Abstract
In a prospective, randomized, clinical trial, we compared a partial (180–200‡, Toupet) with a total fundoplication (360‡, Rossetti) in the surgical treatment of gastroesophageal reflux disease. Seventy-one patients entered the trial; 33 were allocated to a partial fundoplication and 38 to a 360‡ fundic wrap. Each patient was investigated prior to as well as 3 and/or 6 months after the operation, including an endoscopic and clinical assessment. Manometry was carried out via a triple lumen catheter and the pressure in the high pressure zone (HPZ) in the distal esophagus was measured as well as the length of the intraabdominal segment by a “station pull-through” technique. Acid exposure of the esophageal mucosa was evaluated by ambulatory 24-hour pH measurements.
Acid exposure of the esophageal mucosa was “normalized” by the 2 operations. In addition, the length of the HPZ was increased to a “normal” level by both operations. The pressure of the HPZ was, however, “normalized” only in patients allocated to a Rossetti fundoplication, whereas patients operated on with a partial fundoplication had a significantly lower HPZ pressure (p<0.01). The clinical assessment revealed excellent results in both groups with no significant differences between the 2 operations except for a higher incidence of dysphagia at 3 months after a Rossetti fundoplication (p<0.01), which disappeared during the subsequent 3 months.
Résumé
Dans une étude clinique prospective, randomisée, nous avons comparé la plicature partielle de la grosse tubérosité (180–200‡, opération d'A. Toupet) et la plicature totale (opération de Nissen-Rossetti) dans le traitement chirurgical du reflux gastrooesophagien. Parmi les 71 patients inclus dans cette étude, 33 ont eu une plicature partielle et 38, une plicature totale. Chaque patient a eu un examen clinique complet et endoscopique avant son intervention, et 3 et 6 mois après. Tous les patients ont eu une manométrie par cathéter à trois lumières, une mesure de l'hyperpression de l'oesophage distal, ainsi que la celle de la longeur de l'oesophage intra-abdominal. Une pH-métrie a été effectuée pendant 24 heures en ambulatoire pour mesurer l'exposition “acide” de l'oesophage.
L'exposition “acide” a été corrigée par les deux opérations. La pression du bas oesophage n'a été, par contre, que “normalisée” chez les patients ayant eu une plicature totale alors qu'elle a été nettement abaissée chez ceux ayant eu une fundoplicature partielle (p<0.01). L'examen clinique a montré qu'il n'y avait pas de différence significative dans les 2 groupes à part une incidence plus élèvée de dysphagie à 3 mois après l'opération de Nissen-Rossetti. Cette différence disparaissait après 3 mois.
Resumen
En un estudio clínico prospectivo y randomizado hemos comparado una fundoplicación parcial (180–200‡, Toupet) con una total (360‡, Rossetti) en el tratamiento quirÚrgico del reflujo gastroesofágico. Setena y un pacientes ingresaron al estudio; 33 resultaron asignados a fundoplicación parcial y 38 a la total. Cada paciente fue estudiado, antes de la operación y 3 y/o 6 meses después, por endoscopia y valoración clínica. Se realizó manometría por medio de un catéter de triple luz y se efectuó la determinación de la presión en la zona de alta presión (ZAP) del esófago distal, así como la longitud del segmento intraabdominal. La exposición de la mucosa esofágica al ácido fue determinanda por mediciones ambulatorias del pH (24 horas).
La exposición de la mucosa esofágica fue “normalizada” por las 2 operaciones. Además, la longitud de la ZAP fue elevada a un nivel “normal” or ambas operaciones. La presión de la ZAP, sin embargo, sólo fue “normalizada” en los pacientes asignados a la fundoplicación de Rossetti, en tanto que los pacientes tratados con la fundoplicación parcial exhibieron una menor presión en la ZAP (p<0.01). La valoración clínica reveló excelentes resultados en ambos grupos sin diferencia entre las 2 operaciones, excepto por una incidencia mayor de disfagia a los 3 meses después de la fundoplicación, una diferencia que desvaneció en los 3 meses siguientes.
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Supported by grants from the Swedish Medical Research Council and from the Swedish Life Insurance Companies.
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Lundell, L., Abrahamsson, H., Ruth, M. et al. Lower esophageal sphincter characteristics and esophageal acid exposure following partial or 360‡ fundoplication: Results of a prospective, randomized, clinical study. World J. Surg. 15, 115–120 (1991). https://doi.org/10.1007/BF01658980
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DOI: https://doi.org/10.1007/BF01658980