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34
Partial or Total Fundoplication for
Gastroesophageal Reflux Disease in the Presence of Impaired Esophageal Motility
Jedediah A. Kaufman and Brant K. Oelschlager
erly powered randomized trials differentiating outcomes for patients undergoing fundoplication in the setting of impaired esophageal peristalsis do not exist. Objective data is also missing in most studies. Postoperative manometry and pH studies are rarely performed in suffi cient numbers for adequate comparison, and are more often done in patients with recurrent or persistent problems, thus potentially skewing the results.
Still, there are some good studies published recently that can help answer the question: partial or total fundoplication for GERD in the presence of impaired esophageal motility?
Oleynikov and others compared PF and TF outcomes in patients with defective peristalsis [defi ned as distal esophageal amplitude (DEA)
<40mmHg in >70% of swallows].1 Eighty-six patients were studied, 39 underwent PF and 57 underwent TF. No patient in the TF group devel- oped new dysphagia. In fact, preoperative dys- phagia among all TF patients greatly improved.
There were inferior results in the PF group, as existing dysphagia failed to signifi cantly improve after operation. Heartburn improved after both PF and TF, although TF provided much better control of refl ux. While both groups experienced a signifi cant improvement in the objective control of GERD, there were lower levels of acid exposure in the TF group on pH monitoring. The DeMeester scores in the TF group decreased from a median of 57.1 preoperatively to 6.3 postoperatively, com- pared to 72.3 preoperatively to 11.3 postopera- tively for the PF group. Interestingly, postoperative manometry demonstrated a signifi cant increase in amplitude of esophageal peristalsis in the TF Anti-refl ux surgery has evolved greatly in the last
15 years as a durable, viable, and safe option for treatment of gastroesophageal refl ux disease (GERD), mainly due to the advent of minimally invasive techniques. The debate regarding partial fundoplication (PF) versus total fundoplication (TF) for patients with defective peristalsis and GERD has evolved as well. Nissen fundoplication is by far the most common fundoplication tech- nique used for many decades. However, many surgeons prefer a PF in patients with defective peristalsis. This tailored approach developed due to the logical, but unproven, theory that dyspha- gia is more likely when impaired esophageal peri- stalsis fails to propel a swallowed bolus across a 360° fundoplication (or TF). Recent literature has challenged this notion, suggesting that TF is not more likely to cause dysphagia than PF. More- over, there is evidence that PF provides inferior control of refl ux compared with TF, thus tailor- ing may be to the detriment of refl ux control.
We will consider the evidence for performing a partial fundoplication in patients with impaired peristalsis, as well as any differences in postop- erative dysphagia and the ability of TF or PF to control GERD.
34.1. Detailed Review of Key Studies
The literature on anti-refl ux surgery for patients with defective peristalsis has several inherent problems. There are no standard defi nitions for defective and normal peristalsis, and techniques and types of TF and PF vary widely. Large, prop-
group from 30.6mmHg to 49.0mmHg postfundo- plication. While the peristaltic amplitudes increased in the PF patients (27.7mmHg to 35.6mmHg, p = ns), this change was not statisti- cally signifi cant. The sample size in this study is moderate, but the results are compelling. The study looks at specifi c outcomes of laparoscopic partial versus total fundoplication to answer spe- cifi c questions regarding dysphagia, GERD symp- toms, and requirements for invasive or operative treatment for complications or recurrence of symptoms. The study suggests that TF be used in all patients regardless of peristaltic quality (level of evidence 4). However, patients with true aperi- stalsis, such as those with scleroderma, may still be candidates for partial fundoplication.
