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J Thorac Cardiovasc Surg 1995;110:141-147
© 1995 Mosby, Inc.
GENERAL THORACIC SURGERY |
Los Angeles Calif.
From the Department of Surgery, University of Southern California School of Medicine, Los Angeles, Calif.
Address for reprints: Tom R. DeMeester, MD, University of Southern California School of Medicine, Department of Surgery, 1510 San Pablo St., Suite 514, Los Angeles, CA 90033-4612.
Abstract
Tailored surgical antireflux procedures were done in 104 patients during a 7-year period. Presenting symptoms included heartburn in 95 patients (91%), regurgitation in 83 patients (80%), and dysphagia in 61 patients (60%). Evaluation before operation included video barium esophagography, endoscopy, 24-hour esophageal pH monitoring, and esophageal motility studies. On the basis of anatomic and functional findings, the following procedures were performed: 15 laparoscopic and 49 open transabdominal Nissen fundoplications, 23 transthoracic Nissen fundoplications, seven Belsey partial fundoplications, and 10 Collis gastroplasty and Belsey partial fundoplications. The severity of symptoms was assessed before and after operation according to a previously published grading score. Eighty-five of the 104 patients (82%) were able to be contacted for a follow-up evaluation by means of a standardized questionnaire. Median length of follow-up was 4 years, with 40 patients having follow-up beyond 5 years. The tailored operation cured the symptoms of heartburn in 97%, regurgitation in 91%, and dysphagia in 92%. Ninety-eight percent of the patients reported that operation had cured their preoperative symptoms and 93% were satisfied with the outcome of the operation. To obtain optimal results, surgical treatment of gastroesophageal reflux disease should be tailored to the patient's anatomic and functional assessments. For early, uncomplicated disease a transabdominal Nissen fundoplication is done, laparoscopically when expertise exists. Patients with complicated disease should undergo an open antireflux procedure tailored to specific anatomic or functional abnormalities. (J THORACCARDIOVASCSURG1995;110:141-7)
Gastroesophageal reflux disease (GERD) is one of the most common upper gastrointestinal disorders in the Western world, with a prevalence of 0.36% (360 cases per 100,000 population) per year. GERD accounts for approximately 75% of esophageal pathologic conditions.
1 Increased esophageal exposure to gastric juice can occur when the lower esophageal sphincter is mechanically incompetent, when esophageal body motility is ineffective in clearing physiologic reflux episodes, or when abnormalities of the gastric reservoir are present. 2-4 Approximately 25% of patients with GERD will eventually have recurrent, progressive disease and are therefore candidates to undergo antireflux surgical procedures for effective long-term therapy. 5
Successful performance of antireflux operations poses a significant therapeutic challenge. By the time a patient is referred for operation, the disease has often progressed to include functional and anatomic alterations of the foregut. Abnormalities of esophageal motility, shortening of esophageal length, and the presence of stricture or Barrett's metaplasia are common. Antireflux operations in this clinical setting are particularly challenging, and when the abnormalities are not adjusted for the results can be less than satisfactory. The major reason for failure is the lack of appropriate anatomic and functional assessment of the foregut before operation. Such a cause of failure is particularly important in this era of laparoscopic fundoplication because the desire to perform a minimally invasive procedure may lead to further disregard for the abnormalities associated with advanced disease.
The outcomes of 104 patients with GERD whose antireflux procedures were prospectively tailored to the severity of the disease were reviewed. The aim of the study was to document the long-term outcome that can be achieved by selecting the appropriate antireflux procedure according to an assessment of foregut anatomy and function made before operation.
MATERIAL AND METHODS
Study population
During a 7-year period (1986 to 1993), 104 patients underwent primary antireflux procedures for the treatment of gastroesophageal reflux disease. There were 62 male and 42 female patients, with a median age of 51 years and a range from 15 to 86 years. All patients had increased esophageal acid exposure documented on 24-hour esophageal pH monitoring and a mechanically defective sphincter documented on manometry. 3, 6 All patients underwent endoscopy to assess the degree of esophageal mucosal damage. An appropriate antireflux procedure was selected on the basis of habitus, esophageal motility and an assessment of esophageal length by barium esophagram, endoscopy and the findings at operation.
Assessment before operation
Habitus.
In patients judged clinically obese the approach was made through the chest to maximize surgical exposure.
Esophageal motility.
