Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis

  • D. Oleynikov
  • T. R. Eubanks
  • B. K. Oelschlager
  • C. A. Pellegrini
Original Articles

Abstract

Background

Partial fundoplication has traditionally been indicated for patients with gastroesophageal reflux disease (GERD) who have defective peristalsis (DP). Because partial fundoplication had been reported to be a less effective means of controlling acid reflux than total fundoplication, in 1997 we stopped performing partial fundoplication for patients with DP and switched to a floppy total fundoplication. This study analyzes the results of our new strategy and compares it to our former approach.

Methods

We performed a partial fundoplication in 39 patients with DP (distal amplitude>40% of swallows) between 1994 and 1997 and a total fundoplication in 57 patients between 1997 and 2000. Symptoms scores derived from a standard questionnaire with a scale of 0–4, manometry, and 24-h pH monitoring were completed preoperatively in 86 patients and postoperatively in 40 patients.

Results

Heartburn scores improved in both groups (preoperative, 2.8; postoperative, 0.65; p<0.05). Dysphagia was 1.1 preoperatively and 0.62 postoperatively (p=NS) in the partial fundoplication group and 1.2 preoperatively and 0.3 postoperatively (p<0.05) in the total fundoplication group. Furthermore, none of the patients in the total fundoplication group developed new dysphagia and none required dilatation. Distal esophageal acid exposure normalized in both groups after operative treatment (median DeMeester score: 72.3 vs 11.3, p<0.05, For partial fundoplication; 57.1 vs 6.3, p<0.05, For total fundoplication). Distal esophageal amplitudes averaged 27.8 mmHg preoperatively and 35.6 mmHg (p=NS) in the partial fundoplication group, they averaged 28.2 mmHg preoperatively vs 49.0 mmHg postoperatively (p<0.005) in the total fundoplication group. Two patients with a previous partial fundoplication required a conversion to a total fundoplication. No postoperative dilation was required in either group.

Conclusions

Our study shows that both a partial and a total fundoplication are effective in controlling the symptoms of GERD in patients with defective peristalsis. Dysphagia improves significantly after total fundoplication but not after partial fundoplication. Although both operations brought acid reflux to within normal limits, the effect was more pronounced with total fundoplication. Total, but not partial, fundoplication produced a significant increase in amplitude of esophageal peristalsis, which may explain the subjective improvement during deglution. Therefore, fundoplication should be the treatment of choice in patients with GERD and defective peristalsis.

Key words

Gastroesophageal reflux disease (GERD) Total fundoplication Partial fundoplication Toupet fundoplication Dysphagia Esophageal motility Defective peristalsis 

