addition of total fundoplication, gastric pressure is totally transmitted around the gastroplasty tube, and reflux control is effective. (T, = gastroplasty tubal pressure; Ts = sphincteric pressure; D = diaphragm; "I' = intraperitoneal pressure; R R , = transmission of gastric pressure b y the fundoplication .)
+
dysphagia and of endoscopic ulcerative esophagitis and stricture. Almost half of these patients had undergone a previous hiatal hernia procedure that had failed to correct reflux. A variety of surgical approaches for reflux control were used in the early stages of this study, including standard Belsey repair, Belsey repair plus esophageal lengthening by circumferential myotomy, and partial fundoplication gastroplasty. Because ineffective reflux control was obtained using these methods, a total fundoplication gastroplasty was used and none of the 22 patients treated in this manner have had reflux recurrence. Bile diversion was reserved for patients with severe bile gastritis. These patients have progressed satisfactorily, and part of their symptom relief is probably related to the diversion. In those who had follow-up endoscopy, most showed effective resolution of gastritis. The combination of total fundoplication gastroplasty and bile diversion, when necessary, is an effective surgical approach to the patient with bile reflux.
4
GASTROPLASTY TG
/
\TS
571 Henderson: Gastroesophageal Reflux after Gastric Operation
References Wickbom G, et al: A 1. Bushkin FL, Deford JW,
clinical evaluation of postoperative alkaline reflux gastritis. Am Surg 41238, 1975 2. Bushkin FL, Woodward AR: Alkaline reflux esophagitis. Major Probl Clin Surg 29:64, 1976 3. Capper WM, Butler TJ, Kilby JP: Reversal of non-Addisonian achlorhydria by a Roux-en-Y loop. Gut 8:612, 1967 4. Castell DO, Harris LD: Hormonal control of gastroesophageal sphincter strength. N Engl J Med 282:886, 1970 5. Cohen S, Lipshutz W: Hormonal regulation of human lower esophageal sphincter competence; interaction of gastrin and secretin. J Clin Invest 50:449, 1971 6. Coppinger WR, Job H, De Lauro JE, et al: Surgical treatment of reflux gastritis and esophagitis. Arch Surg 106:463, 1973 7. Henderson RD: Motor Disorders of the Esophagus. Baltimore, Williams & Wilkins, 1976, P 48 8. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:206, 1977 9. Henderson RD: The gastroplasty tube as a method of reflux control. Can J Surg 21:264, 1978 10. Henderson RD, Magashe FL, Jeejeebhoy KN, et al: Synergism of acid and bile salts in the production of experimental esophagitis. Can J Surg 16:12, 1973 11. Henderson RD, Pearson FG: Preoperative assessment of esophageal pathology. J Thorac Cardiovasc Surg 72:512, 1976 12. Henderson RD, Rodney K: Tone of the gastroesophageal junction; its response to abdominal compression and to swallowing. Can J Surg 14:328, 1971 13. Himal HS: Alkaline gastritis and alkaline esophagitis: a review. Can J Surg 20:403, 1977 14. Ingelfinger FJ: The sphincter that is a sphinx. N Engl J Med 284:1095, 1971 15. Lind JF, Warrian WG, Warkling WJ: Responses of the gastroesophageal junctional zone to increases in abdominal pressure. Can J Surg 9:32, 1966 16. Windsor CWO: Gastroesophageal reflux after partial gastrectomy. Br Med J 2:1233, 1964
Discussion (St. Louis, MO): I was pleased that Dr. Henderson provided me with a copy of the manuscript before the meeting because I found the abstract somewhat confusing and the title of the paper perhaps a little misleading. It suggests that gastric resection per se produces reflux, which, I think, is not the case. Esophageal reflux after a gastric operation means DR. THOMAS B . FERGUSON
to me one of two things: either the patient had a preexisting hiatal hernia that was not repaired at the time of gastric operation or a hiatal hernia was created at the time of gastric operation by mobilization and destruction of the supporting ligaments around the cardioesophageal junction. That preexisting hernia was a factor in Dr. Henderson’s series is suggested by the fact that 50% of the patients had had a “previous hiatal hernia repair.” The paper does not elaborate on these operations, nor is there laboratory or roentgenographic data as to the efficacy of the repairs done before gastrectomy. The second cause for reflux-disruption of the phrenoesophageal ligament-may result from abdominal vagectomy, just as hernia with reflux has been reported after laparotomy for a Heller myotomy to correct achalasia. In fact, 28 of the 70 patients in the present series, or 40%’ had vagectomy. I have no experience with this group of patients, but I polled the gastric surgeons at Barnes Hospital who tell me that in their combined experience the incidence of reflux, bile or otherwise, after a gastric resection is almost nil unless the patient has had an associated hiatal hernia that was not corrected. It would be interesting to know the population base from which these 70 patients were derived. Also, in the experience of the Barnes surgeons the incidence of bile gastritis and esophagitis is very low. They agree that when either does occur, enteroenterostomy is not a good procedure and recommend an isoperistaltic jejunal loop combined with a Nissen fundoplication. On the positive side, Dr. Henderson’s study does point out that when symptomatic reflux is present in association with a previous gastric operation, control of the reflux is more difficult than when uncomplicated hiatal hernia is present. His method of dealing with the problem, namely, gastroplasty combined with Nissen fundoplication, seems from his data to be the most effective method of control. DR. NICHOLAS J . DEMOS (Jersey City, NJ): Out of a group of more than 50 patients having hiatal hemioplasty, 7 who underwent subtotal gastrectomy required an antireflux operation. Our simple gastroplasty combined with total fundoplication is anatomically frugal and avoids a major reduction of the small gastric remnant. We divide neither the stomach nor the short gastric vessels. We simply staple the fundus to prolong the esophagus and obviate extensive esophageal dissection and its complications. A few sutures at the rim of the plicated fundus anchor the organ under the diaphragm. No sutures are made in the fragile esophageal wall at any time. In the very rare instance of an irreducible cardia, our stapling is done lower down in the fundus, which easily achieves an infradiaphragmatic position for the plicated fundus.