Esophageal manometry was performed as described elsewhere. 3, 7 When an esophageal contraction dropped in amplitude below the fifth percentile of the values measured in healthy subjects at the same level of the esophagus, it was considered a failed contraction. When the velocity between two contraction peaks was 20 cm/sec or more, the wave was considered to be simultaneous rather than peristaltic. Failure of esophageal body function was identified by the presence of one or both of the following characteristics: a contraction amplitude below 20 mmHg in one or more of the three lowest 5 cm esophageal segments or a prevalence of more than 20% simultaneous waves through these segments.
Endoscopy.
Fiberoptic endoscopic examination was used to measure the position of the diaphragmatic crura, the location and distinctiveness of the squamocolumnar junction, and the presence of mucosal injury. Esophagitis was scored as grade I for an erythematous and friable mucosa, grade II for linear erosions, and grade III for deeper and wider linear erosions with islands of edematous mucosa between erosive furrows. Grade I esophagitis was considered subjective and was not included as a complication for the purposes of analysis. An esophageal stricture was identified by the inability to pass a 36F endoscope with ease. The diagnosis of Barrett's esophagus was made when histologic examination confirmed specialized columnar-type epithelium above the anatomic gastroesophageal junction.
Esophageal length.
Esophageal length was assessed by means of videoroentgenographic contrast studies and endoscopic findings. The esophageal length was considered too short for an abdominal approach if a hiatal hernia that failed to reduce in the upright position was seen on the video barium esophagram or if the distance measured on endoscopy between the diaphragmatic crura, identified by having the patient sniff, and the gastroesophageal junction was greater than 5 cm. These patients were approached transthoracically, and length of the esophagus was again assessed after the esophagus had been mobilized from the diaphragmatic hiatus up to the aortic arch. The gastroesophageal junction was marked with a stitch, and if the length of the esophagus was insufficient to place a repair beneath the diaphragm without tension, the esophagus was considered short.
Procedure selection
Procedure selection was based on anatomic and functional findings, as shown in the decision algorithm in Fig. 1. Of the 104 patients, 64 were selected for an abdominal approach and 40 were selected for a thoracic approach. For those who underwent the abdominal procedure, a Nissen fundoplication was done open in 49 patients and, more recently, laparoscopically in 15. Twenty-three patients had normal esophageal length and motility and underwent transthoracic Nissen fundoplication; most of these patients were obese. Seven patients had normal esophageal length but poor contractility or wave progression. These patients underwent transthoracic Belsey partial fundoplication. Ten patients had a short esophagus confirmed at operation and underwent transthoracic Collis gastroplasty and Belsey fundoplication.
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Table I). 8 Of the 104 patients, 85 were able to be contacted and answered a postoperative questionnaire. In addition to a postoperative evaluation of symptoms, the patients were asked to judge the overall outcome of the surgical procedure. Persistent symptoms or permanent dysphagia after the procedure were considered indicative of failure. In individual patients, successful relief of the primary symptom was considered to have been achieved if a change in the symptom score to 1 or lower was observed after operation. The interval between operation and assessment is shown in Table II. The median follow-up was 4 years, with 40 patients having follow-up beyond 5 years.
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Clinical features before operation
The primary symptoms for each group are shown in Table III and the clinical features are shown in Table IV. The severity of the disease in the overall group is reflected by the presence of severe esophagitis in 32%, stricture in 22%, and Barrett's metaplasia in 31%. Patients with a short esophageal length necessitating Collis gastroplasty were characterized clinically by the presence of a hiatal hernia in 100%, stricture in 40%, and Barrett's metaplasia in 70%. Short esophageal length was associated with a high prevalence of esophageal motor failure seen on manometric studies (Fig. 2). Abnormal motility did occur in the absence of a short esophagus, but this was uncommon and occurred in only 14% of the patients.
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Table V compares the clinical results of the four antireflux procedures. The poorest results were seen in patients with poor motility and normal esophageal length who underwent Belsey partial fundoplication.
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Table VI shows that failure to relieve the primary symptom responsible for surgery was uncommon. This success is also reflected in a statistical improvement for each symptom severity score after operation. When asked, 98% of patients reported that their symptoms were cured or improved after the operation, and 94% were satisfied with the outcome of operation.
