COMPLETE VERSUS PARTIAL FUNDOPLICATION

COMPLETE VERSUS PARTIAL FUNDOPLICATION

L. Lundell

Department of Surgery, Karolinska University Hospital, Huddinge, Stockholm, Sweden

No doubt, a total fundoplication, either modified from or constructed according to the principles originally out- lined by Nissen [1], is the most frequently performed antireflux operation worldwide [2]–[4]. This surgical ap- proach, to the long-term control of gastroesophageal re- flux disease

, has even further been popularised by the introduction of laparoscopy. Although the issue has been discussed quite vigorously, the current consen- sus is that the long-term results after laparoscopy equal that following open operations [5]–[8]. The well-known downside of a total fundoplication is the mechanical side effects which seem to occur as a consequence of an over correction of the antireflux barrier in the gastroesopha- geal junction

area. This results in some degree of dysphagia, inability to belch, postprandial bloating and flatulence [9]–[13]. These issues are of crucial impor- tance particularly so in a clinical situation where effective medical therapeutic alternatives are available and har- bour documented efficacy. To circumvent at least some of these drawbacks with the total fundoplications various forms of partial fundoplications have been launched and further explored to ascertain their efficacy and mode of action [14]–[16]. In order to understand the eventual role of partial fundoplications in the surgical treatment of

one has to understand the essentials of patho- genetic mechanisms into which fundoplication opera- tions interact. Furthermore, the mechanisms which cause postfundoplication complaints have to be clarified, and the degree by which partial or total fundoplications interfere with those to become relevant for the occur- rence of postoperative complaints. Last but not least, this chapter will focus on the available evidence which shows that partial fundoplications truly are effective in the long-term control of

.

Key pathogenetic mechanisms in GERD

The interplay between aggressive and defensive mechanisms is pivotal in the causation and prevention

of esophageal mucosal damage in

[17]. The de- fence against reflux is multi factorial: firstly the antire- flux barrier in the gastroesophageal junction, normally prevents acid to reflux into the esophagus. Secondly an intra esophageal bolus regularly triggers esophageal primary and sometimes also secondary peristalsis re- sulting in esophageal clearance of refluxed material. Fi- nally the esophageal mucosal resistance consists of acid buffering and/or dilution capacity by bicarbonate and mucus secreted by submucosal glands. Moreover, tight junctions in the basalolateral membranes can mechani- cally prevent the influx of hydrogen ions and thereby play an important role [18]. Apart from impaired clearance ability, lower esophageal sphincter pressure was long believed to be a key factor causing frequent reflux in

. The lower esophageal sphincter

is a specialised part of the distal esophagus with circular and oblique smooth muscle fibre with a length of approximately 4 cm and generates a constant high- pressure zone preventing reflux [19]. The

appears to have the following properties:

(1) The

maintains an elevated resting pressure relative to the proximal stomach and distal esophagus

(2) The

reduces the resting pressure to equal the intra gastric pressure response to proximal disten- tion (i.e., swallowed food bolus).

(3) The

contracts in response to various physio-

logical stimuli. Although it has been recognised

that in the majority of reflux patients

(see below) are the main mechanism behind re-

flux. A subgroup of patients have been found to

have a sustained reduced

pressure often

associated with severe esophagitis [19]. In those

instances reflux occurs as a consequence of steady

decline and complete relaxation of the

accompanied by a transient increase in abdo-

minal pressure whereupon spontaneous free re-

flux occurs.

assessment of

tone, over a longer period of time, has shown that

pressure is considerably higher af- ter a total fundoplication than after partial posterior one. Importantly, in the latter group pressure levels in the

region were very close to what is seen in nor- mal healthy controls.

tone assessments have dem- onstrated that after a variety of antireflux procedures, the pressure never reaches a level at which free reflux can be considered to occur (for exceptions see below).

With a growing insight into the mechanical con- sequences of a total fundoplication, the adverse conse- quences associated with a super-competent pressure zone in the lower esophageal sphincter area have become apparent. In similar situations the

relaxes incompletely on swallowing which is accompanied by abolition of gas reflux and therefore inability to belch.

