Fundic Wrap Research Articles

Esophagogastric junction pressure topography after fundoplication

Objectives: This study compared the pressure topography after laparoscopic Nissen fundoplication to that of normal subjects and patients with hiatal hernia and reflux disease. Methods: Seven patients with fundoplication, 7 normal subjects and 7 patients with hiatal hernia, were studied. The squamocolumnar junction and intragastric margin of the esophagogastric junction (EGJ) were marked with metal clips. Axial and radial characteristics of EGJ pressure were mapped relative to the hernia and clipped during concurrent fluoroscopy and manometry. Responses to inspiration and abdominal compression were also analyzed. Results: Fundoplication modifies the EGJ by restoration of the hiatal component of EGJ pressure and elongation of the subdiaphragmatic component. Maximal EGJ pressure after fundoplication is mainly dependent on the extrinsic effect of the hiatal canal that compresses the esophagus; the resultant length of the EGJ reflects the length of the fundic wrap. Integrity of the EGJ after fundoplication is independent of the intrinsic lower esophageal sphincter itself. Conclusions: Fundoplication alters the pressure topography of the EGJ by reducing the hiatal hernia, tightening the hiatal orifice, and constructing a subdiaphragmatic wrap of variable length. Each effect depends on different technical aspects of the surgery with the potential of substantial variability in the resultant pressure topography. (Surgery 2000;127:200-8.)

The long term results of open antireflux surgery in a community-based health care center.

There is no previous study concerning long term results of open Nissen fundoplication performed by general surgeons in a nonspecialized unit. Of 45 consecutive patients in a general provincial center, 39 were available for follow-up after a mean period of 78 months. All patients were interviewed using a standard questionnaire, and 35 of them consented to undergo endoscopy. Of the patients, 85% had no or only mild reflux symptoms. The figures for dysphagia, flatulence, and bloating were 31%, 67%, and 46%, respectively. Endoscopy showed defective fundic wrap in 37% of the patients and erosive esophagitis in 29%. Five patients (13%) with recurrent esophagitis were referred for H2-blocker or omeprazole medication, and five others (13%) were scheduled for repeat antireflux surgery. The results were somewhat worse in regard to prevalence of defective fundic wrap and recurrent esophagitis than in other reports, which were from specialized units.

The long term results of open antireflux surgery in a community-based health care center

OBJECTIVE: There is no previous study concerning long term results of open Nissen fundoplication performed by general surgeons in a nonspecialized unit. METHODS: Of 45 consecutive patients in a general provincial center, 39 were available for follow-up after a mean period of 78 months. All patients were interviewed using a standard questionnaire, and 35 of them consented to undergo endoscopy. RESULTS: Of the patients, 85% had no or only mild reflux symptoms. The figures for dysphagia, flatulence, and bloating were 31%, 67%, and 46%, respectively. Endoscopy showed defective fundic wrap in 37% of the patients and erosive esophagitis in 29%. Five patients (13%) with recurrent esophagitis were referred for H2-blocker or omeprazole medication, and five others (13%) were scheduled for repeat antireflux surgery. CONCLUSIONS: The results were somewhat worse in regard to prevalence of defective fundic wrap and recurrent esophagitis than in other reports, which were from specialized units.

Functional Outcome After Laparoscopic or Open Nissen Fundoplication

To compare the results of open and laparoscopic fundoplication. Nonrandomized controlled study with a 3-year follow-up. Fifty-seven consecutive patients with erosive reflux esophagitis underwent laparoscopic (30 patients) or open (27 patients) fundoplication. Interview by an independent person. In addition, 52 patients (91%) underwent postoperative endoscopy, and 38 patients (67%) underwent esophageal 24-hour pH recording. Temporary dysphagia was reported by 20 patients (67%) after laparoscopic and by 11 (41%) after open fundoplication (P = .05). There were no differences between groups concerning incidence of persistent dysphagia (20% vs 18%, respectively) and mild to no reflux symptoms (97% vs 100%, respectively). In addition, bloating (50% vs 63%, respectively) and increased flatus (77% vs 78%, respectively) were equally common. Visual analog scale scores for dysphagia, bloating, and increased flatus were 0.6, 2.4, and 4.3, respectively, in the laparoscopic and 0.6, 3.5, and 3.4, respectively, in the open groups. Normal belching ability was reported by 12 patients (40%) after laparoscopic and by 20 (74%) after open fundoplication (P = .01). Visick grade 1 or 2 was reported by 21 patients (70%) after laparoscopic and by 24 (89%) after open fundoplication (P = .08). Defective fundic wrap was detected in 4 patients (13%) in the laparoscopic and in none in the open group. In addition, abnormal results of 24-hour pH recording were found in 4 patients (22%) after laparoscopic and in 2 (10.5%) after open fundoplication. From a functional point of view, both techniques were equally effective except concerning belching ability and temporary dysphagia.

