Nissen Fundoplication for Reflux Peptic Esophagitis FREDERIC L. BUSHKIN, M.D., CHARLES L. NEUSTEIN, M.D., TELFAIR H. PARKER, M.D., EDWARD R. WOODWARD, M.D.
One hundred sixty-five patients with reflux peptic esophagitis have been treated by Nissen fundoplication. When compared with a group of 104 patients reported five years ago, the incidence of persistent or recurrent esophagitis remains approximately the same (10% versus 8%). This is consistent with the assumption that the Nissen procedure when initially successful tends to remain so and that late recurrence appears to be uncommon. The unpleasant postoperative sequela which we have termed the "gas-bloat syndrome" was noted in 1971 to be present in the early postoperative period in approximately one-half the patients. Late follow-up, however, averaging four years indicates a marked reduction in this disorder with either absence or clinical insignificance in 87% of patients. Nonetheless, moderate symptoms persist in 11% and severe symptoms requiring active treatment in 2%. Manometric study of the lower esophageal sphincter indicates nearly a three-fold increase in resting pressure following Nissen fundoplication (p < .001). It is hoped that manometric study will provide a more reliable prognostic measure of sphincter restoration than the measurement of pH across the gastroesophageal junction. E REPORTED
in 1971
a
comparison of the tradi-
VYtional posterior crural approximation in the repair of sliding hiatal hernia and reflux esophagitis with the results of the Nissen fundoplication procedure.5 It was found that the latter was more effective in control of reflux esophagitis, but had a higher incidence of undesirable side effects. Further, the addition of vagotomy and pyloroplasty to either procedure had no significant influence on control of esophagitis but did contribute significantly to the chronic morbidity. It was concluded that this additive surgery was not indicated as a regular part of surgery for reflux peptic esophagitis. In addition, it was found that using the method of Tuttle and Grossman4 pH recordings indicated persistent gastroesophageal reflux in many patients in both groups who remained completely asymptomatic. The purposes of the present study are threefold: (1) to determine if the early favorable effects of Nissen fundoplication in the control of peptic esophagitis Presented at the Annual Meeting of the Southern Surgical Association, December 5-8, 1976, Palm Beach, Florida. Submitted for publication: December 10, 1976. This work was supported in part by NIH grant AM-13544.
672
From the Department of Surgery, College of Medicine, University of Florida, Gainesville, Florida
would persist; (2) to determine if the undesirable side effects, particularly the "gas-bloat" syndrome, continued to be a persistent deterrent to use of this method; and (3) to compare the use of manometric evaluation of the lower esophageal sphincter rather than pH measurements in the laboratory determination of return of effective sphincter function. During the period 1964 to 1975 Nissen fundoplication has been utilized in 165 patients with reflux peptic esophagitis. Sixteen patients (10lo) had peptic strictures successfully dilated with mercury weighted bougies prior to surgery. Forty-seven (28%) had historical and/or radiographic evidence of coexisting or prior peptic ulcer, nearly always duodenal in location. Fourteen of these patients had had prior surgery for peptic ulcer. This is approximately three times the incidence of peptic ulcer in the populace at large indicating the likelihood that certain factors common to both diseases probably exist. Thirty-nine patients (24%) had had prior surgery in an attempt to correct gastroesophageal reflux; four of these had had two previously unsuccessful operations (Table 1). One hundred patients were operated upon by the transabdominal approach and 65 by the left transthoracic. The ability to select the approach depending on individual circumstances is an important plus for the fundoplication operation. We have found four circumstances where the transthoracic approach is clearly preferable. First and foremost consists of those patients in whom one or more previous unsuccessful efforts have been made at surgical correction of gastroesophageal reflux. Exposure is clearly superior for mobilization of the esophagus, cardia and fundus, particularly separation from pericardium, diaphragm and the left lobe of the liver. The upper pole of the spleen is in direct vision and can be more certainly protected. Second, we prefer the thoracic approach when radiologic examination indicates that extensive scarring has apparently resulted in acquired
VOl. 185 . NO. 6
TABLE 2. Gas-Bloat Syndrome
TABLE 1. 1964-75-Procedures 16 (10%) 47 (28%) 39 (24%)
673
PEPTIC ESOPHAGITIS