Partial fundoplication procedures seem to be associated with a lower incidence of mechanical complications but some concern has been expressed that reflux control may be suboptimal or less durable than after a total fun- doplication [37]–[40]. Furthermore, in patients pro- spectively studied after a total fundoplication, it was suggested that compensatory mechanisms are operatio- nal within the esophageal wall to overcome an outflow obstruction in the gastro-esophageal junction, a phe- nomenon which is expressed in terms of increased esophageal peristaltic wave amplitude [41], [42]. It has been suggested that these mechanical adverse con- sequences may be counteracted by making the wrap shorter, looser and by the use of intra operative bougie [43]–[45]. In this context it is interesting to note that studies from our laboratory did not record any dif- ference in obstructing complaints between the patients randomised to either a total or a posterior partial fund- oplication even when these patients were investigated more than 10 years after the operation [13], [46]. The fact that we observed somewhat more complaints of odynophagia in those having a total wrap may be a subtle sign of an esophageal outflow obstruction.

One key mechanism behind side effects after fundo- plication procedures seems to reside in the postopera- tive function of the

and its capacity to relax on an appropriate stimulation. Studies have suggested that a partial posterior fundoplication normalises the

tone but does not impair the ability of the

to relax on proper stimulation but still counteracts the triggering of transient

relaxations [34], [47], [48]. In fact the

tone after a posterior partial fundoplication never Subsequent work by Dent and his co-workers [20],

[21] showed that virtually all reflux events in healthy subjects are associated with complete transient low esophageal sphincter relaxations

not associ- ated with swallowing. Most of the acid reflux events observed in

patients also occurred during

. The

are manometrically defined as an abrupt

-pressure to the level of intra gastric pressure that is not associated with a swallow. During

the activity of the crural diaphragm is also inhibited thus facilitating gastroesophageal reflux [22]–

[24]. Furthermore, other phenomena, which regularly accompany a

, are a common cavity reflecting venting of air from the stomach and an esophageal peristalsis after contraction. Gastric distention, partic- ularly of the cardic region, is a major stimulus for

through activation of gastric mechano recep- tors [19], [25]. These receptors play a pivotal role in the occurrence of

and gastroesophageal reflux.

Postprandial adaptive relaxation of the proximal stom- ach is also associated with an increase in

fre- quency and acid gastroesophageal reflux, illustrating the important relationship between gastric motor events and the occurrence of reflux [26], [27]. Intra luminal electrical impedance studies have shown that almost all

are associated with any form of re- flux, being either of gas nature, mixed or liquid content in both

patients and controls [28]. To day it is unexplained why

in

patients are more frequently associated with acid reflux. Impaired gastric emptying and augmented storage of nutrients in the gastric fundus might play a role [26], [29], [30].

Postfundoplication complaints and their causation

It is likely that a fundoplication being either total, partial anterior or posterior prevents reflux through similar mechanisms. These effects involve purely me- chanical consequences in addition to alterations in esophageal motor function since these procedures are effective not only when placed in the chest in vivo but also when tested in animal viscera in vivo [30], [31].

These operations have major effects on

func-

tion. Resting pressure of the

and the length of the

abdominal portion of the high-pressure zone are in-

creased by these operations [32]–[36]. Continued

reaches the level which is seen in healthy subjects after maximal inhibitory stimulation, and more importantly only exceptionally are

pressure levels recorded which are considered to allow free reflux over the bar- rier. By and large, dysphagia is a transient postoperative phenomenon [49]–[51], where there seems to be a relationship between recorded basal

tone and the magnitude of similar obstructive complaints. Both of these events seem to diminish with growing experience of the surgeon [52]. Fundoplication patients have a re- stricted hiatal opening and an incomplete glutative

relaxation. Consequently the

transit time is pro- longed, the degree of which is directly related to the degree of postoperative dysphagia [26], [28].

Regarding postoperative dysphagia data have been presented to show that even a subclinical outflow ob- struction in the area of the gastroesophageal junction can manometrically be assessed both in the form of increased intra bolus pressure in the distal esophagus (ramp pressure) but also expressed in terms of increased peristaltic amplitude [34]. A consistent finding in studies comparing a posterior and anterior partial fund- oplication was that a higher intra bolus pressure was recorded in the Toupet group suggesting a high level of outflow obstruction exerted by the posterior fund- oplication [53], [54]. Interestingly enough somewhat more patients in this group reported dysphagia like symptoms compared to those having an anterior partial wrap. It is reasonable to assume that the angulation of the gastroesophageal junction, created by the position- ing of the wrap behind the esophagus constitutes a major causative factor. Apparently, we as surgeons have to master a delicate balance between offering optimal reflux control and minimising the mechanical side effects of respective reconstructive procedure.