Fundoplication for gastroesophageal reflux: Success can be achieved with less than 360° fundic wrap if three technical elements are included

Fundoplication for gastroesophageal reflux: Success can be achieved with less than 360° fundic wrap if three technical elements are included

Tailored augmentation of the lower esophageal sphincter in experimental antireflux operations.

Modern upper GI function studies allow for the detection of several pathophysiological factors that contribute to gastroesophageal reflux disease. The information obtained can lead to therapeutic consequences in patients with an indication for a surgical intervention, i.e., an individualized choice of antireflux procedure according to the existing pathophysiologic defect. In an experimental study on mini-pigs the mechanical effect of four standardized antireflux operations (anterior and posterior 180 degrees hemifundoplication, Nissen-DeMeester and Nissen-Rossetti 360 degrees fundoplication) on the lower esophageal sphincter (LES) was investigated. It was the aim of the study to objectively determine the extent of changes in pressure and length parameters at the LES according to the performed antireflux procedure. It could be demonstrated that different degrees of fundic wrap formation lead to a proportional mechanical effect at the LES according to the size of this wrap. Choosing a distinct type of fundoplication will allow for a tailored augmentation of the LES according to the individual functional defect.

Intraoperative esophageal manometry: our experience.

In order to improve the results of functional surgical procedures on the esophagus, the authors, after a number of experimental studies, proposed the use of intraoperative esophageal manometry (IEM). The technique was performed for the first time in 1972. IEM has been employed in the course of Heller's cardiamyotomies and Nissen-Rossetti (N-R) fundoplications, respectively, to document the ablation of the lower esophageal sphincter (LES) high-pressure zone (HPZ) and to calibrate the pressure of the fundal wrap between values ranging from 20 to 40 mmHg ('hypercalibrated Nissen'). This hypercalibration resulted from the retrospective evaluation of a former series when, at the beginning of our experience, we used to calibrate the fundoplication to pressure values similar to those of a normal sphincter ('normocalibrated Nissen': 10-20 mmHg). This experience, in fact, was followed by a high rate of gastroesophageal reflux (GER) recurrence (28.5%) in the first 12 months after surgery. Since 1985 to date, IEM has been employed in the course of 309 functional surgical procedures on the esophagus. This paper, however, reports on 281 patients: 144 with achalasia treated with Heller's myotomy + Nissen-Rossetti fundoplication and 137 with gastroesophageal reflux disease (GER-D) submitted to Nissen-Rossetti fundoplication. Our data suggest that IEM can be a useful tool in the field of functional surgery of the esophagus, and its routine use seems to be able to improve the postoperative results. In this series, in fact, IEM was able to detect the persistence of an HPZ in 15.2% of apparently complete myotomies, all performed with the aid of intraoperative endoscopy. As regards the manometric calibration of the n-HPZ, our results seem to confirm the validity of the technique, yet some findings still remain unexplained: i.e. two patients with a hypotonic n-HPZ and GER recurrence and two with an n-HPZ, exceeding 20 mmHg with postoperative persistent dysphagia. Finally, we would like to emphasize that the concept of a 'hypercalibrated Nissen' contrasts with the 'floppy Nissen' of Donahue and DeMeester; our wrap is also loose around the esophagus and does not impair the esophagogastric transit.

Evaluation of the antireflux mechanism following laparoscopic fundoplication.

Laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastro-oesophageal reflux disease (GORD), but the underlying motility mechanisms that explain the success of this operation remain unclear. Twenty patients with a history of GORD underwent stationary oesophageal manometry and prolonged ambulatory pH monitoring, both before and 3 months after fundoplication. Eighteen patients were completely cured of reflux symptoms and stopped all antireflux medication after operation. After fundoplication there was a significant increase (P < 0.01) in median resting lower oesophageal sphincter (LOS) pressure and length. Median residual LOS pressure during swallow-induced LOS relaxation also increased significantly after operation (P < 0.01). The number of reflux episodes decreased from a median of 48 to 3 after fundoplication (P < 0.01). The time at pH less than 4 decreased from 5.7 to 0 per cent in the supine position (P < 0.01), and from 9.8 to 0.2 per cent while upright (P < 0.001). Early subjective results at 3 months following laparoscopic antireflux surgery show improved symptoms. One of the mechanisms underlying the antireflux action of fundoplication is an increase in median residual LOS pressure at the gastro-oesophageal junction. This may be a purely mechanical effect of the fundic wrap extrinsic to the LOS.