Peptic strictures Present or prior peptic ulcer Prior surgery for reflux esophagitis
short esophagus of some degree. Although we find that in many such cases it is possible to reduce the repair below the diaphragm, this is not possible to assess preoperatively and the thoracic approach permits part or all of the fundoplication to be left above the diaphragm. Clinical and manometric evaluation indicates that the valvuloplastic effect of the fundoplication is equally effective under the latter circumstance. Also in such cases the degree of periesophagitis may be unexpectedly severe, the thoracic approach permitting sharp dissection under direct vision with more certain preservation of the vagal trunks, a step which is usually desired. Third, the transpleural approach has proved to be useful in the obese, thick, and muscular individual where exposure of the lower esophagus and esophagogastric junction is difficult through an abdominal incision. Fourth, we prefer the approach from above in patients who have had left upper abdominal surgery, particularly vagotomy. Again, the exposure is more straightforward, the dissection easier, and we believe also safer. For example, we have had 11 injuries to the spleen in these 165 patients, 9 during transabdominal surgery (9%o) and only two during transthoracic surgery, an incidence of only 3% or one-third that incurred through transabdominal surgery. This difference is magnified when one considers the greater complexity of the cases operated upon by the transthoracic route. There were two operative deaths (1.2%) during this period (not included in the case total), both due to sepsis. One patient developed the delayed onset of mediastinitis and died of sepsis despite drainage. The second patient had a splenic injury necessitating splenectomy and developed subphrenic abscess with delayed blow-out of the ligated splenic artery. We feel it is important to recognize that the Nissen fundoplication is probably never a completely sterile procedure. The fundus of the stomach is so thinwalled that the approximating sutures probably always traverse the lumen of the fundus, thus unavoidably introducing a small amount of contamination. We feel this reinforces the strong desirability of avoiding splenic injury because of its pronounced predisposition toward left subphrenic abscess. This complication occurred in two other patients where splenectomy was performed. There have been 22 deaths during the follow-up period. One patient died of hemorrhage from a marginal
None
78
(49%)
61 18 3 160
(38%) (11%) (2%)
139 Mild Moderate Severe
87%)
ulcer; all others were unrelated to upper gastrointestinal tract disease. Forty-six patients have been lost to current follow-up evaluation having had an average follow-up of 25 months. The follow-up of patients has been by questionnaire, by telephone interview, and by clinic visit. Laboratory evaluation has been attempted pre and postoperatively in all patients, but postoperative radiologic and endoscopic examinations have generally been performed only on symptomatic patients. Average follow-up in the entire group has been four years including the 22 who have expired. Seventy-six patients have been followed for five years or longer. Thirteen patients (8%) have symptoms of persistent or recurrent reflux esophagitis. This compares with an incidence of 10%o in the 104 cases reported in 1971 with a shorter follow-up.5 This would support the contention that initial success in correcting reflux esophagitis by Nissen fundoplication tends to give a permanently satisfactory result. Our failure rate correlates well with the report on a much larger series of cases by Rosetti and Allgower.3 It is of interest that only 9 of these 13 patients have been symptomatic enough to submit to further study. Recurrent esophagitis was documented endoscopically in 7 of the 9 for a proven recurrence rate of 4%. Five of these 7 patients had symptoms severe enough to warrant further surgery. In four of the five patients, it was discovered at the time of reoperation that the fundoplication had disrupted and the gastric fundus had returned to its customary location under the cupula of the left diaphragm. A follow-up on the prevalence of the gas-bloat syndrome was obtained in 160 of the 165 patients. Seventyeight (49o) were completely without symptoms. An additional 61 patients (38%) had only mild and intermittent symptoms which were considered clinically insignificant. Thus, 139 or 87% of the patients did not TABLE 3. Subjective Response
Very pleased
59
)
Satisfied Not satisfied Very displeased
42 12 13 126
80%
10% 10%
674
BUSHKIN AND OTHERS PRE-OP LESP
POST-OP LESP
401
40
0~~~~~~~~~~~~ 30
0
25
30
0 25
0 0 o
-20
20
00000 0 0000
* 15. *
0 0 .15 000 0 000 0 10 0 ~~~~~~~~~~~0 0 0 00
*
* 10' *
@0
*
o0
*
0
E
5.,
Cm
Cm H20
H20
@ 0 0*00
0
0.
