Fundoplication for Reflux Esophagitis: Misadventures with the Operation of Choice HIRAM C. POLK, JR., M.D.

Fundoplication, whether performed by thoracic or abdominal approach, is a sound method for control of reflux esophagitis. A series of 312 operations have been reviewed to assess the frequency of complications and the methods by which these can be prevented or treated effectively. Each source of an untoward outcome is examined in detail, and suggestions as to prevention or recognition are advanced. The current low death and complication rates have been lowered even more by a conscious effort to refine the procedure further; such efforts have been associated with a failure rate of less than 5% in a mean followup of 4 years.

T HE OPERATIVE APPROACH to hiatal hernia and reflux esophagitis has evolved significantly both in concept and precept, particularly over the last decade. Indeed, the early operations oriented toward anatomic reconstruction of a hernial defect have been subjugated to the physiologic correction of the associated symptomatic abnormality, i.e., reflux esophagitis secondary to reflux of gastric acid. Although working independently, Nissen and Belsey and their respective colleagues8'11 simultaneously turned to valvuloplasty operations to control the

debilitating reflux of gastric acid into the lower esophagus. Anatomic hernia repair remained a secondary component of their procedures. Although this concept is more than a score of years old, only within the last decade has widespread acceptance been achieved. The clinical results associated with these operations include very reasonable morbidity and mortality and a substantial increase in efficacy and alleviation of symptoms, especially when compared to what had been achieved by anatomic reconstruction. Whereas a failure rate of 25% or Presented at the Annual Meeting of the Southern Surgical Association, December 8-10, 1975, The Homestead, Hot Springs, Virginia.

From the Department of Surgery and the Price Institute of Surgical Research, the University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky 40201

more was common with operations devoted to restoring normal anatomy, failure rates of well under 10% are associated with the valvuloplasty procedures. Impressive pre- and postoperative physiologic observations in man by DeMeester and associates2 point to the significant beneficial effects of the fundoplication procedure (Nissen) with respect to the two other popular valvuloplasty operations. DeMeester's data derived from esophageal pH monitoring1 clearly indicate the superiority of the fundoplication procedure as studied in his patients regarding acid reflux, minimal esophageal pH < 4, number of reflux episodes, esophageal motility, and distal esophageal sphincter pressure and length. Our attention now turns to considering the adverse results of what is the operation of choice for a relatively prevalent disease. The purpose of this report is to describe a substantial personal experience with the operative procedure and to emphasize the adverse results so that those with less experience or those undertaking the procedure initially may eliminate these particularly painful, and perhaps now unnecessary, hazards.

Description of Over-All Experience In prior studies reported by Zeppa and Polk,9 only 90 fundoplication operations for reflux esophagitis were performed even though some 7,000 patients with hiatal hernia were diagnosed radiographically within their

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TABLE 1. Indications for Fundoplication for Reflux Esophagitis

Intractable Esophagitis Dysphagia Co-existent Illness Acute Incarceration Pulmonary Aspiration Angina Syndrome

92% 3% 2% 1% 1% 1%

medical center. During this experience at the University of Miami, very few procedures for this particular illness were performed by other surgeons. Whether this is a valid proportion of patients with hiatal hernia who warrant operation or not is a subject addressed previously.9 The purpose here is only to qualify the experience from which this particular report is derived. The author's personal experience now numbers 312 operations performed for reflux esophagitis in which the principal component of repair was fundoplication. The prime indication for operation has been reflux esophagitis unresponsive to nonoperative management. Table 1 lists the specific indications for operation; there were 220 transabdominal operations and 92 performed by transthoracic incision. It is better to adapt the particular operative approach to the circumstances characterizing the patient in question, than for approach to be dictated by the surgeon's preference or limitations in technique. Morbidity attending this operation is in part a function of the frequency of associated operations, categorized by transthoracic or transabdominal approaches (Table 2). The over-all morbidity is 14%. Three of the 312 patients died during hospitalization and are discussed in depth. Operating time for fundoplication averaged just under two hours when performed by the transthoracic route and just under one hour when performed by the transabdominal route as an isolated procedure. Postoperative hospitalization averaged 8.2 days. The ultimate measure of success is the consistent amelioration of symptoms. The initial 100 patients were studied in detail, with emphasis on repeated endoscopic studies (carried out frequently in the early postoperative period and less frequently thereafter) of the patients to confirm the continuing absence of esophagitis.9 The failure rate with a mean followup of 3.8 years on the patients reported herein is 4.1%. Approximately half the failures related to primary anatomic recurrence of hernia, usually associated with gastroesophageal competence. However, the other half (2%) are more or less anatomically satisfactory but represent recurrence of reflux esophagitis. This early failure rate is highlighted by Nissen's earlier observation that most of his failures became apparent within three years of operation.8 The failure rate in our first group of patients has not increased between the fourth and seventh postoperative years.

