Complete Fundoplication Research Articles

Effective Treatment of Rumination With Nissen Fundoplication

Rumination is a syndrome characterized by the effortless regurgitation of recently ingested food. It has been linked to severe medical and psychosocial conditions including malnutrition, aspiration pneumonia, and complete social withdrawal. Psychotherapy, the current treatment modality for rumination, may improve symptoms but requires significant motivation and is rarely curative. We hypothesized that a complete fundoplication would eliminate, or at least impair, the ability to regurgitate gastric contents through the esophagogastric junction. We performed a Nissen fundoplication in five patients with a classic history of rumination. In all cases, symptoms had been resistant to medical and psychiatric intervention prior to fundoplication. Formal preoperative testing included esophageal manometry, 24-hour pH monitoring, endoscopy, and upper gastrointestinal barium swallow studies. All patients reported their primary symptom to be effortless recurrent postprandial regurgitation for 1 to 2 hours after meals consistent with rumination. Four (80%) of the five patients had low resting lower esophageal sphincter pressures with evidence of gastroesophageal reflux disease on 24-hour pH monitoring. All patients reported complete cessation of ruminating behavior after Nissen fundoplication. We report, for the first time, complete elimination of rumination symptoms after a Nissen fundoplication. Although further trials are needed to confirm our results, we recommend considering a Nissen fundoplication for treatment of rumination refractory to behavioral and medical interventions. ( J Gastrointest Surg 2002;6:638–644.)

Provocation of transient lower esophageal sphincter relaxations by gastric distension with air.

Transient lower esophageal sphincter relaxations (TLESRs) are the major mechanism permitting not only gastroesophageal reflux but also venting of air from the stomach. Triggering of TLESRs is provoked by gastric distension. Antireflux surgery is associated with impaired ability to belch. It is not known whether a reduced capacity to belch results from postoperative reduction in TLESRs. We studied the occurrence of TLESRs, common cavities (indicator for gas gastroesophageal reflux), and belching after standardized acute gastric distension by air insufflation (750 ml). Control subjects (n = 10), patients with gastroesophageal reflux disease (GERD) (n = 22), and patients after fundoplication (n = 24) were studied. LES and esophageal motilities were recorded with perfusion manometry. Gastric distension with air significantly (p < 0.05) increased TLESR frequency in controls (1.6+/-0.3 to 3.5+/-1.0 per 20 min), GERD patients (1.2+/-0.3 to 3.1+/-0.5 per 20 min), and patients after fundoplication (0.5+/-0.1 to 1.8+/-0.6 per 20 min). Postfundoplication the number of TLESRs was significantly reduced (p < 0.05) both under fasting conditions and after air insufflation. The number of common cavities and belches after gastric air distension also was significantly reduced (p < 0.05) after fundoplication: 2.3+/-0.6 versus 4.7+/-0.4 in controls and 4.1+/-0.4 in GERD patients. About half of the common cavities occurred during TLESRs, and half during other mechanisms. An impaired ability to belch in daily life correlated with an impaired belching response during the test. An impaired ability to belch occurred only in patients with complete fundoplication and not in patients with partial fundoplication and was associated with a reduced number of common cavities after gastric air insufflation. Short-lasting gastric air distension 1) provokes TLESRs but does not differentiate GERD patients from controls, 2) reveals impaired belching capacity in patients after complete fundoplication, and 3) shows that common cavities do not exclusively occur during TLESRs.

Provocation of transient lower esophageal sphincter relaxations by gastric distension with air