* 35 PATIENTS
0 45 PATIENTS
FIG. 1. Effect of Nissen fundoplication lower esophageal sphincter.
on
resting
pressure
in the
have this unpleasant symptom complex to a degree significant to interfere with the surgical result. Eighteen or 11% of the patients, however, had clear-cut symptoms which however did not interfere with nutrition or their usual activities and were considered by the patients to be less troublesome than their previous reflux esophagitis. Three patients (2%) were completely incapacitated by the syndrome. Two were so severely disabled that at their request the fundoplication was dismantled and a posterior gastropexy substituted. The third patient learned self nasogastric intubation and controlled her symptoms adequately until her death from cardiovascular disease (Table 2). Forty-three patients who had complained of the syndrome in 1971 were identified but current responses could be obtained in only 29. In this group, however, 23 of the 29 had either no or insignificant symptoms, 6 moderate symptoms, and none had severe symptoms. When compared with the very high incidence noted in our early follow-up in 1971, it is obvious that the syndrome demonstrates a pronounced tendency toward improvement even to the point of disappearance with longer follow-up. This again corresponds well with the experience reported by Rosetti and Allgower where they noted some degree of the "post-fundoplication syndrome" in 10%o of their long-term cases.3 An attempt was made to determine on clinical
Ann.
Surg. * June 1977
grounds the satisfaction of the patient both in terms of relief from esophagitis and absence of the gas-bloat syndrome. Sufficient data were accumulated in 126 of the 165 cases to make such an assessment. Eighty percent of the patients were satisfied, 10%o were not wholly satisfied, and 10%o were actually displeased with the result of surgery. In the overall clinical analysis of both recurrent esophagitis and the gas-bloat syndrome there were no differences apparent between patients operated upon by the transabdominal versus the transthoracic approach (Table 3). Disenchanted because so many patients after Nissen fundoplication had positive reflux when studied by the Tuttle-Grossman pH probe method, since 1969 we have been utilizing manometric study of the lower esophageal sphincter (LES). Figure 1 compares the resting LES pressure in 35 preoperative patients with 45 postoperative patients. In each case the end expiratory pressure was measured in centimeters of water through each of three open tip tubes with the subject reclining. The average preoperative LES pressure was 5.7 cm H20 with an SEM of 1.4 cm H20. After a Nissen fundoplication 45 patients had an average LES resting pressure of 14.8 cm H20 with an SEM of 1.0 cm H20. Thus, the postoperative resting pressures were approximately triple the preoperative. These differences are highly significant statistically with p < .001. Fifteen patients had preoperative manometry which was repeated three to 6 months postoperatively (Fig. 2). LES pressure averaged 4.3 cm H20 preoperatively and 11.7 cm H20 at the time of the postoperative evaluation. Again, the resting pressure increased approximately three-fold and was highly significant statistically with a 40'
30
L
E
t1
201 t
S
p 10-
0.
I
PRE-OP
0LESP 40
0 POST- OP
LESP
40 I
0 0-0
I 0
8
I
FIG. 2. LESP following fundoplication (individual patients). Resting lower esophageal sphincter pressure in 15 patients before and after Nissen fundoplication.