Patti and others compared their experience with a tailored approach (1992–1999) to their more recent nontailored approach (2000–2002).2 With the tailored approach they had more refl ux (15% TF vs. 33% PF) and the same amount of dysphagia (11% TF vs. 8% PF). In patients with defective peristalsis (55), early dysphagia occurred in 5 (9%), resolving in 3 patients after an average of 5 months (3–6 months) and after dilation in 2 patients. No patient in either group required operation or had residual dysphagia after dila- tion. There was no difference in rates of dyspha- gia, dysphagia scores, lower esophagael sphincter (LES) length, amplitude of peristaltic waves, medication requirements, or re-operations between TF and PF. There were differences in the competency of the cardia, as TF resulted in better relief of heartburn, increased LES pressure, and lower DeMeester scores. In the subsequent period of time when the tailored approach was aban- doned, routine TF resulted in superior objective and subjective control of GERD, while dysphagia rates did not increase. The authors suggest that a tailored approach should be abandoned in favor of routine TF (level of evidence 4). The large sample size and excellent comparison of both defective peristalsis patients undergoing PF and TF as well as normal peristalsis patients undergo- ing TF allows proper analysis of outcomes of new dysphagia and recurrent GERD symptoms.
Rydberg and others randomized one hundred and six patients to PF or TF irrespective of their preoperative esophageal peristalsis characteris- tics.3 Sixty-seven patients had defective peristal-
sis (defi ned as DEA ≤30mmHg, failed primary peristalsis, or >20% simultaneous contractions).
Of the patients with defective peristalsis, 34 underwent TF and 33 PF. Follow-up for these patients was at least 3 years. Overall, dysphagia incidence decreased from 20% preoperatively to 8% postoperatively at a minimum of 3-year follow-up. No difference in symptoms was found postoperatively between those receiving PF and TF. There were fewer patients with hyperfl atu- lence after PF than TF (23 vs. 58). The authors concluded that tailoring antirefl ux surgery based on preoperative esophageal motor function was not supported (level of evidence 2b). This is a well-designed trial with 3 years minimum follow- up. Although only a small sample size was reported, the results are reproducible in many other similar-sized studies. The authors specifi - cally analyzed their data utilizing several methods and were still unable to fi nd correlations between outcomes, peristalsis, and type of fundoplica- tion. The length of follow-up strengthens the con- clusions that tailoring anti-refl ux surgery to peristaltic quality is unfounded.
In a well-designed, short-term prospective, randomized trial, Zornig and others evaluated 200 consecutive patients undergoing anti-refl ux surgery.4 They were not selected according to their esophageal motility; however, patient out- comes were analyzed according to motility post hoc. Patients were randomly assigned TF or PF.
Defective peristalsis was defi ned as mean DEA
<40mmHg and/or failed primary peristalsis in
>40% of 10 wet swallows. Results were analyzed at 1 week and 4 months postoperatively only, thus long-term results are not available. This nega- tively affects the impact of this study. Patients with early dysphagia, even after only 1 week, underwent early endoscopic evaluation and dila- tion. At four months, 41 patients had dysphagia (57 had dysphagia preoperatively), and of these 41, 19 had normal peristalsis and 22 had defective peristalsis preoperatively. The incidence of dys- phagia increased in the TF group (from 24 to 30 patients) while decreasing in the PF group (from 33 to 11 patients). New dysphagia was found in 24 patients, equally distributed between patients with normal and defective peristalsis. Fourteen patients required redo fundoplication (13 TF, 1 PF), 10 for recurrent refl ux with esophagitis and
mild dysphagia, and 4 for severe dysphagia. Of these 14 redo patients, 10 TF patients herniated their intact wrap above the diaphragm, a known anatomical cause of dysphagia postfundoplica- tion. Therefore, it is possible that poor construc- tion and not the 360° nature of the TF caused these failures. In the defective peristalsis group, no signifi cant difference in dysphagia was seen based on operation performed, with seven under- going TF and fi ve with PF.
