A prospective study of effects of belsey MK IV antireflux surgery on endoscopic esophagitis, lower esophageal sphincter pressure, and 24-Hr pH measurements

Abstract

A prospective study on the effect of the Belsey MK IV operation on esophagitis, lower esophageal sphincter pressure (LESP), and acid reflux as monitored on 24-hr pH recording was conducted to investigate the association between objective changes and the effect of operation on reflux-associated symptoms. Thirty-one patients were included. The effect of surgery on symptoms was recorded in all patients, and 22 patients agreed to undergo endoscopy, manometry, and 24-hr pH recording. Follow-up ranged from three to nine years (mean five years); 87% reported long-lasting improvement (50% free of symptoms, 37% major improvement, no medication needed). The combination of symptomatic improvement and absence of esophagitis was found in 70%. LESP significantly increased [8±6 mm Hg preoperatively, 14±5 mm Hg postoperatively (P<0.001)] to a level above 5 mm Hg in 96% of the patients. No endoscopic esophagitis was found in 17 of 20 patients (85%;P<0.05) (two patients refused endoscopy). The 24-hr pH monitoring normalized in 11 of the 20 patients (55%) (one registration failed). The operation-induced rise in LESP correlated with improvement on endoscopy (r=0.51;P<0.002) and with reduction of reflux parameters (number of episodes with pH<4:r=0.64;P<0.05, percentage of total time pH<4:r=0.42;P=0.07). A rise in LESP must be an important aim of antireflux surgery. The Belsey MK IV does not induce a rise to a level that causes severe dysphagia or bloating, but the trade-off is less control of acid reflux. The Belsey MK IV provides long-lasting symptomatic improvement in 87% of patients. Normalization of the 24-hr pH profile is an essential marker for successful surgery, and we propose to score the results of antireflux surgery by a combination of clinical symptoms and endoscopic findings.