675
PEPTIC ESOPHAGITIS
Vol. 185 . No. 6
p value of .001. However, it must be noted that in one patient the resting pressure which was originally low remained unchanged and a second patient whose preoperative resting pressure was in the normal range had a marked fall in resting pressure following surgery. These studies correlate well with those reported by Demeester et al.1 and coincide almost precisely with those reported by Ellis et al.2 It is planned in studies under progress to correlate long-term clinical results with long-term LES manometry. As noted in our previous report, vagotomy and pyloroplasty are not useful adjuncts to the surgical treatment of reflux peptic esophagitis and significantly increase morbidity. In the patient with active duodenal ulcer without stenosis combined with reflux peptic esophagitis requiring surgery, we have successfully utilized parietal cell vagotomy combined with Nissen fundoplication and without a drainage operation. In our experience this has completely obviated both "dumping" and post-vagotomy diarrhea. Summary
One hundred sixty-five patients with reflux peptic esophagitis have been treated by Nissen fundoplication. When compared with a comparable group of patients reported five years earlier, the incidence of persistent or recurrent esophagitis remains approximately the same. This is consistent with the assumption that
DISCUSSION
DR. JOHN L. SAWYERS (Nashville, Tennessee): We have gone through an evolutionary process in the surgical management of patients who have esophageal reflux, beginning first with the Allison repair, which concentrated upon repairing the hiatal hernia. Then we became enchanted with Berman's "balanced procedure," and added truncal vagotomy and pyloroplasty to the transabdominal repair of hiatal hernia. Fortunately, these procedures have now been abandoned, and we now perform true antireflux operations-the Belsey, Hill, or Nissen procedures. I wish that I could report to you on a prospective study regarding these procedures, but we have not done such a study; however, our retrospective analysis shows that the Belsey procedure has the highest recurrence rate, running about 15%. Our best results in the treatment of esophageal reflux have been with the Nissen fundoplication; so that we would agree with Dr. Woodward's conclusion. His early report on the high incidence of the gas bloat syndrome caused us some concern, and I am pleased to hear that this has not been a long-term, severe problem. We have never had severe gas bloat problems in our patients following fundoplication. We thought that this was due to a conscientious effort to keep the wraparound from becoming too tight. We check the competency of the valvuloplasty created by the fundoplication by filling the stomach with saline after the wraparound and squeezing it like a bagpipe, to make sure that saline doesn't reflux back up into the esophagus.
the Nissen procedure when initially successful tends to remain so and late recurrence appears to be uncommon. The unpleasant postoperative sequela which we have termed the gas-bloat syndrome was noted in 1971 to be present in the early postoperative period in approximately one-half the patients. Later follow-up, however, averaging four years indicates a marked reduction in this disorder with either absence or clinical insignificance in 87% of patients, moderate symptoms in 11%, and severe symptoms requiring active treatment in 2%. Manometric study of the lower esophageal sphincter indicates nearly a threefold increase in resting pressure following Nissen fundoplication. Currently available data do not permit correlation of this laboratory finding with clinical results. References 1. Demeester, T. R., Johnson, L. F., and Kent, A. H.: Evaluation of Current Operations for the Prevention of Gastroesophageal Reflux. Ann. Surg., 180:511, 1974. 2. Ellis, F. H., Jr., El-Kurd, M. F. A., and Gibb, S. P.: The Effect of Fundoplication on the Lower Esophageal Sphincter. Surg. Gynecol. Obstet., 143:1, 1976. 3. Rosetti, M. and Allgower, M.: Fundoplication for Treatment of Hiatal Hernia. Prog. Surg. (Karger, Basel), 12:1, 1973. 4. Tuttle, S. G. and Grossman, M. I.: Detection of Gastroesophageal Reflux by Simultaneous Measurement of Intraluminal Pressure and pH. Proc. Soc. Exp. Biol. Med., 98: 225, 1958. 5. Woodward, E. R., Thomas, H. F., and McAlhany, J. C.: Comparison of Crural Repair and Nissen Fundoplication in the Treatment of Esophageal Hiatus Hernia with Peptic Esophagitis. Ann. Surg., 173:782, 1971.
For patients who have an associated duodenal ulcer, I think that the addition of proximal gastric vagotomy is ideal in combination with fundoplication. Dr. Woodward and his colleagues have brought us a significant report on the long-term results in a large number of patients, well studied, with the Nissen fundoplication. DR. HIRAM C. POLK, JR. (Nashville, Tennessee): Those of you who have had the opportunity to visit the unique referral situation that Dr. Woodward has built at Gainesville will have some respect for the kinds of cases that he presented to you. These patients presented to you, while smaller in number, are certainly a different group of patients than we have seen. They have a higher proportion of significant coexisting duodenal ulcer disease and a higher proportion of reoperative cases. The threads that are common in this respect is that the valvuloplasty operations, most especially the fundoplication, are useful. The gas bloat syndrome, which has always been infrequent in our experience, seems likely to go away, at least, if you get it. I think that the over-all results that he has presented to you are relatively favorable. I would like to show you two or three slides, to show you how our experience differs and complements Dr. Woodward's. (Slide) I only show this to remind you that if one looks at a group of patients with hiatal hernia and measures their gastric acid, it's normal unless you include patients who have duodenal ulcer as well.