572 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
We have not needed additional procedures to enlarge the gastric reservoir, which looks adequate after the frugal fundoplication that we perform. DR. MARK BURTON ORRINGER (Ann Arbor, MI): I would like to commend Dr. Henderson for his outstanding results in this very difficult group of patients. In our hands, the combination of the Collis gastroplasty and Belsey hiatal hernia repair has been associated with a 16% incidence of recurrent reflux symptomatically and almost a 30”/0 incidence of recurrent reflux with pH reflux testing. Therefore we now use the Collis gastroplasty in combination with a 360-degree Nissen fundoplication and have documented much better early reflux control. 1 want now to focus on the real problem under discussion-not the best means of controlling reflux, but rather how to manage the patient with severe epigastric and chest pain, early satiety, regurgitation, vomiting, and weight loss following a prior gastric operation. Gastroesophageal reflux may often be present, but precise documentation of the associated esophageal and gastric pathophysiology is essential in planning a rational program of management. If gastric analysis shows continued acid production after vagotomy or gastric resection, a transthoracic completion vagotomy in addition to an antireflux operation is needed. If there is bile in the stomach at endoscopy or as proved by high sodium concentration in the gastric aspirate, bile gastritis may be the major problem even though there may be no clear evidence of inflammation of the stomach. In this instance, diversion of bile from the stomach may be quite adequate therapy. A Collis-Belsey or Collis-Nissen operation can certainly be performed when there is only a small gastric remnant, and control of reflux can be achieved. But if there is gastric irritation by bile, continued abdominal pain and early satiety may remain incapacitating and require the addition of a later biliary diversion procedure. This added procedure was necessary in 4 of our 12 patients with this condition who were treated with either a Collis-Belsey or Collis-Nissen operation. Finally, the pain in 2 of our postgastrectomy patients was not from reflux esophagitis or bile gastritis, but rather from esophageal spasm that required esophagomyotomy for relief. I would ask Dr. Henderson, then, if he does not think additional diagnostic measures-specifically, gastric analysis, gastroscopy, and a histamine stimulation test-might be indicated to differentiate the patient with peptic esophagitis from the one in whom bile reflux esophagitis or gastritis or a combination of these is occurring. In our experience, this differentiation is of paramount importance in planning successful operative treatment.