Does oesophageal motor function improve with time after successful antireflux surgery? Results of a prospective, randomised clinical study.

MAIN OBJECTIVE: There is a continuing debate whether motor abnormalities associated with gastro-oesophageal reflux disease (GORD) are primary phenomena or occur as a consequence of repeated injury caused by inflammation....

Disruption of experimental fundic folds is prevented by interserosal scarring

The main cause of recurrent reflux symptoms after Nissen fundoplication is disruption of the fundic wrap. Reoperation has shown a lack of scar tissue between the serosal surfaces of the fundic folds in these cases. Attempts were made to induce serosal scarring during fundoplication performed in rabbits. In group 1 the serosal folds were attached to the upper fundus with three non-absorbable seromuscular sutures. In group 2 Teflon pledgets were placed between these sutures. Fibrin glue was injected between the folds in group 3 and polyglycolic acid mesh was inserted in group 4. When the rabbits were killed 6 months later, the serosa had unfolded and no macroscopic or microscopic scar tissue was found between the serosal surfaces, except in five of the six rabbits in group 3, in which fibronectin, laminin and collagen types I and III were present in interserosal scar tissue. Application of fibrin glue between the serosal surfaces of the fundic folds may prevent disruption of Nissen fundoplication.

Cardiac Trauma

Cardiac Trauma

Fundoplication with anastomotic wrap

Gastric fundoplication is an accepted treatment for disabling or life-threatening gastro-oesophageal reflux in childhood, and a modified Nissen's procedure is most commonly used. Wrap failure is a common complication and occurs most frequently and earliest in neurologically impaired children. To obviate this complication, the procedure was modified by anastomosis of the two limbs of the fundal wrap. The maintenance of the wrap then relies on healing and physical union of the stomach wall, rather than on sutures that eventually cut out, leading to recurrence of reflux. The procedure has been performed in four neurologically impaired children, in three after failure of a previous Nissen procedure. There has been one complication, an adhesive bowel obstruction, and follow-up is too short to assess the ultimate results.

Delayed primary repair of intrathoracic esophageal perforation: Is it safe?

The management of intrathoracic esophageal perforation with delayed diagnosis is a subject of controversy. Because of the obvious advantages of primary repair as a simple single-stage operation, this technique was preferentially used to treat 18 of 22 consecutive patients with esophageal perforation. These patients were stratified into three groups according to the time interval between perforation and repair: group A, less than 6 hours, five patients (28%); group B, 6 to 24 hours, six patients (33%); and group C, more than 24 hours, seven patients (39%). Group A patients were older ( p < 0.05) and group B had fewer iatrogenic perforations (B, 17%; A, 80%; C, 57%, p < 0.1). Additional tissue was used to buttress the repair site in all three groups (A, 3/5 patients, 60%; B, 4/6 patients, 67%; C, 6/7 patients, 86%; p = not significant). In seven patients (39%), a fundic wrap was used to reinforce the site of primary repair. The outcomes of the three groups were analyzed. Group A had the lowest proportion of postoperative leaks (A, 0/4 patients, 0%; B, 4/6 patients, 67%; C, 5/6 patients, 83%; p < 0.05) and postoperative morbidity (A, 2/5 patients, 40%; B, 6/6 patients, 100%; C, 6/7 patients, 86%; p < 0.1). However the increased incidence of leak and morbidity did not lead to an increase in mortality. One death occurred in each group, with an overall mortality of 17% (A, 1/5 patients, 20%; B, 1/6 patients, 17%; C, 1/7 patients, 14%; p = not significant). We conclude that in the era of advanced intensive care capabilities, primary repair of intrathoracic esophageal perforation can be safely accomplished in most patients regardless of the time interval between perforation and operation. Leakage at the suture site is common unless primary repair is carried out without delay. Postoperative leakage, however, is usually inconsequential and does not necessarily result in an adverse outcome. (J T HORAC C ARDIOVASC S URG 1996;111:114-22)