One hundred sixty-five patients with reflux peptic esophagitis have been treated by Nissen fundoplication. When compared with a group of 104 patients reported five years ago, the incidence of persistent or recurrent esophagitis remains approximately the same (10% versus 8%). This is consistent with the assumption that the Nissen procedure when initially successful tends to remain so and that late recurrence appears to be uncommon. The unpleasant postoperative sequela which we have termed the "gas-bloat syndrome" was noted in 1971 to be present in the early postoperative period in approximately one-half the patients. Late follow-up, however, averaging four years indicates a marked reduction in this disorder with either absence or clinical insignificance in 87% of patients. Nonetheless, moderate symptoms persist in 11% and severe symptoms requiring active treatment in 2%. Manometric study of the lower esophageal sphincter indicates nearly a three-fold increase in resting pressure following Nissen fundoplication (p < .001). It is hoped that manometric study will provide a more reliable prognostic measure of sphincter restoration than the measurement of pH across the gastroesophageal junction. E REPORTED
in 1971
a
comparison of the tradi-
VYtional posterior crural approximation in the repair of sliding hiatal hernia and reflux esophagitis with the results of the Nissen fundoplication procedure.5 It was found that the latter was more effective in control of reflux esophagitis, but had a higher incidence of undesirable side effects. Further, the addition of vagotomy and pyloroplasty to either procedure had no significant influence on control of esophagitis but did contribute significantly to the chronic morbidity. It was concluded that this additive surgery was not indicated as a regular part of surgery for reflux peptic esophagitis. In addition, it was found that using the method of Tuttle and Grossman4 pH recordings indicated persistent gastroesophageal reflux in many patients in both groups who remained completely asymptomatic. The purposes of the present study are threefold: (1) to determine if the early favorable effects of Nissen fundoplication in the control of peptic esophagitis Presented at the Annual Meeting of the Southern Surgical Association, December 5-8, 1976, Palm Beach, Florida. Submitted for publication: December 10, 1976. This work was supported in part by NIH grant AM-13544.
672
From the Department of Surgery, College of Medicine, University of Florida, Gainesville, Florida
would persist; (2) to determine if the undesirable side effects, particularly the "gas-bloat" syndrome, continued to be a persistent deterrent to use of this method; and (3) to compare the use of manometric evaluation of the lower esophageal sphincter rather than pH measurements in the laboratory determination of return of effective sphincter function. During the period 1964 to 1975 Nissen fundoplication has been utilized in 165 patients with reflux peptic esophagitis. Sixteen patients (10lo) had peptic strictures successfully dilated with mercury weighted bougies prior to surgery. Forty-seven (28%) had historical and/or radiographic evidence of coexisting or prior peptic ulcer, nearly always duodenal in location. Fourteen of these patients had had prior surgery for peptic ulcer. This is approximately three times the incidence of peptic ulcer in the populace at large indicating the likelihood that certain factors common to both diseases probably exist. Thirty-nine patients (24%) had had prior surgery in an attempt to correct gastroesophageal reflux; four of these had had two previously unsuccessful operations (Table 1). One hundred patients were operated upon by the transabdominal approach and 65 by the left transthoracic. The ability to select the approach depending on individual circumstances is an important plus for the fundoplication operation. We have found four circumstances where the transthoracic approach is clearly preferable. First and foremost consists of those patients in whom one or more previous unsuccessful efforts have been made at surgical correction of gastroesophageal reflux. Exposure is clearly superior for mobilization of the esophagus, cardia and fundus, particularly separation from pericardium, diaphragm and the left lobe of the liver. The upper pole of the spleen is in direct vision and can be more certainly protected. Second, we prefer the thoracic approach when radiologic examination indicates that extensive scarring has apparently resulted in acquired
VOl. 185 . NO. 6
TABLE 2. Gas-Bloat Syndrome
TABLE 1. 1964-75-Procedures 16 (10%) 47 (28%) 39 (24%)
673
PEPTIC ESOPHAGITIS
Peptic strictures Present or prior peptic ulcer Prior surgery for reflux esophagitis