Technical aspects of anti-refl ux surgery are no doubt important in avoiding dysphagia and control of GERD after fundoplication. The authors concluded that PF is superior to TF in prevention of postoperative complications such as dysphagia (level of evidence 2b), although the very high incidence of recurrent hiatal hernia casts doubt on this conclusion. The authors also pursued an unorthodox approach of early dila- tion for dysphagia within the fi rst few weeks, a practice that has been associated with fundopli- cation disruption. Finally, dysphagia after TF is common 3 to 6 months following surgery, and most surgeons do not intervene as it usually resolves. The extremely short follow-up of this study severely detracts from the ability to gener- alize its fi ndings.
The small randomized, prospective trial by Chrysos and others evaluates 33 patients with defective peristalsis (defi ned as DEA <35mmHg) comparing TF (Nissen–Rossetti) with PF (Toupet) and found no differences in dysphagia at 12 month follow-up.5 In the short term (3-month follow-up), TF was associated with more dyspha- gia (57% TF vs. 16% PF); however, by 1 year, only 14% of TF patients and 16% of PF patients reported mild dysphagia. No patient had severe dysphagia at 1 year. In a similar pattern, gas-bloat syndrome occurred more often in the TF at 3 months, but this difference was not apparent at 1 year when 21% of TF and 16% of PF patients reported bloat- ing symptoms. Postoperative LES pressures were signifi cantly improved in all patients, with no difference between TF and PF. Total fundoplica- tion and PF equally controlled refl ux with post- operative DeMeester scores decreasing to 12 in PF and 14 in TF. The authors recommended TF in patients with defective peristalsis due to litera- ture indicating it as a superior long-term barrier of refl ux compared to PF (level of evidence 2b).
This is a small study without the appropriate power to determine whether TF or PF is superior;
however, it was properly randomized and double blinded. The results concur with large studies regarding TF in patients with defective peristalsis.
The study by Ludemann and others evaluates long-term follow-up of a randomized, double- blinded trial between laparoscopic TF versus anterior 180° PF.6 Although patients with motil- ity problems were not included, this well-designed and executed paper is an excellent comparison between PF and TF. At 5 years, 101/107 (98%) patients were included, with 51 undergoing TF and 50 undergoing PF. There were no signifi cant differences between the groups with regards to control of heartburn, patient satisfaction, or use of proton-pump inhibitors. Dysphagia for solids, bloating, inability to belch, and fl atulence were more common after TF. Recurrent refl ux was more common after PF. Re-operation was required for three patients with TF for dysphagia and three patients with PF for recurrent refl ux.
Few studies have 5-year follow-up, with 98%
response in a moderate-sized patient group (level of evidence 2b). In addition, the researchers remained blinded initially and at 5 years, elimi- nating reporter bias. The main weakness is that results are based solely on questionnaire answers of patients and no objective data is reported.
However, at 6 months, the same patient group underwent manometry, pH monitoring, and clin- ical evaluation. Results showed that both opera- tions normalized esophageal acid exposure, TF improved LES pressures compared to PF, and a higher incidence of dysphagia at 3 months was seen with TF. This increase disappeared at 6- month follow-up.7 The authors concluded that anterior PF was as effective as TF for long-term GERD symptom control. However, a higher risk of recurrent GERD symptoms was seen with PF.
The available quality of evidence throughout the literature is comprised of predominantly case series of small-to-moderate numbers of patients.
The vast number of technical differences found in anti-refl ux procedures and the subtle differ- ences in defi nitions of motility disorders often hampers proper comparison of studies and tech- niques. Without larger, signifi cantly powered studies with defi nitions that are agreed upon for
accurate patient comparison, specifi c guidelines are diffi cult to create. Based on the available data and substantial experience utilizing both a tai- lored and nontailored approaches to anti-refl ux surgery, we fi nd little to support PF for patients with poor motility (level of evidence 2b; recom- mendation grade B). Although a few large case series show PF does improve refl ux (although less than TF), and although TF may have higher rates of early complications, no convincing evidence supports the tailored approach. Evidence contin- ues to mount showing PF is inferior for refl ux control and a properly constructed TF causes little signifi cant dysphagia or decreased quality of life beyond 3 to 6 months from surgery.