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Patients with GERD are often treated medically for years before referral for an antireflux operation. When referred, they are likely to have anatomic and functional consequences of long-standing GERD. Previous studies have shown that long-standing GERD can result in progressive mucosal injury (esophagitis, stricture, and the development of Barrett's esophagus) and lead to fibrosis of the esophageal body, loss of the esophageal motility, and eventual shortening of the esophagus. 9-11 In other words, long-standing GERD leads to organ failure. Studies of the natural history of reflux esophagitis suggest that nearly 25% of patients will manifest this recurrent, progressive form of the disease despite medical therapy. 12
The goal of surgical treatment for GERD is to relieve the symptoms of reflux through the permanent restoration of cardioesophageal competence. This should be done without inducing dysphagia, which can occur when the outflow resistance of the reconstructed cardia exceeds the peristaltic power of the body of the esophagus. Achievement of this goal requires an understanding of the natural history of GERD, assessment of the status of the patient's esophageal function, and selection of the appropriate antireflux procedure. We have reviewed outcomes of 85 patients with a wide spectrum of disease. The selection of the surgical approach was based on body weight and on assessment of esophageal contractility and length. A transabdominal approach was used in patients who were not obese and had normal esophageal contractility and length. In obese patients and those with poor contractility or questionable esophageal length, the approach was transthoracic. Those with weak esophageal contractions, abnormal wave progression, or both were treated with partial fundoplication to avoid the increased outflow resistance associated with complete fundoplication. If the esophagus was short after it was mobilized from diaphragm to aortic arch, a Collis gastroplasty was done to provide additional length and to avoid placing the repair under tension.
Despite the presence of advanced disease in one third of the patients, this approach resulted in a clinical outcome similar to that seen among patients with early and less progressive disease. Of interest, patients selected for Belsey partial fundoplication, because of poor motility in the presence of normal esophageal length, were the least benefited. This result suggests that in patients with reflux disease a motility disorder in the presence of a normal esophageal length may be primary, rather than caused by the reflux disease.
Results of published studies support the concept that failure to tailor the operation in patients with late-stage disease (those most likely to have poor function) results in a high percentage of unsatisfactory outcomes. 13-16 Failure of a surgeon to use a tailored approach resulted in a long-term outcome of only 65% good or excellent results in a study of Luostarinen and coworkers. 16 Salama and Lamont 14 reported that the clinical success of a Belsey fundoplication was 90% in patients with no esophagitis, compared with 50% in patients with symptoms of Barrett's esophagus; this result again emphasizes that results are related to severity of disease. This relationship was emphasized by Skinner and Belsey 17 in their original description of Belsey partial fundoplication. They noted a 40% recurrence rate in patients with esophageal stricture and shortening.
Patient assessment before an antireflux operation becomes particularly important in light of the growing enthusiasm for minimally invasive techniques. Widespread application of laparoscopic Nissen fundoplication in all patients, without objective assessment of esophageal function and length, will lead to poor results in a significant number of patients who have advanced disease.
The reasons that some patients have recurrent, progressive disease are just beginning to be understood. Several studies have shown that the severity of esophageal injury is related to the nature of the material refluxed. More severe injury occurs when mixtures of bile and gastric acid are refluxed. 18 Under these conditions, acid-suppression therapy reduces acid exposure and relieves the symptom of heartburn while exposure to duodenal juice, bile, and neutralized gastric juice continues unabated. This exposure can result in persistent injury to the esophageal mucosa and progression of mucosal damage into deeper structures, with the development of stricture or Barrett's metaplasia. More important is that mucosal damage can occur even when the patient has improvement of symptoms. 12 An antireflux procedure is the only means of cure for this progressive form of the disease because it restores the barrier between stomach and esophagus and prevents the reflux of both gastric and duodenal juices. Ideally, the procedure should be performed as soon as it has been determined that the patient is at risk for progressive disease. This risk is indicated by the presence of a mechanically defective sphincter, supine reflux, the reflux of both gastric and duodenal juices, and the presence of mucosal injury or Barrett's metaplasia.
Our experience suggests that for approximately 65% of patients referred for operation, transabdominal Nissen fundoplication is the most suitable treatment. The remaining 35% of patients are best treated with an antireflux procedure tailored to the underlying anatomic and functional abnormalities. This approach results in excellent long-term relief of reflux symptoms across the whole spectrum of GERD.
Appendix: DISCUSSION
Dr. Alex G. Little (Las Vegas, Nev.
). I agree with the overall philosophy expressed in this article but have a few disagreements with particulars. I would like to direct my comments in two directions.