short esophagus of some degree. Although we find that in many such cases it is possible to reduce the repair below the diaphragm, this is not possible to assess preoperatively and the thoracic approach permits part or all of the fundoplication to be left above the diaphragm. Clinical and manometric evaluation indicates that the valvuloplastic effect of the fundoplication is equally effective under the latter circumstance. Also in such cases the degree of periesophagitis may be unexpectedly severe, the thoracic approach permitting sharp dissection under direct vision with more certain preservation of the vagal trunks, a step which is usually desired. Third, the transpleural approach has proved to be useful in the obese, thick, and muscular individual where exposure of the lower esophagus and esophagogastric junction is difficult through an abdominal incision. Fourth, we prefer the approach from above in patients who have had left upper abdominal surgery, particularly vagotomy. Again, the exposure is more straightforward, the dissection easier, and we believe also safer. For example, we have had 11 injuries to the spleen in these 165 patients, 9 during transabdominal surgery (9%o) and only two during transthoracic surgery, an incidence of only 3% or one-third that incurred through transabdominal surgery. This difference is magnified when one considers the greater complexity of the cases operated upon by the transthoracic route. There were two operative deaths (1.2%) during this period (not included in the case total), both due to sepsis. One patient developed the delayed onset of mediastinitis and died of sepsis despite drainage. The second patient had a splenic injury necessitating splenectomy and developed subphrenic abscess with delayed blow-out of the ligated splenic artery. We feel it is important to recognize that the Nissen fundoplication is probably never a completely sterile procedure. The fundus of the stomach is so thinwalled that the approximating sutures probably always traverse the lumen of the fundus, thus unavoidably introducing a small amount of contamination. We feel this reinforces the strong desirability of avoiding splenic injury because of its pronounced predisposition toward left subphrenic abscess. This complication occurred in two other patients where splenectomy was performed. There have been 22 deaths during the follow-up period. One patient died of hemorrhage from a marginal
None
78
(49%)
61 18 3 160
(38%) (11%) (2%)
139 Mild Moderate Severe
87%)
ulcer; all others were unrelated to upper gastrointestinal tract disease. Forty-six patients have been lost to current follow-up evaluation having had an average follow-up of 25 months. The follow-up of patients has been by questionnaire, by telephone interview, and by clinic visit. Laboratory evaluation has been attempted pre and postoperatively in all patients, but postoperative radiologic and endoscopic examinations have generally been performed only on symptomatic patients. Average follow-up in the entire group has been four years including the 22 who have expired. Seventy-six patients have been followed for five years or longer. Thirteen patients (8%) have symptoms of persistent or recurrent reflux esophagitis. This compares with an incidence of 10%o in the 104 cases reported in 1971 with a shorter follow-up.5 This would support the contention that initial success in correcting reflux esophagitis by Nissen fundoplication tends to give a permanently satisfactory result. Our failure rate correlates well with the report on a much larger series of cases by Rosetti and Allgower.3 It is of interest that only 9 of these 13 patients have been symptomatic enough to submit to further study. Recurrent esophagitis was documented endoscopically in 7 of the 9 for a proven recurrence rate of 4%. Five of these 7 patients had symptoms severe enough to warrant further surgery. In four of the five patients, it was discovered at the time of reoperation that the fundoplication had disrupted and the gastric fundus had returned to its customary location under the cupula of the left diaphragm. A follow-up on the prevalence of the gas-bloat syndrome was obtained in 160 of the 165 patients. Seventyeight (49o) were completely without symptoms. An additional 61 patients (38%) had only mild and intermittent symptoms which were considered clinically insignificant. Thus, 139 or 87% of the patients did not TABLE 3. Subjective Response
Very pleased
59
)
Satisfied Not satisfied Very displeased
42 12 13 126
80%
10% 10%
674
BUSHKIN AND OTHERS PRE-OP LESP
POST-OP LESP
401
40
0~~~~~~~~~~~~ 30
0
25
30
0 25
0 0 o
-20
20
00000 0 0000
* 15. *
0 0 .15 000 0 000 0 10 0 ~~~~~~~~~~~0 0 0 00
*
* 10' *
@0
*
o0
*
0
E
5.,
Cm
Cm H20
H20
@ 0 0*00
0
0.