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References

  1. 1.
    Baigrie RJ, Watson DI, Myers JC, Jamieson GG (1997) Outcome of laparoscopic Nissen fundoplication in patients with disordered preoperative peristalsis. Gut 40: 381–385PubMedGoogle Scholar
  2. 2.
    Beckingham IJ, Cariem AK, Bornman PC, Callanan MD, Louw JA (1998) Oesophageal dysmotility is not associated with poor outcome after laparoscopic Nissen fundoplication. Br J Surg 85: 1290–1293PubMedCrossRefGoogle Scholar
  3. 3.
    Bell RC, Hanna P, Mills MR, Bowrey D (1999) Patterns of success and failure with laparoscopic Toupet fundoplication. Surg Endosc 13: 1189–1194PubMedCrossRefGoogle Scholar
  4. 4.
    DeMeester TR, Stein HJ (1992) Minimizing the side effects of antireflux surgery. World J Surg 16: 335–336PubMedCrossRefGoogle Scholar
  5. 5.
    Eubanks TR, Omelanczuk P, Richards C, Pohl D, Pellegrini CA (2000) Outcomes of laparoscopic antireflux procedures. Am J Surg 179: 391–395PubMedCrossRefGoogle Scholar
  6. 6.
    Farrell TM, Archer SB, Galloway KD, Branum GD, Smith CD, Hunter JG (2000) Heartburn is more likely to recur after Toupet fundoplication than Nissen fundoplication. Am Surg 66: 229–237PubMedGoogle Scholar
  7. 7.
    Guarner V (1990) The posterior fundoplasty in the treatment of gastroesophageal reflux. Surg Gynecol Obstet 170: 451–452PubMedGoogle Scholar
  8. 8.
    Horgan S, Pellegrini CA (1997) Surgical treatment of gastroesophageal reflux disease. Surg Clin North Am 77: 1063–1082PubMedCrossRefGoogle Scholar
  9. 9.
    Horvath KD, Jobe BA, Herron DM, Swanstrom LL (1999) Laparoscopic Toupet fundoplication is an inadequate procedure for patients with severe reflux disease. J Gastrointest Surg 3: 583–591PubMedCrossRefGoogle Scholar
  10. 10.
    Jobe BA, Wallace J, Hansen PD, Swanstrom LL (1997) Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux. Surg Endosc 11: 1080–1083PubMedCrossRefGoogle Scholar
  11. 11.
    Joelsson BE, DeMeester TR, Skinner DB, LaFontaine E, Waters PF, O’Sullivan GC (1982) The role of the esophageal body in the antireflux mechanism. Surgery 92: 417–424PubMedGoogle Scholar
  12. 12.
    Johnson LF, DeMeester TR (1986) Development of the 24-hour intraesophageal pH monitoring composite scoring system. J Clin Gastroenterol 8 (supp 11): 52–58PubMedCrossRefGoogle Scholar
  13. 13.
    Lund RJ, Wetcher GJ, Raiser F, Glaser K, Perdikis G, Gadenstatter M, Katada N, Filipi CJ, Hinder RA (1997) Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility. J Gastrointest Surg 1: 301–308PubMedCrossRefGoogle Scholar
  14. 14.
    Patti MG, De Pinto M, de Bellis M, Arcerito M, Tong J, Wang A, Mulvihill SJ, Way LW (1997) Comparison of laparoscopic total and partial fundoplication for gastroesophageal reflux. J Gastrointest Surg 1: 309–315PubMedCrossRefGoogle Scholar
  15. 15.
    Pellegrini CA (1995) Therapy for gastroesophageal reflux disease: the new kid on the block. J Am Coll Surg 180: 485–487PubMedGoogle Scholar
  16. 16.
    Pessaux P, Arnaud J, Ghavami B, Flament JB, Trebuchet G, Meyer C, Huten N, Champault G (2000) Laparoscopic antireflux surgery: comparative study of Nissen, Nissen-Rossetti, and Toupet fundoplication. Surg Endosc 14: 1024–1027PubMedCrossRefGoogle Scholar
  17. 17.
    Peters JH, Heimbucher J, Kauer WK, Incarbone R, Bremner CG, DeMeester TR (1995) Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication. J Am Coll Surg 180: 385–393PubMedGoogle Scholar
  18. 18.
    Reardon PR, Scarborough T, Matthews B, Preciado A, Marti JL, Brunicardi FC (2000) Laparoscopic Nissen fundoplication: a technique for the easy and precise manufacture of a true fundoplication. Surg Endosc 14: 298–299PubMedCrossRefGoogle Scholar
  19. 19.
    Rydberg L, Ruth M, Abrahamsson H, Lundell L (1999) Tailoring antireflux surgery: a randomized clinical trial. World J Surg 23: 612–618PubMedCrossRefGoogle Scholar
  20. 20.
    Stein HJ, Bremner RM, Jamieson J, DeMeester TR (1992) Effect of Nissen fundoplication on esophageal motor function. Arch Surg 127: 788–791PubMedGoogle Scholar
  21. 21.
    Wetscher GJ, Glaser K, Wieschemeyer T, Gadenstaetter M, Prommegger R, Profanter C (1997) Tailored antireflux surgery for gastroesophageal reflux disease: effectiveness and risk of postoperative dysphagia. World J Surg 21: 605–610PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2002

Authors and Affiliations

  • D. Oleynikov
    • 1
  • T. R. Eubanks
    • 1
  • B. K. Oelschlager
    • 1
  • C. A. Pellegrini
    • 1
  1. 1.Department of SurgeryUniversity of Washington School of MedicineSeattleUSA

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