Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Esophagography predicts favorable outcomes after laparoscopic Nissen fundoplication for patients with esophageal dysmotility

BACKGROUND

We undertook this study to determine if clearance of a food bolus at preoperative esophagography predicts acceptable outcomes after laparoscopic Nissen fundoplication for patients with manometrically abnormal esophageal motility.

STUDY DESIGN

Patients with gastroesophageal reflux disease (GERD) or symptomatic hiatal hernia with evidence of esophageal dysmotility by stationary manometry underwent videoesophagography to document the ability of their esophagus to clear food boluses of varying consistencies. Sixty-six patients were identified who had manometric dysmotility yet were able to clear a food bolus at esophagography, and subsequently underwent laparoscopic Nissen fundoplication. These patients were compared with 100 randomly selected patients with normal motility who underwent laparoscopic Nissen fundoplication. Symptom reduction and satisfaction were assessed through followup. Patients with normal motility were compared with those with manometrically moderate and severe dysmotility.

RESULTS

Preoperative patient demographic data, symptoms, and symptom scores were similar among patients with normal motility and moderate or severe dysmotility. After fundoplication, symptom reduction was notable for all patients regardless of preoperative motility (p < 0.01, paired Student's t-test). There was no notable difference in postoperative symptom scores (p = NS, Kruskal-Wallis ANOVA) or in patient satisfaction (p = NS, chi-square analysis) among patients stratified by esophageal motility.

CONCLUSIONS

Patients with esophageal dysmotility documented by manometry who are able to clear a food bolus at contrast esophagography, have functional results after laparoscopic Nissen fundoplication similar to patients with normal motility. Preoperative esophagography predicts successful outcomes after laparoscopic Nissen fundoplication for patients with manometric esophageal dysmotility.

Effects of manometrically discovered nonspecific motility disorders of the esophagus on the outcomes of antireflux surgery

Nonspecific motility disorders (NMDs) of the esophagus are common manometric findings in patients evaluated for gastroesophageal reflux disease (GERD). However, it is unclear how these disorders affect the outcomes of antireflux surgery. The purpose of this study was to assess symptomatic outcomes of patients with and without NMDs undergoing surgical treatment for GERD. A prospectively gathered database of all patients undergoing antireflux surgery was retrospectively reviewed for preoperative symptoms, symptom severity using the GERD-HRQL (best score 0, worst score 50), esophageal manometry measurements, presence of NMD, type of operation, any transient or permanent postoperative dysphagia, severity of postoperative dysphagia (best score 0, worst score 5), and postoperative symptom severity. A total of 239 patients were studied; 24% had a NMD identified by preoperative esophageal manometry, and 17% of this +NMD group had preoperative dysphagia or atypical chest/epigastric pain compared to 28% of those without a NMD (-NMD group) (P=NS). Preoperative symptom scores were +NMD 33 vs. -NMD 27 (P=0.01). Postoperative symptom scores were +NMD 5 vs. -NMD 3 (P=NS). There were no differences in preoperative or postoperative dysphagia scores. Transient postoperative dysphagia was 15.8% in the +NMD group vs. 16.4% in the -NMD group (P=NS). Postoperative dilation was 0% in the +NMD group vs. 2% in the -NMD group (P=NS). Manometrically discovered NMDs do not appear to affect preoperative symptoms or symptomatic outcomes of patients surgically treated for GERD. These findings my reflect the severity of GERD and may improve with antireflux surgery.

Antireflux surgery for Barrett's oesophagus

Barrett's oesophagus is usually the result of severe reflux disease. Relief of reflux symptoms is the primary aim of treatment in patients with Barrett's oesophagus who do not have high-grade dysplasia. Some studies with medium-term (2-5 years) follow up show that antireflux surgery can provide good or excellent symptom control, with normal oesophageal acid exposure, in more than 90% of patients with Barrett's oesophagus. Antireflux surgery, but not medical therapy, can also reduce duodenal nonacid reflux to normal levels. There is no conclusive evidence that antireflux surgery can prevent the development of dysplasia or cancer, or that it can reliably induce regression of dysplasia, and patients with Barrett's oesophagus should therefore remain in a surveillance programme after operation. Some data suggest that antireflux surgery can prevent the development of intestinal metaplasia (IM) in patients with reflux disease but no IM. The combination of antireflux surgery plus an endoscopic ablation procedure is a promising treatment for patients with Barrett's oesophagus with low-grade dysplasia.

Surgical and endoscopic treatment of gastroesophageal reflux disease

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.

Longterm results of esophageal myotomy for achalasia

BACKGROUND

Achalasia is a progressive, noncurable, motor disorder of the esophagus. Myotomy of the distal esophagus is the principal method of providing palliation. A major controversy is the necessity for a complementary antireflux procedure.

STUDY DESIGN

Forty-two patients were studied by clinical history manometrically, roentgenographically, and endoscopically. Transabdominal Heller myotomy is the preferred approach. Nine patients had Nissen fundoplication and parietal cell vagotomy (group 1), and 16 had posterior gastropexy and parietal cell vagotomy (group II). Initially 16 of 17 patients underwent transthoracic Heller myotomy without fundoplication (group III). Twenty-five patients were followed a mean of 10 years (range 5 to 26 years).

RESULTS

One postoperative death was from adult respiratory distress. Results in group I were excellent in five, good in three, and fair in one. The patient with a fair result developed a diverticulum at the myotomy site and significant reflux at 9 years. Results in group II patients were excellent in 2, good in 11, there was 1 operative death, and no followup in 1. Of the 17 patients in group III, 3 had resection of an esophageal diverticulum, and 3 had closure of esophageal perforation caused by pneumatic dilatation. Results in the 13 patients followed were excellent in 6, good in 5, and poor in 2.

CONCLUSIONS

There is no statistical difference in results by chi-square analysis between transthoracic Heller myotomy without fundoplication and transabdominal Heller myotomy with parietal cell vagotomy and Nissen fundoplication or posterior gastropexy.