* 35 PATIENTS
0 45 PATIENTS
FIG. 1. Effect of Nissen fundoplication lower esophageal sphincter.
on
resting
pressure
in the
have this unpleasant symptom complex to a degree significant to interfere with the surgical result. Eighteen or 11% of the patients, however, had clear-cut symptoms which however did not interfere with nutrition or their usual activities and were considered by the patients to be less troublesome than their previous reflux esophagitis. Three patients (2%) were completely incapacitated by the syndrome. Two were so severely disabled that at their request the fundoplication was dismantled and a posterior gastropexy substituted. The third patient learned self nasogastric intubation and controlled her symptoms adequately until her death from cardiovascular disease (Table 2). Forty-three patients who had complained of the syndrome in 1971 were identified but current responses could be obtained in only 29. In this group, however, 23 of the 29 had either no or insignificant symptoms, 6 moderate symptoms, and none had severe symptoms. When compared with the very high incidence noted in our early follow-up in 1971, it is obvious that the syndrome demonstrates a pronounced tendency toward improvement even to the point of disappearance with longer follow-up. This again corresponds well with the experience reported by Rosetti and Allgower where they noted some degree of the "post-fundoplication syndrome" in 10%o of their long-term cases.3 An attempt was made to determine on clinical
Ann.
Surg. * June 1977
grounds the satisfaction of the patient both in terms of relief from esophagitis and absence of the gas-bloat syndrome. Sufficient data were accumulated in 126 of the 165 cases to make such an assessment. Eighty percent of the patients were satisfied, 10%o were not wholly satisfied, and 10%o were actually displeased with the result of surgery. In the overall clinical analysis of both recurrent esophagitis and the gas-bloat syndrome there were no differences apparent between patients operated upon by the transabdominal versus the transthoracic approach (Table 3). Disenchanted because so many patients after Nissen fundoplication had positive reflux when studied by the Tuttle-Grossman pH probe method, since 1969 we have been utilizing manometric study of the lower esophageal sphincter (LES). Figure 1 compares the resting LES pressure in 35 preoperative patients with 45 postoperative patients. In each case the end expiratory pressure was measured in centimeters of water through each of three open tip tubes with the subject reclining. The average preoperative LES pressure was 5.7 cm H20 with an SEM of 1.4 cm H20. After a Nissen fundoplication 45 patients had an average LES resting pressure of 14.8 cm H20 with an SEM of 1.0 cm H20. Thus, the postoperative resting pressures were approximately triple the preoperative. These differences are highly significant statistically with p < .001. Fifteen patients had preoperative manometry which was repeated three to 6 months postoperatively (Fig. 2). LES pressure averaged 4.3 cm H20 preoperatively and 11.7 cm H20 at the time of the postoperative evaluation. Again, the resting pressure increased approximately three-fold and was highly significant statistically with a 40'
30
L
E
t1
201 t
S
p 10-
0.
I
PRE-OP
0LESP 40
0 POST- OP
LESP
40 I
0 0-0
I 0
8
I
FIG. 2. LESP following fundoplication (individual patients). Resting lower esophageal sphincter pressure in 15 patients before and after Nissen fundoplication.