Noniatrogenic esophageal trauma

Few guidelines are available with which to facilitate treatment in patients with noniatrogenic injuries of the esophagus. Early diagnosis and proper management are essential if a good outcome is to be expected. In an effort to define better the treatment of patients with penetrating and blunt injuries of the esophagus, we report our recent 5-year experience at an urban trauma center. From July 1988 to June 1993, nineteen patients with esophageal perforations from penetrating (18) and blunt (1) trauma were identified by our trauma registry. There was no mortality in this group of patients and morbidity was mostly due to associated injuries. Eleven cervical esophageal injuries were repaired. One cervical injury was treated by stopping oral intake and giving intravenous antibiotics. The neck was not drained in 10 of the surgical cases. In 1 patient a tracheoesophageal fistula developed, which later was repaired with a pectoralis muscle flap. Seven perforations were identified in the thoracic (2) and abdominal (5) portions of the esophagus. All were due to gunshot wounds. In 4 cases, a fundal wrap was used to reinforce the repairs. Postoperative contrast studies confirmed that all repairs were intact. We conclude that penetrating and blunt tears of the esophagus can be repaired safely with minimal mortality. Morbidity is usually from associated injuries such as to the spinal cord and trachea. When identified early, cervical esophageal injuries do not need to be drained routinely.

Effect of Intraoperative Manipulation and Anaesthesia on Lower Oesophageal Sphincter Function during Fundoplication

The variables influencing the intraoperative measurement of lower oesophageal sphincter (LOS) pressure and a new method of assessing the effect of a fundal wrap on LOS function were investigated in 13 patients undergoing fundoplication. All patients had a 360 degrees wrap fashioned around a 50-Fr bougie; four also underwent highly selective vagotomy. The effect of the fundal wrap, independent of LOS pressure, was assessed by inducing LOS relaxation with balloon distension. Preoperative mean(s.e.m.) LOS pressure (14.1(2.6) mmHg) did not correlate with that at the start of operation (11.5(1.5) mmHg). After mobilization of the oesophagus mean(s.e.m.) LOS pressure increased significantly (to 19.8(2.0) mmHg; P < 0.0005) and oesophageal distension elicited LOS relaxation on 16 of 33 occasions. After completion of the wrap there was no further increase in LOS pressure, but LOS relaxation occurred after only five of 33 distensions (P < 0.01). These findings indicate that anaesthesia and intraoperative manipulation during fundoplication have significant effects on LOS function that detract from the validity of intraoperative assessment. They question the rationale of current approaches to intraoperative manometry for the assessment of antireflux surgery.

Laparoscopic repair of gastroesophageal reflux disease

This report describes our preliminary experience with two surgical laparoscopic fundoplication procedures, the Nissen technique and the Toupet operation, in which the fundal wrap is reduced from 360 degrees to 180-200 degrees. Fourteen patients with symptomatic gastroesophageal reflux disease who were refractory to pharmacologic and medical therapy underwent a laparoscopic Nissen fundoplication; in an additional 14 patients, we performed a laparoscopic Toupet partial fundoplication. Our laparoscopic approach to the two procedures does not differ significantly from the traditional open methods and the effectiveness of the laparoscopic fundoplication procedures appears similar to that of the same conventional techniques. Oral feedings can be resumed on the first postoperative day and patients typically are discharged on the second day after surgery. Operative time for performing the Toupet procedure averaged just approximately 1.6 h and was shorter than that for the Nissen fundoplication, due to the use of a stapler to secure the fundal wrap. Confirming earlier observations, the laparoscopic Toupet 180-200 degrees fundoplication was associated with a lower incidence of postoperative digestive complications, such as dysphagia, than was the laparoscopic Nissen operation. The laparoscopic fundoplication approach offers the advantages of clear visualization, adequate dissection and precise repair, along with the benefits associated with endoscopic surgery: diminished postoperative pain and discomfort, reduced hospitalization, and quicker return to normal activities. Our experience indicates that the Toupet fundoplication may be preferable to the Nissen technique for many patients requiring surgical treatment of their reflux disease.