Another important reflux promoting mechanism that antireflux procedures interfere with is the trig- gering of the

[55], [56]. Repeated studies have shown total and partial fundoplications to be extremely effective in more or less abolishing these relaxations. Moreover, no major differences have been found between these different type of opera- tions. By use of well-developed experimental set-ups it has been shown that posterior partial fundoplica- tions seemed to exert advantages over a Nissen type of total fundoplication with numerically fewer dis- tension induced

in the latter group, ten- tatively explaining the differences in bloating and flatulence side effects [26], [27], [57]. When studies have been extended to the group of patients having an anterior partial wrap, the

nadir pressure dur- ing water swallows was significantly lower than in the posterior fundoplication group both in the resting state as well as after a meal or gas distension of the stomach. Patients having an anterior partial fundoplication seemed to more easily vent air from the stomach, whereas the downside of that effect may be less effective control of reflux compared to the posterior partial fundoplication according to Toupet [40], [53], [58].

The clinical importance of reducing troubles of rectal flatulence, for example by partial fundoplica- tion has to be recognised (Fig. 1). Observations of particular significance have come from a recent mul- ticenter Nordic trial in which patients were perspec- tively interviewed both before and after an antireflux operation as part of a protocol comparing medical and surgical therapy. Flatulence was found to be one of the few so-called postfundoplication symptoms that indeed increased after the operation.

Fig. 1. Postfundoplication complaints (flatulence) after either a total or a partial posterior fundo- plication

partial fundoplication fascilitating venting of air from the stomach. In conclusion evidence are accumulating to show that a partial fundoplication to a greater and a more tuned extent normalises the physiology of the

which of course is closely related to the profile and magnitude of the side effects.

Long-term reflux control

The effects of partial versus total fundoplications have been investigated in 9 randomised clinical trials. 6 were open laparotomy operations and 3 trials used lap- aroscopic approach and these studies have been pub- lished from 1974 to 2002. To these are also added some signle institution, preospective but uncontrolled observations [40], [58]–[71]. Concerning the partial fundoplications, the posterior partial type of operation was evaluated in 5 of these trials, the Hill repair in 2, the Lind subtotal posterior wrap in 1 and the anterior fundoplication in 1 study. The scheduled postoperative follow-up period ranged from 4 months to 8 years. No significant differences were found between partial versus total fundoplications in terms of new onset dys- phagia and recurrence of gastroesohageal reflux symp- toms (Fig. 2). Re-operations for failure were carried out in 1,5% of those having a partial fundoplication compared to 9,6% of those having a total fundoplica- tion, a difference which was considered to be signifi- cant [72]. In the largest randomised trial comparing a posterior with a total fundoplication which covered more than 10 years of follow up, both procedures dis- played the same level of reflux control. Based on the Although a laparoscopic fundoplication impairs

TLESRs

elicitation and renders an esophagogastric junction relaxation incomplete, the gastric accommo- dation to mechanical distention is not impaired [26], [27], [29], [30]. On the other hand, these operations exert an effect that leads to an attenuated accommo- dation of the proximal stomach followed by an in- creased distension of the distal stomach. This augmented distal stomach distension has to be better explored as potential causative factor behind post- fundoplication complaints. Patients having a posterior partial fundoplication exhibit a large meal induced in- crease in proximal stomach volume and a higher

rate than patients after a complete fund- oplication [26]. The overall pressure profile across the esophagogastric junction has been demonstrated to be markedly higher after a complete fundoplication compared to partial fundoplication. The axial esopha- gogastric junction pressure gradient may play a crucial role in the occurrence of acid reflux during a transient lower esophageal sphincter relaxation. In patients having a complete fundoplication, meal induced prox- imal gastric volume increase is reduced to a greater extent compared to those having a posterior partial fundoplication. A reduced proximal gastric volume results in a diminished cardiac cross-sectional area which in turn results in increased wall elongation and thereby reducing the activation of stretch volume receptors responsible for eliciting the transient lower esophageal sphincter relaxations. A larger postpran- dial proximal gastric volume may therefore explain the somewhat higher rate of postprandial transient lower esophageal sphincter relaxations found after a

Fig. 2. Pooled OR of reoperation for failure after partial vs total fundoplication

reassuring long-term follow-up data, it is difficult to understand why some investigators have found Toupet fundoplication not to be as successful as a total fundo- plication, in severe cases of reflux disease particularly when performed by means of a laparoscopy [39]. It cannot be denied, of course, that some procedures are more difficult to perform when modern minimal inva- sive techniques are applied. In a search for factors that may have affected the outcome after the respective procedures, we have been unable to demonstrate that the severity, the duration of disease, hiatal closure by crural repair or body mass index had any impact on the level of long-term reflux control [66].