34.2. Impact on Clinical Practice
Application of the literature to determine the correct approach for patients with defective peri- stalsis depends on its interpretation. One must apply knowledge of the key technical aspects of fundoplication construction and look critically at causes of dysphagia and poor refl ux control. It is clear that there is not a degree of impaired peri- stalsis, as determined by manometry, which con- sistently results in a greater rate of postoperative dysphagia if a TF is performed.8 Therefore, for most abnormalities of peristalsis, a TF can be safely performed. Partial fundoplication does not appear to reliably decrease the incidence of dysphagia either in patients with or without defective peristalsis. No properly weighted and designed study yet demonstrates true correlation between preoperative factors and the develop- ment of postoperative dysphagia.9 The literature currently supports that patients with defective peristalsis undergoing TF have more early (6–12 weeks) dysphagia than those undergoing PF;
however, this seems to be transient and no differ- ence between TF and PF remains at 1 year and beyond. In fact, esophageal motility tends to improve after TF, perhaps due to better control of GERD, reducing esophageal infl ammation and injury.1,3,10,11 The compilation of long-term data seems to suggest that preoperative motor function does not predict postoperative dysphagia,3,12,13 but that operative technique is more likely the culprit than preoperative variables. Anatomical
causes such as tight, twisted, or slipped fundopli- cations and use of the stomach body rather than the fundus to create the wrap, essentially causing a bilobed, obstructed, or ineffi cient wrap, all sig- nifi cantly effect postoperative dysphagia and GERD control.4,14–17 New or worsening dysphagia occurs after fundoplication in 2% to 14% of patients.3,18 Barring signifi cant technical errors, unexplained dysphagia, with a normal fundopli- cation, decreases to around 1% to 2%.
With a few notable exceptions, the literature currently supports that patients with defective peristalsis and TF have better control of GERD than those undergoing PF.1,2,8,19–26 Most studies show inferior results of PF, both in patients with and without defective peristalsis. In most sur- geons’ hands, PF does not provide as reliable control of GERD as a TF. There are, however, some exceptions as shown in the articles reviewed.
Thus, the best way to prevent dysphagia and control refl ux is a well constructed fundoplica- tion. Tailoring the fundoplication, based solely on the peristalsis measured by manometry, is not supported by data, and the approach should be abolished.
34.3. Opinion Statement
We perform TF for all patients with defective peristalsis except in those patients who have essentially no peristaltic activity (i.e., aperistal- sis). We feel that our experience and the evidence suggest that this provides the best combination of refl ux control while limiting side effects. We perform preoperative manometry with imped- ance on all patients to (1) properly identify the LES for accurate pH probe placement, (2) provide objective information about the physiology of GERD in each patient (LES function, esophageal clearance, etc.), and (3) regularly identify patients with achalasia and other primary esophageal motility disorders that affect management.
We place great importance on certain techni- cal aspects of the Nissen fundoplication in order to relieve GERD and avoid dysphagia.27 These steps include:
1. Mobilization of the distal esophagus ade- quately into the mediastinum to obtain 3 to 4 cm
of intra-abdominal esophageal length to prevent recurrent hernia. Results of studies examining outcomes of patients with extensive mediastinal dissection show that lengthening procedures such as the Collis gastroplasty are rarely needed, even with large paraesophageal hernias.28,29
2. Complete gastric fundus mobilization, including all short gastric vessels to avoid torque or angulation. A few studies refute division of the short gastric vessels, however an abstract by Jones and colleagues showed signifi cant decrease in dysphagia with complete fundal mobiliza- tion.30 Experienced clinicians fi nd that leaving these fundic and body attachments increases torque and angulation of the gastroesophageal junction and potentially increases postoperative dysphagia.31
3. Creation of a 360° fundoplication over a bougie 52 to 60 Fr to help assure a very fl oppy fundoplication. Although disagreement over the appropriate size bougie or whether to use one at all still exists, the loss of palpation of the esopha- gus and wrap looseness supports the idea of using multiple methods to avoid creating too tight a wrap. Most accepted technique for this includes use of a larger bougie, especially with dysmotility.32
4. Careful construction of the wrap with equal portions of posterior and anterior fundus, avoid- ing errors such as using the body of the stomach or leaving redundant fundus behind the wrap.33 By utilizing equal portions of the anterior and posterior fundus, the esophagus is imbricated into a neutral fundus, preventing torque and minimizing angulation.