In terms of agreeing with the philosophy, I am reminded of a gentlemen from Greek folklore, Procrustes. Procrustes was a burly fellow who lived along the side of the road, and when travelers came by he had a bed on which he laid each individual. If they were a little too long, he would trim them off to fit the bed. Contrarily, if they were a little short, he would lengthen them with a winch. Again, they would end up fitting his designation of the ideal length. I think that there is a similar temptation to force all patients who need antireflux operations into the same surgical format— Nissen or, perhaps even more alarmingly, laparoscopic Nissen fundoplication. I thus agree with the article's philosophy. We should have an approach that suits each patient, disease, physiology, and anatomy. Having said this, I have a few questions and comments.
First is the question of esophageal length. The group has usefully separated the concepts of contractility (or performance) and length, but I am not convinced that the thoracic approach is necessary every time the esophagus is a little short. Perhaps an alternative would be to suggest that when the length and the contractility are normal either laparoscopic or open Nissen fundoplication (depending on local expertise and experience) is appropriate. When contractility is normal but length is shortened, the options are either a transthoracic approach or an open abdominal approach with generous mobilization of the esophagus, something that is not routinely achievable by most of us laparoscopically. Mobilization of the esophagus transabdominally up to the aortic arch through the hiatus is not terribly challenging, will result in the same outcome as a transthoracic approach, and is easier on the patient in terms of thoracotomy versus laparotomy pain and other sequelae.
Regarding patients with reflux and abnormal contractility, I have just a few comments. I know that your group recognizes a difference between simple assessment of contractility and how (or whether) that translates into symptomatic difficulty for the patient in terms of dysphagia. I also know that there have been reports suggesting that esophageal clearance that is abnormal before operation can be improved or restored to normal by a successful antireflux operation. How might that consideration fit into your thinking? Finally, we now know of reasonable laparotomy antireflux procedures that, like the Belsey, are not full fundoplications and do not produce either the same degree of obstruction or the same elevated lower sphincter pressure as does the Nissen. Again, I wonder how insistent you are on the thoracic approach for this group of patients.
The article clearly focused on the technique of antireflux surgery, but I wonder whether you could comment just a little bit on the indications for operation. In this day and age, and following up on one of your early premises that earlier operation is better than delayed operation, what are the indications for antireflux operations?
Finally, I was a little struck by the occurrence in some of your patients of simultaneous contractions that would fit the standard definition of diffuse spasm. Did those patients have a different outcome than did patients with reflux but without that motor disorder?
Dr. Peters.
Thank you, Dr. Little; I will try to respond briefly. The main questions related to the issue of esophageal length. The first problem is how to define esophageal length. There are basically three ways. One can define it, as we have in this study, on the basis of radiographic and endoscopic findings. This finding really becomes a suspicion of esophageal shortening, rather than definite esophageal shortening. We suspected that shortening was present in 20 of these patients, and nine of them required a Collis procedure. Shortening thus was actually present in only about half of those in whom it was suspected. The other way to determine esophageal length is manometrically. Possibly the best way to define a short esophagus is through the intraoperative need for esophageal lengthening, which has bearing on the last two questions that you asked. If a lengthening procedure is required to get a fundoplication below the diaphragm, a short esophagus is undoubtedly present.
The ability to add a Collis procedure is the reason we would not advocate a transabdominal approach in the case of a suspected short esophagus. In the case of poor motility, which tends to go along with a short esophagus, we would indeed favor a partial fundoplication. In our group, this procedure would be a Belsey Mark IV. When esophageal shortening is suspected, we feel much more comfortable operating in the chest, where the esophagus can be lengthened with greater ease than through the abdomen.
Footnotes
Read at the Twentieth Annual Meeting of The Western Thoracic Surgical Association, Olympic Valley, Calif., June 22-25, 1994. 
References
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 S. Mattioli, M. L. Lugaresi, M. Costantini, A. Del Genio, N. Di Martino, L. Fei, U. Fumagalli, V. Maffettone, L. Monaco, M. Morino, et al. The short esophagus: intraoperative assessment of esophageal length. J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 834 - 841. [Abstract] [Full Text] [PDF]
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D I WATSON, P G DEVITT, and G G JAMIESON The changing face of treatment for hiatus hernia and gastro-oesophageal reflux Gut, December 1, 1999; 45(6): 791 - 792. [Full Text] [PDF]
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