OBJECTIVES: Transient lower esophageal sphincter relaxations (TLESRs) are the major mechanism permitting not only gastroesophageal reflux but also venting of air from the stomach. Triggering of TLESRs is provoked by gastric distension. Antireflux surgery is associated with impaired ability to belch. It is not known whether a reduced capacity to belch results from postoperative reduction in TLESRs. METHODS: We studied the occurrence of TLESRs, common cavities (indicator for gas gastroesophageal reflux), and belching after standardized acute gastric distension by air insufflation (750 ml). Control subjects (n = 10), patients with gastroesophageal reflux disease (GERD) (n = 22), and patients after fundoplication (n = 24) were studied. LES and esophageal motilities were recorded with perfusion manometry. RESULTS: Gastric distension with air significantly ( p < 0.05) increased TLESR frequency in controls (1.6 ± 0.3 to 3.5 ± 1.0 per 20 min), GERD patients (1.2 ± 0.3 to 3.1 ± 0.5 per 20 min), and patients after fundoplication (0.5 ± 0.1 to 1.8 ± 0.6 per 20 min). Postfundoplication the number of TLESRs was significantly reduced ( p < 0.05) both under fasting conditions and after air insufflation. The number of common cavities and belches after gastric air distension also was significantly reduced ( p < 0.05) after fundoplication: 2.3 ± 0.6 versus 4.7 ± 0.4 in controls and 4.1 ± 0.4 in GERD patients. About half of the common cavities occurred during TLESRs, and half during other mechanisms. An impaired ability to belch in daily life correlated with an impaired belching response during the test. An impaired ability to belch occurred only in patients with complete fundoplication and not in patients with partial fundoplication and was associated with a reduced number of common cavities after gastric air insufflation. CONCLUSIONS: Short-lasting gastric air distension 1) provokes TLESRs but does not differentiate GERD patients from controls, 2) reveals impaired belching capacity in patients after complete fundoplication, and 3) shows that common cavities do not exclusively occur during TLESRs.

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fundoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 ± 1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (≤30 mm Hg mean distal esophageal body pressure or ≤80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted.

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Fundoplication wrap disruption: an experimental study in rats.

Antireflux surgery usually gives long lasting control of gastroesophageal reflux disease, but late failures can occur from fundoplication wrap disruption. Disruption presumably occurs when physiological mechanical stresses cause the sutures to pull out of the fundoplication wrap. We hypothesized that complete fundoplications (fundus sutured to fundus) would withstand disruptive forces better than partial fundoplications (fundus sutured to esophagus). Forty-eight rats underwent fundoplication (24 partial and 24 complete). Fundoplication wraps were disrupted by distending the stomach (bursting pressure technique) and by distracting the wrap in a tensiometer (breaking strength technique). Bursting pressures were similar in the partial (103.7 +/- 13.5 mmHg) and complete (100.5 +/- 13.1 mmHg) fundoplication wraps (P = 0.93, not significant). In both groups, all disruptions occurred by sutures tearing through the stomach wall. Breaking strength was also equivalent for the two types of wrap. Partial wraps disrupted at 6.69 +/- 1.49 N and complete wraps disrupted at 6.52 +/- 1.28 N (P = 0.77, not significant). Sutures tore out of the stomach side of the partial wrap in five rats and out of the esophagus in the other seven rats with partial wraps. Disruption occurred by sutures tearing through the stomach in all rats with complete fundoplications. This experimental study in the rat did not show any difference in the ability of partial and complete fundoplication wraps to withstand disruptive forces.

Laparoscopic fundoplication.

Symptomatic gastroesophageal reflux in children has been identified with increasing frequency over the last two decades. Agreement regarding the elements of a complete diagnostic work-up and the timing and specific surgical procedures for treating reflux has been difficult to achieve. Laparoscopic fundoplication is a routine procedure in some pediatric surgery centers. This surgical technique has the potential to reduce the pain and morbidity associated with open fundoplication. The outcomes after laparoscopic fundoplication have been equivalent to open fundoplication and are associated with faster recovery. Consensus regarding when to perform a partial fundoplication as compared to a complete fundoplication in addition to the appropriateness of gastric outlet procedures has not been achieved.

Laparoscopic fundoplication and gastrostomy.