Although we can hope for larger, randomized studies, with long-term clinical and objective results to more defi nitively end this debate, the existing evidence does not support the construc- tion of a PF because of impaired esophageal peri- stalsis. Rather, it suggests that the surgeon perform the best fundoplication he/she can in terms of controlling refl ux and avoiding compli- cations. This opinion is based on level 2b evi- dence and should only be applied specifi cally to the techniques described. Several pitfalls exist in interpreting this data, pitfalls we have found ameliorated by very careful techniques that, although may not prevent all complications, cer-
tainly minimized postoperative dysphagia. Suf- fi ciently powered studies to prove these techniques do not exist, and yet our investigations have shown that overall technical aspects of the opera- tion are more often the cause of dysphagia than quality of peristalsis.
References
1. Oleynikov DET, Oelschlager BK, Pellegrini CA.
Total fundoplication is the operation of choice for patients with gastroesophageal refl ux and defec- tive peristalsis. Surg Endosc 2002;16:909–913.
2. Patti MG, Robinson T, Galvani C, Gorodner MV, Fisichella PM, Way LW. Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg 2004;198:863–869; discussion 869–870.
3. Rydberg L, Ruth M, Abrahamsson H, Lundell L.
Tailoring antirefl ux surgery: a randomized clini- cal trial. World J Surg 1999;23:612–618.
4. Zornig C, Strate U, Fibbe C, Emmermann A, Layer P. Nissen vs Toupet laparoscopic fundoplication.
Surg Endosc 2002;16:758–766.
5. Chrysos E, Tsiaoussis J, Zoras OJ, et al. Laparo- scopic surgery for gastroesophageal refl ux disease patients with impaired esophageal peristalsis:
total or partial fundoplication? J Am Coll Surg 2003;197:8–15.
6. Ludemann R, Watson DI, Jamieson GG, Game PA, Devitt PG. Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication. Br J Surg 2005;92:
240–243.
7. Lundell L, Abrahamsson H, Ruth M, Sandberg N, Olbe LC. Lower esophageal sphincter characteris- tics and esophageal acid exposure following partial or 360 degrees fundoplication: results of a prospective, randomized, clinical study. World J Surg 1991;15:115–120; discussion 121.
8. Beckingham IJ, Cariem AK, Bornman PC, Calla- nan MD, Louw JA. Oesophageal dysmotility is not associated with poor outcome after laparoscopic Nissen fundoplication. Br J Surg 1998;85:1290–
1293.
The existing evidence does not support the construction of a partial fundoplication in the management of GERD because of impaired esophageal peristalsis (level of evidence 2b;
recommendation grade B).
9. Wills VL, Hunt DR. Dysphagia after antirefl ux surgery. Br J Surg 2001;88:486–499.
10. Heider TR, Farrell TM, Kircher AP, Colliver CC, Koruda MJ, Behrns KE. Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility. J Gas- trointest Surg 2001;5:36–41.
11. Heider TR, Behrns KE, Koruda MJ, et al. Fundo- plication improves disordered esophageal motil- ity. J Gastrointest Surg 2003;7:159–163.
12. Mughal MM, Bancewicz J, Marples M. Oesopha- geal manometry and pH recording does not predict the bad results of Nissen fundoplication.
Br J Surg 1990;77:43–45.
13. Hakanson BS, Thor KB, Pope CE 2nd. Preopera- tive oesophageal motor activity does not predict postoperative dysphagia. Eur J Surg 2001;167:
433–437.
