Operations for gastro-esophageal reflux disease. Studies on mode of action and how to improve functional outcomes

Abstract

Fundoplication operations have gained wide acceptance as an effective and durable treatment for chronic gastro-esophageal reflux disease (GERD). However, further valid data are required on the long-term efficacy and above all the corresponding profile of operation specific side effects. Depending on the magnitude of the postfundoplication problems, there is an obvious need for well-controlled data on how the design of a fundoplication procedure should be further developed in order to minimise the side effects without compromising with the level of reflux control.Patients and methodsThe present investigation incorporates three series of chronic GERD patients who were found suitable of antireflux surgery. Originally 137 patients were randomised to be either on open total fundoplication (Nissen-Rossetti) or a posterior partial wrap (Toupet). This group was subsequently followed during a median period of almost 12 years. Secondly 99 chronic GERD patients were randomly allocated to have a laparoscopic total fundoplication with or without a complete mobilisation of the fundus by division of all short gastric vessels. Finally 95 patients had either a Toupet partial fundoplication or an anterior partial wrap according to Watson. These operations were done laparoscopically. In the pre and postoperative evaluation all the patients were investigated by standardised questionnaire to assess symptoms, manometry and ambulatory 24-hour pH monitoring as well as endoscopy. In the postoperative setting endoscopy was only regularly used in study I. In a subset of patients a more extensive manometric protocol was followed, incorporating the use of sleeve sensor and gasdistension of the stomach.ResultsA posterior partial fundoplication was found to be equally effective in controlling GERD as a total fundic wrap. The downside of the latter procedure was, however, that gasbloat like complaints were more frequent and remained fairly stable even after 12 years. The most frequent complain was from rectal flatus. When doing a laparoscopic total fundoplication no major clinical differences emerged between the two operative approaches. However, in patients with intact short gastric vessels data were obtained to suggest better abilities to vent air from the stomach (more TLESRs on distension). An anterior partial fundoplication was clearly inferior to a laparoscopic Toupet procedure in terms of reflux control without major differences in the profile of post fundoplication complaints.ConclusionA posterior fundoplication has obvious advantages over a total fundoplication with fewer associated postfundoplication symptoms with maintained high level of reflux control. An anterior partial wrap does not correct the physiology of the gastroesophageal junction nor the gastroesophageal reflux. When doing a total fundoplication there seems to be no advantage by mobilising the fundus through division of all short gastric vessels.