675
PEPTIC ESOPHAGITIS
Vol. 185 . No. 6
p value of .001. However, it must be noted that in one patient the resting pressure which was originally low remained unchanged and a second patient whose preoperative resting pressure was in the normal range had a marked fall in resting pressure following surgery. These studies correlate well with those reported by Demeester et al.1 and coincide almost precisely with those reported by Ellis et al.2 It is planned in studies under progress to correlate long-term clinical results with long-term LES manometry. As noted in our previous report, vagotomy and pyloroplasty are not useful adjuncts to the surgical treatment of reflux peptic esophagitis and significantly increase morbidity. In the patient with active duodenal ulcer without stenosis combined with reflux peptic esophagitis requiring surgery, we have successfully utilized parietal cell vagotomy combined with Nissen fundoplication and without a drainage operation. In our experience this has completely obviated both "dumping" and post-vagotomy diarrhea. Summary
One hundred sixty-five patients with reflux peptic esophagitis have been treated by Nissen fundoplication. When compared with a comparable group of patients reported five years earlier, the incidence of persistent or recurrent esophagitis remains approximately the same. This is consistent with the assumption that
DISCUSSION
DR. JOHN L. SAWYERS (Nashville, Tennessee): We have gone through an evolutionary process in the surgical management of patients who have esophageal reflux, beginning first with the Allison repair, which concentrated upon repairing the hiatal hernia. Then we became enchanted with Berman's "balanced procedure," and added truncal vagotomy and pyloroplasty to the transabdominal repair of hiatal hernia. Fortunately, these procedures have now been abandoned, and we now perform true antireflux operations-the Belsey, Hill, or Nissen procedures. I wish that I could report to you on a prospective study regarding these procedures, but we have not done such a study; however, our retrospective analysis shows that the Belsey procedure has the highest recurrence rate, running about 15%. Our best results in the treatment of esophageal reflux have been with the Nissen fundoplication; so that we would agree with Dr. Woodward's conclusion. His early report on the high incidence of the gas bloat syndrome caused us some concern, and I am pleased to hear that this has not been a long-term, severe problem. We have never had severe gas bloat problems in our patients following fundoplication. We thought that this was due to a conscientious effort to keep the wraparound from becoming too tight. We check the competency of the valvuloplasty created by the fundoplication by filling the stomach with saline after the wraparound and squeezing it like a bagpipe, to make sure that saline doesn't reflux back up into the esophagus.
the Nissen procedure when initially successful tends to remain so and late recurrence appears to be uncommon. The unpleasant postoperative sequela which we have termed the gas-bloat syndrome was noted in 1971 to be present in the early postoperative period in approximately one-half the patients. Later follow-up, however, averaging four years indicates a marked reduction in this disorder with either absence or clinical insignificance in 87% of patients, moderate symptoms in 11%, and severe symptoms requiring active treatment in 2%. Manometric study of the lower esophageal sphincter indicates nearly a threefold increase in resting pressure following Nissen fundoplication. Currently available data do not permit correlation of this laboratory finding with clinical results. References 1. Demeester, T. R., Johnson, L. F., and Kent, A. H.: Evaluation of Current Operations for the Prevention of Gastroesophageal Reflux. Ann. Surg., 180:511, 1974. 2. Ellis, F. H., Jr., El-Kurd, M. F. A., and Gibb, S. P.: The Effect of Fundoplication on the Lower Esophageal Sphincter. Surg. Gynecol. Obstet., 143:1, 1976. 3. Rosetti, M. and Allgower, M.: Fundoplication for Treatment of Hiatal Hernia. Prog. Surg. (Karger, Basel), 12:1, 1973. 4. Tuttle, S. G. and Grossman, M. I.: Detection of Gastroesophageal Reflux by Simultaneous Measurement of Intraluminal Pressure and pH. Proc. Soc. Exp. Biol. Med., 98: 225, 1958. 5. Woodward, E. R., Thomas, H. F., and McAlhany, J. C.: Comparison of Crural Repair and Nissen Fundoplication in the Treatment of Esophageal Hiatus Hernia with Peptic Esophagitis. Ann. Surg., 173:782, 1971.
For patients who have an associated duodenal ulcer, I think that the addition of proximal gastric vagotomy is ideal in combination with fundoplication. Dr. Woodward and his colleagues have brought us a significant report on the long-term results in a large number of patients, well studied, with the Nissen fundoplication. DR. HIRAM C. POLK, JR. (Nashville, Tennessee): Those of you who have had the opportunity to visit the unique referral situation that Dr. Woodward has built at Gainesville will have some respect for the kinds of cases that he presented to you. These patients presented to you, while smaller in number, are certainly a different group of patients than we have seen. They have a higher proportion of significant coexisting duodenal ulcer disease and a higher proportion of reoperative cases. The threads that are common in this respect is that the valvuloplasty operations, most especially the fundoplication, are useful. The gas bloat syndrome, which has always been infrequent in our experience, seems likely to go away, at least, if you get it. I think that the over-all results that he has presented to you are relatively favorable. I would like to show you two or three slides, to show you how our experience differs and complements Dr. Woodward's. (Slide) I only show this to remind you that if one looks at a group of patients with hiatal hernia and measures their gastric acid, it's normal unless you include patients who have duodenal ulcer as well.