Survey of the controlled, clinical trial literature concerning posterior partial fundoplication shows that the level of clinical reflux control is not entirely similar to what can be reached by a total wrap, when studied by ambulatory 24 pH-monitoring. After the latter procedure it becomes evident that the esophageal acid exposure is reduced to near zero values. This contrast to observations made in patients having a partial wrap where corresponding values are in the ranges considered to be normal.

In 1999, Watson and his co-workers [73] re- ported a randomised trial comparing laparoscopic Nissen fundoplication with an anterior partial vari- ant. The partial anterior fundopolication comprised an 180 wrap, where the wrap was anchored to the right hiatal pillar and the esophageal wall. The im- mediate postoperative results were very encouraging and recently the 5-year follow-up outcome was pub- lished [60]. These data have confirmed the results of the initial report showing that reflux control was somewhat better after a total fundoplication but this was reached at the prise of significantly more dys- phagia, more epigastric bloating and inferior preservation of belching. This resulted in a larger proportion of patients reporting a good or excellent overall outcome at 5 years following anterior fundo- plication (94 vs. 86%).

Are all partial fundoplications followed by the same results?

Since prevention is the best strategy, not the least since we lack effective treatment of established se- vere postfundoplication symptoms, it is important to

raise the question whether all partial fundoplications are followed by the same results? It seems beyond any doubt that less troubles and complaints of rectal flatulence follows a partial fundoplication compared to a total wrap. In a recent randomised clinical trial the questions was addressed whether there are im- portant differences between an anterior and a poste- rior partial fundoplication in terms of reflux control and side effects [53]. This trial incorporated almost 100 patients with a limited follow-up. Despite these drawbacks, significant differences were noted in fa- vour of the posterior fundoplication regarding the level of reflux control. Even when only daytime acid exposure was objectively assessed, the outcome after laparoscopic anterior partial fundoplication (accord- ing to Watson) was found to be clearly inferior (Fig. 3). Regarding side effects it was not possible to reveal any differences in obstructive complaints be- tween the two partial fundoplications but interest- ingly enough significantly more patients reported an ability to vomit after the anterior fundoplication.

This observation probably reflects the efficacy of the respective repair. Why should an anterior partial

Fig. 3. Esophageal acid exposure before (a) and (b) months after an anterior (Watson) or posterior (Toupet) partial fundo- plication. Adapted after [53]

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fundoplication function differently from a posterior one? The extent of the distal esophageal body that is encircled by the actual wrap varies somewhat be- tween the respective procedures. The posterior fun- doplication elevates the abdominal portion of the esophagus from its native bed in the hiatus and by necessity angluates the gastroesophageal junction.

The significance of this has to be better clarified but may have the potential to cause some esophageal outflow obstruction but it is totally unclear whether it contributes to a better mechanical barrier to pre- vent gastroesophageal reflux. The anterior partial fundoplication performed and recently validated by Watson and co-workers from Australia [60], differs somewhat from that originally described in 1991 [16]. The message is, however clear, if an anterior fundoplication is chosen it has to be a complete an- terior 180 wrap but more studies are required to give firm guidance to the clinicians.

Concluding remarks

With the aim of optimising the outcome of antire- flux surgery, the surgeon has to perform and master a delicate act of balance on the choice between va- rious fundoplication procedures. On one hand we have the total fundoplication with its proved efficacy regarding reflux control but with it associated me- chanical side-effects leading to symptoms relating to the relative obstruction in the gastroesophageal junction and the inability to vent air from the stomach and the sequelae that follow. The posterior partial fundoplication has obvious advantages with less postfundoplication complaints without com- promising with the level of reflux control and can therefore be generally recommended. Some anterior partial fundoplication present very promising results but confirmative studies are warranted.

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