Fundoplication and gastrostomy are among the more common operative procedures performed in infants and children. This article reviews the techniques, results, and complications of the surgical treatment of gastroesophageal reflux in 389 consecutive pediatric patients over the last 5 years. Chronic unremitting vomiting, failure to thrive, and an array of pulmonary symptoms were the leading indications for fundoplication in these children. Children who eat by mouth were primarily treated by a Toupet fundoplication, whereas gastrostomy-fed children generally received a Nissen fundoplication. The time to perform fundoplication and gastrostomy in our patients averaged about 3 hours for the first 10 patients but required a little over 1 hour for the last 50 patients. Most patients were discharged by the second or third postoperative day. Recurrent symptoms have developed in about 5% of our patients. Five of the 201 children who received a Toupet fundoplication (partial wrap) have been converted to a complete wrap fundoplication. Two of the patients having a Nissen fundoplication have required reoperation for their symptoms. The primary complications were seven cases of transient dysphagia, one case of esophageal perforation, and one case of gastric perforation. Laparoscopic fundoplication seems to achieve results equivalent to open fundoplication and is associated with considerably less postoperative pain and morbidity as well as a more rapid recovery.

Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication

Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication

Collis gastroplasty: Origin and evolution

In 1957 J. Leigh Collis published his innovative operation for treating the difficult problem of the irreducible hiatal hernia, esophagitis, and stricture. The design of the operation was based on the relatively primitive understanding of hiatal hernia and the newly emerging concept of reflux esophagitis. A variety of antireflux operations by different surgeons emerged over the years to follow. The original Collis gastroplasty has been subsequently modified with the addition of both partial and complete fundoplication procedures. The place of the modified Collis gastroplasty-fundoplication operations in today's approach to the problems of hiatal hernia and gastroesophageal reflux disease remains unsettled.

Current Thinking on the Role of Surgery in Gastroesophageal Reflux

Gastroesophageal reflux is common in infants and children. In most cases it causes little more than inconvenience and remits spontaneously with time and maturation. A small and select group of refluxing children, however, will develop complications of reflux severe enough to justify operative control when medical treatment fails. Recurrent pulmonary infections, obstructive apnea, nutritional wasting, and progressive inflammatory injury to the esophagus all qualify as surgical indications, provided a reasonable cause-effect relationship with reflux can be established. The procedure of choice depends very much upon the skill and experience of the surgeon. The complete fundoplication seems to offer more complete control of reflux, but it has the potential for more frequent and more complicated side-effects.

The combined Collis gastroplasty-Nissen fundoplication: surgical procedure and radiographic evaluation.

The combined Collis gastroplasty-Nissen fundoplication consists of a combination of an esophagus-lengthening Collis gastroplasty with 360 degrees complete Nissen fundoplication operation. This report reviews the clinical and radiographic features of 60 consecutive patients who underwent this operation for the control of symptomatic gastroesophageal reflux. The surgical procedure, the technique of postoperative radiographic examination, normal radiographic anatomy, and abnormalities detectable radiographically are briefly described. All patients were examined on the seventh postoperative day initially with iodinated water-soluble contrast medium followed by barium to establish integrity of the gastroplasty tube, fundoplication wrap, and dilated esophageal stricture. Later in the postoperative period, elective barium esophagrams were prompted by complaints of dysphagia (three patients) and symptoms of gastroesophageal reflux (five patients).

Stapled, Uncut Gastroplasty for Hiatal Hernia: 12-Year Follow-up

A total of 82 patients with gastroesophageal reflux were consecutively treated with stapled, uncut gastroplasty and complete fundoplication over a 12-year period. The conditions treated included symptomatic reflux; esophageal stricture; massive hernia; collagen esophagus; short esophagus; Barrett's esophagus; recurrent, massive bleeding or anemia; small gastric remnant after gastrectomy; and acute volvulus. The transthoracic approach of stapled, uncut gastroplasty gives superb exposure. Outstanding features of the procedure are (1) the safety and versatility resulting from the small amount of fundus required, (2) no need either to ligate short gastric vessels or to suture the esophagus itself, and (3) preservation of anatomical continuity between the wrapping fundus and the wrapped gastric tubular segment. There have been no deaths and no cases of anatomical or symptomatic recurrence in the series. Complications included some nondebilitating and mainly self-limiting symptoms.