14. Watson DI, Jamieson GG, Mitchell PC, Devitt PG, Britten-Jones R. Stenosis of the esophageal hiatus following laparoscopic fundoplication. Arch Surg 1995;130:1014–1016.
15. Horgan S, Pohl D, Bogetti D, Eubanks T, Pellegrini C. Failed antirefl ux surgery: what have we learned from reoperations? Arch Surg 1999;134:809–815;
discussion 815–817.
16. Soper NJ, Dunnegan D. Anatomic fundoplication failure after laparoscopic antirefl ux surgery. Ann Surg 1999;229:669–676; discussion 676–677.
17. Hunter JG, Smith CD, Branum GD, et al. Laparo- scopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 1999;230:595–604; discussion 606.
18. Wetscher GJ, Glaser K, Gadenstaetter M, Profanter C, Hinder RA. The effect of medical therapy and antirefl ux surgery on dysphagia in patients with gastroesophageal refl ux disease without esopha- geal stricture. Am J Surg 1999;177:189–192.
19. Eubanks TR, Omelanczuk P, Richards C, Pohl D, Pellegrini CA. Outcomes of laparoscopic antire- fl ux procedures. Am J Surg 2000;179:391–395.
20. Jobe BA, Wallace J, Hansen PD, Swanstrom LL.
Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal refl ux. Surg Endosc 1997;11:1080–1083.
21. Farrell TM, Archer SB, Galloway KD, Branum GD, Smith CD, Hunter JG. Heartburn is more likely to
recur after Toupet fundoplication than Nissen fundoplication. Am Surg 2000;66:229–236; discus- sion 236–237.
22. Pessaux P, Arnaud JP, Ghavami B, et al. Laparo- scopic antirefl ux surgery: comparative study of Nissen, Nissen–Rossetti, and Toupet fundoplica- tion. Societe Francaise de Chirurgie Lapa- roscopique. Surg Endosc 2000;14:1024–1027.
23. Bell RC, Hanna P, Mills MR, Bowrey D. Patterns of success and failure with laparoscopic Toupet fundoplication. Surg Endosc 1999;13:1189–1194.
24. Horvath KD, Jobe BA, Herron DM, Swanstrom LL.
Laparoscopic Toupet fundoplication is an inade- quate procedure for patients with severe refl ux disease. J Gastrointest Surg 1999;3:583–591.
25. Livingston CD, Jones HL Jr, Askew RE Jr, Victor BE, Askew RE Sr. Laparoscopic hiatal hernia repair in patients with poor esophageal motility or paraesophageal herniation. Am Surg 2001;67:
987–991.
26. Baigrie RJ, Cullis SN, Ndhluni AJ, Cariem A. Ran- domized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplica- tion. Br J Surg 2005;92:819–823.
27. Pellegrini CA. Therapy for gastroesophageal refl ux disease: the new kid on the block. J Am Coll Surg 1995;180:485–487.
28. O’Rourke RW, Khajanchee YS, Urbach DR, et al.
Extended transmediastinal dissection: an alterna- tive to gastroplasty for short esophagus. Arch Surg 2003;138:735–740.
29. Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presenta- tion, and treatment in the era of laparoscopic anti- refl ux surgery. Ann Surg 2000;232:630–640.
30. Jones DBDD, Soper NJ. Dysphagia after laparo- scopic fundoplication is diminished by dividing short gastric vessels. Gastroenterology 1995;4(suppl 3):A1224.
31. Hunter JG, Swanstrom L, Waring JP. Dysphagia after laparoscopic antirefl ux surgery. The impact of operative technique. Ann Surg 1996;224:51–57.
32. Limpert PA, Naunheim KS. Partial versus com- plete fundoplication: is there a correct answer?
Surg Clin North Am 2005;85:399–410.
33. Oelschlager BK, Pellegrini CA. Minimally invasive surgery for gastroesophageal refl ux disease. J Lap- aroendosc Adv Surg Tech A 2001;11:341–349.