DR. JOEL COOPER (Toronto, Ont, Canada): 1, too, congratulate Dr. Henderson on approaching a difficult and very complicated subject. 1 had the good fortune
to train with Mr. Belsey, as did my colleague Dr. Pearson, and 1 was a colleague of Dr. Henderson’s for four years when he was with our division at the Toronto General Hospital. I want to emphasize a point he has already made, namely, that his operation differs in an essential way from the Belsey Mark IV repair. The Belsey repair employs three mattress sutures that incorporate esophagus, stomach, and diaphragm and hold these structures in a fixed relationship. Dr. Henderson’s repair does not utilize these three sutures. Therefore, I think it inappropriate for Dr. Henderson to describe his own, “Henderson,” repair as a Belsey or a modified Belsey repair. Furthermore, it is particularly inappropriate to use the unsatisfactory results obtained with his repair to indict the Belsey Mark IV repair. The differences between the Henderson repair and the Belsey repair are evident in the results. Manometrically, Dr. Henderson has reported that sphincter pressures at one year following operation in his group of Collis-Henderson repairs are belozu the preoperative values. In our series of Collis-Belsey repairs, the sphincter pressures average 2% times the preoperative values, even at one year following operation. Clinically, Dr. Henderson has found an incidence of 25% of recurrent, troublesome symptoms following the Henderson-Collis combination. However, in 214 patients who had a Collis-Belsey repair for complicated problems and who have been followed from two to thirteen years with 96% seen during 1977 for evaluation, only 5% have symptomatic recurrence. Therefore, 1 would ask Dr. Henderson to what he attributes the unsatisfactory results when he adds the Collis gastroplasty to his own repair, particularly since he seems satisfied with the results of his own repair-recurrence of only 3%. If he traces the unsatisfactory results to the Collis gastroplasty, why does he now add that procedure to the Nissen repair? DR. HENDERSON: 1 have been in this argument before, and the topics covered are very familiar. With reference to Dr. Cooper’s remarks, there are some points that are very important. First, the method 1 have used for doing the Belsey or partial fundoplication gastroplasty is identical to that used by Dr. Pearson except for the addition of sutures from the fundus of the stomach to the diaphragm. This does not in any way alter the amount of gastroplasty tube wrapped by stomach and is not associated with a higher incidence of anatomical recurrence. Knowing these facts, 1 am surprised Dr. Cooper considers the point important. Second, the repair done by Dr. Pearson is not a Belsey Mark 1V repair. It incorporates three rows of sutures from gastroplasty to stomach and is clearly a variation of the Belsey technique. This point is displayed in Dr. Pearson’s movie on the Belsey gastroplasty. Third, Dr. Orringer has used an absolutely standard Belsey Mark IV technique and is reporting a
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Henderson: Gastroesophageal Reflux after Gastric Operation
30% incidence of continued reflux. Further, Dr. Pearson was reporting 6.5% bad results last year. He continues to have about the same percentage of bad results but recognizes that 13% of patients have reflux. In my experience, when radiological reflux develops in a large number of patients, additional major symptoms occur. The final point 1 would like to make is that using the standard Belsey repair, Dr. DeMeester has documented a 50% incidence of gastroesophageal reflux in follow-up; 20% of these patients were symptomatic. We have to accept that the Belsey type of partial fundoplication is associated with a high incidence of continued reflux. Mr. Belsey himself does not believe
that his wrap-around has anything to d o with reflux control. Dr. Ferguson’s remarks were very pertinent. He questions whether or not a previous gastric operation produces reflux. Windsor published a paper in 1964 indicating that in 50% of patients who had previously undergone a gastric procedure, reflux does develop. Finally, I want to emphasize that many of the patients in my study are extremely ill. Indeed, many are in the salvage group who were true gastric cripples following a radical Billroth I1 resection. In this type of patient, effective reflux control coupled with bile diversion has produced a very satisfactory result.
Notice from the Editor and the Editorial Board The Editor and members of the Editorial Board are grateful for the assistance given in the review of certain manuscripts during the past year by the following persons: Ralph D. Alley, M.D. Albany, NY
Paul Knight, M.D. Ann Arbor, MI
John A. Penner, M.D. Ann Arbor, MI
Douglas M. Behrendt, M.D. Ann Arbor, MI
Nicholas T. Kouchoukos, M.D. Birmingham, AL
Bertram W. Pitt, M.D. Ann Arbor, MI
David G. Bjoraker, M.D. Ann Arbor, MI
Hiram T. Langston, M.D. Chicago, IL
Amnon Rosenthal, M.D. Ann Arbor, MI
Lawrence I. Bonchek, M.D. Milwaukee, WI
Sidney Levitsky, M.D. Chicago, IL
Stuart S. Sagel, M.D. St. Louis, MO
Allan Brown, M.D. Ann Arbor, MI
Keith G. Lieding, M.D. Ann Arbor, MI
Arthur B. Simon, M.D. Ann Arbor, MI
James F. Brymer, M.D. Ann Arbor, MI
Peter Mansfield, M.D. Seattle, WA
Nicholas P. D. Smyth, M.D. Washington, DC
Richard J. Cleveland, M.D. Boston, MA
James McKenzie, M.D. Piscataway, NY
James E. Stanley, M.D. Ann Arbor, MI
Peter J. Cohen, M.D. Ann Arbor, MI
Hassan Najafi, M.D. Chicago, IL
Albert Starr, M.D. Portland, O R
Arnold G. Coran, M.D. Ann Arbor, MI
John C. Norman, M.D. Houston, TX
Panagiotis N. Symbas, M.D. Atlanta, GA
W. Sterling Edwards, M.D. Albuquerque, NM
Mark B. Orringer, M.D. Ann Arbor, MI
John R. Thornbury, M.D. Ann Arbor, MI
C. Frederick Kittle, M.D. Chicago, IL
F. Griffith Pearson, M.D. Toronto, Ont, Canada
Harold C. Urschel, Jr., M.D. Dallas, TX