Prevention of reflux after oesophageal resection and reconstruction with a gastric tube

Severe reflux is a common adverse consequence of oesophageal resection and reconstruction with a gastric tube. An intrathoracic fundoplication has been constructed around and above the oesophagogastrostomy with the intention to prevent reflux. The efficacy of this fundoplication has been studied by manometry, endoscopy and dual point ambulatory 24-h pH metry with the electrode positioned 3–5 cm above the anastomosis and in the gastric tube as well. Seven patients were investigated at least 6 months after an oesophageal resection due to carcinoma. Four patients operated on with a conventional intrathoracic oesophago-gastrostomy end-to-side served as controls. During manometry, no high pressure zone could be demonstrated at the oesophago-gastric junction in either patient category. However, in all patients having an intrathoracic fundoplication, acid reflux into the proximal oesophagus was not demonstrable, whereas in all control patients, severe reflux occurred both in the upright as well as the supine position. The mode of action of this intrathoracically applied fundic wrap is thus most likely through creation of a flap valve mechanism, which could also be anatomically demonstrated during endoscopy.

Laparoscopic Nissen Fundoplication

A technique for laparoscopic Nissen fundoplication is described and a series of 11 cases is presented. The technique secures the patient to the operating table with three safety straps and the patient is then placed in a reverse Trendelenburg position with the hips flexed. The surgeon operates from the patient's right side using two midline trocar sites as the main operating ports. Other ports provide retraction and laparoscope access. The liver retractor is held by a mechanical arm. Once the esophageal peritoneum has been opened, the esophagus and diaphragmatic crura are dissected out and elevated by a Penrose drain sling. The short gastrics are divided and the fundus is brought posterior to the esophagus passing from left to right. A large Maloney dilator is placed in the esophagus and the fundal wrap is sutured to the anterior aspect of the stomach by three sutures; the inferior--most of which incorporates the anterior wall of the esophagus. Once the fundoplication is completed, the dilator is replaced by a nasogastric tube. Postoperatively, patients are given clear liquids and when these are tolerated the nasogastric tube is removed. Most patients are discharged on the second or third postoperative day. Operating time averaged 147 min, and all patients returned to unrestricted activity within 2 to 3 weeks. All patients reported complete relief of gastroesophageal reflux. Average follow up was 120 days with a median of 148 days. Long-term follow up is in progress.

Refundoplication for recurrent gastroesophageal reflux.

Reoperation after a failed antireflux procedure is a surgical challenge. Many operative techniques have been proposed, but reports on systematic follow-up with endoscopy and esophageal function tests are few. The purpose of the present study was to evaluate the results of repeated fundoplication in cases of recurrent reflux, including assessment of esophageal function. Of the 18 cases of repeat fundoplication performed for recurrent reflux during 1970-1991 at Tampere University Hospital, 15 were evaluated a median of 18 (range 5-152) months after reoperation. Follow-up studies included endoscopy in all and esophageal function tests (esophageal 24-hour pH recording, manometry, and radionuclide transit) in 14 cases. All the patients had defective fundic wrap before reoperation, whereas at follow-up 12 of the 15 wraps were intact. Reflux symptoms were diminished in all 15. Six patients (40%), however, had objective recurrence of reflux (esophagitis or pathologic pH recording). Three of the recurrences were due to slipped fundic wrap, but the others were probably caused by impaired esophageal function. By repeat fundoplication the wrap could be repaired as reliably as in primary operation. Symptomatic outcome and objective results were reasonable. The results were, however, not as good as after primary operation, which was due to more impaired esophageal motility caused by prolonged reflux or repeated surgery (or both).

Fate of Nissen fundoplication after 20 years. A clinical, endoscopical, and functional analysis.

Of 46 patients who had Nissen fundoplication for proved gastro-oesophageal reflux, 25 were available for follow up after a median of 20 years, 15 had died of unrelated causes, and six could not be traced. All 25 patients in the follow up study were personally interviewed: 21 consented to an endoscopy, 14 to 24 hour recording of oesophageal pH and manometry, and 15 to radionuclide transit test. Repeat fundoplication for recurrent reflux was performed in two cases during the study. Heartburn and regurgitation were significantly lessened (p < 0.005), but the incidence of dysphagia was slightly increased. Endoscopy showed six of 21 fundic wraps to be defective. Erosive oesophagitis was seen in two patients, and Barrett's oesophagus (histologically confirmed) in one of them and six other patients. Total reflux time was abnormal in four of 14 patients. No patient with an intact fundic wrap seen on endoscopy, only two of seven with Barrett's oesophagus, and one of four with abnormal reflux had oesophagitis. Fundoplication in itself did not affect oesophageal motility or transit, provided that the wrap was intact. It is concluded that Nissen fundoplication gave a reasonably good longterm effect in chronic reflux disease, with the stage of the fundic wrap as the main determinant of outcome.