| dc.description.abstract | The pathogenesis in GORD is unclear. Motor dysfunctions in the oesophageal body, as well as in the gastro- oesophageal junction, are commonly seen. An important question is whether these motor disturbances are of primary pathogenetic nature or appear as a consequence of the mucosal inflammation caused by chronic reflux? Antireflux surgery is effective concerning reflux control. It is, however, unclear whether a partial fundoplication (Toupet, 180- 200( fundic wrap) is as effective as a total fundoplication (Nissen- Rossetti, 360( fundoplication). One method to establish the efficacy of the surgical therapy is to carry out studies with long-term follow-up, and evaluate the degree of reflux and symptom control at predefined time intervals. Furthermore, a pivotal question is how to select patients with GORD to optimise the clinical results and to minimise the postoperative sequelae? Methods: The background patient material consisted of 137 chronic GORD patients suitable for surgical therapy. They were randomised to either a total or a partial fundoplication. The postoperative follow up extended to at the most 5 years and were carried out, at regular time intervals, by an independent physician. The investigations included clinical assessment, upper endoscopy, 24 hour pH monitoring, and manometry of the oesophageal body as well as of the lower oesophageal sphincter (LOS). For assessment of the LOS tone and function two techniques were used. Firstly the LOS tone was assessed by use of a îstation pull throughî technique and was carried out by a water perfused triple lumen catheter with 3 side holes positioned 120( apart. In order to assess LOS tone over long time periods and to study the transient lower sphincter relaxations (TLOSR:s), we used the îsleeveî technique. To trigger TLOSR:s, 750 ml of air was insufflated into the stomach. The manometric investigation of the oesophageal body was performed by use of a water perfused catheter assembly with lateral side openings at 5 cm intervals. The primary peristalsis was analysed after water swallows and secondary peristalsis after boluses of air injected into the mid oesophagus. Interpretation and calculation of all manometric findings were carried out by one person, without knowledge of the nature of surgery undertaken in each patient and also unaware of the group affiliation of the subject. Results: Since no change in the motor function with time was observed, despite postoperative perfect reflux control, our results did not support the hypothesis that the motor dysfunction arises as a result of transmural inflammation caused by uncontrolled reflux. Furthermore, no apparent change in the deficient ability to excite secondary peristalsis was observed after successful surgery. We were unable to observe any correlation between findings at preoperative manometry and the postoperative clinical outcome, irrespective of the type of fundoplication. The two surgical procedures (total and partial fundoplication, respectively), were equally effective concerning reflux control. However, we demonstrated important differences in that symptoms of obstructive nature in the early postoperative period and complaints of rectal flatulence later during the follow-up period were more frequently seen after a total fundoplication. This favourable effect of the partial fundoplication could be explained by the fact that a partial fundic wrap was followed by a lower basal tone in the LOS, lower nadir pressure at maximal LOS relaxation and a greater ability to vent air from the stomach. Conclusions: Preoperative manometry is not the tool, which allows us to tailor the surgical procedure in order to minimise postoperative side effects. The partial fundoplication (Toupet fundoplication) seems to be superior to the total fundoplication (Nissen- Rossetti) depending on equal effectiveness in controlling GORD but fewer adverse sequelae. Finally our data on motor function of the oesophagus add to the notion that motor dysfunctions observed in GORD are of primary pathogenetic nature. | en |