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Adverse Results

Minor Problems Among the less catastrophic misadventures which have generally not influenced either the long-term health of the patient or detracted from the over-all benefits of the operation is the vexing problem of incidental splenectomy. Indeed, when one must mobilize-occasionally in the face of prior operation-distal esophagus and proximal stomach, injury to the spleen occurs: 1) directly by the surgeon's instruments; 2) indirectly by retractors; 3) more commonly by traction medially and downward on the esophagogastric junction, producing capsular splenic tears. Seven per cent of patients have required treatment for unintentional injury to the spleen, partially justified by the wide exposure essential for fundoplication. Our initial response was that operatively injured spleens required excision. In recent years, following the lead of Hardy and Yelverton,3 we have on four occasions found patients with limited and readily controlled capsular tears which could be treated by nonexcisional methods after release of the traction and careful attention to hemostasis in the splenic capsule. The late adverse effect of splenectomy in an often middle-aged to elderly adult population is not serious. However, the ultimately nonfatal complication of hiatal hernia repair in our experience has been subphrenic abscess. This has never occurred in the absence of splenectomy, although only two abscesses have followed the 20 splenectomies. Operative wound infection has been an irregular product of this particular procedure, occurring more frequently in patients undergoing abdominal operations (Table 3). If data are adjusted for frequency of operations devoted only to the treatment of reflux esophagitis and hiatal hernia and excluding adjunctive procedures TABLE 2. Complications of Fundoplication

Transabdominal Operations Isolated for Esophagitis* Systemic (4) Infection Wound (4) Deep (2) Includes Concomitant Procedures Systemic (I 1) Infection Wound (7) Deep (2) Obstruction (1) Transthoracic Operationst Systemic (7) Infection Wound (2) Atelectasis/Pneumonia (2) Local, Other (1) * Includes unintentional splenectomy. t Includes both isolated and concomitant procedures.

220 116

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for other illnesses, the percentage of operative wound infection becomes consistent with that in other clean operations. When an operative attack is aimed at reflux esophagitis alone, the operation is indeed a clean one, and none of the special measures known to control infection with potentially contaminated operations appears to be indicated. A third nuisance has been dehiscence of the fundoplication, often discovered on some later radiographic studies. Hernial repair was maintained in 6 patients and gastroesophageal competence in 4 patients. In one patient, the fundoplication remained intact but slipped down around the midportion of the stomach, producing an hourglass gastric deformity unassociated with symptoms; it continues as such in that particular patient. At least two of the physiologic failures were associated with dehiscence of the fundoplication. Subsequently, we have replaced atraumatic gastrointestinal sutures of 3-0 silk used for the plication with 2-0 variety, eliminating dehiscence of the fundoplication. Whether this is a matter of suture bulk or improper placement is undetermined. We believe that we have consistently used deeply placed seromuscular sutures in the gastric fundus. How does one insure that the fundoplication stays in place about the distal, intra-abdominal esophagus? If the fundoplication is of normal length and the left gastric artery does not have to be transected to provide exposure, the plication simply rests upon the insertion of the left gastric artery on the lesser curvature of the stomach. In some circumstances when that insertion is particularly low or when it has been necessary to transect this insertion, the fundoplication should be anchored at the lower portion of the now intra-abdominal esophagus. The most secure suture for this purpose should be placed at the lower border of the fundoplication where with the lowest plicating suture the stomach can be included very near the esophagogastric junction along the lesser curvature. Never have we secured the fundoplication to the diaphragm itself because these two components of esophagogastric competency function better independently. The most frequent nuisance complication of fundoplication is transient dysphagia, typically appearing on the tenth postoperative day and disappearing by the twentieth postoperative day. Presumably, this results from local edema and the usual progression from a liquid to a solid diet over this period. Each of the 58 patients who developed this problem responded immediately when a liquid diet was maintained for two weeks and there was no recurrence of the dysphagia. Associated studies of evidence of vagal function carried out in a few such patients have indicated that inadvertent vagal injury is not responsible.

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TABLE 3. Wound Infection After Abdominal Fundoplication for Reflux Esophagitis Isolated Operations for Esophagitis With Splenectomy Without Splenectomy Total Concomitant Operationst For Ulcer Disease For Biliary Tract Disease For Colonic Disease For Others Total

3/18* 1/98 4/116

16% 1% 3%

3/21 1/28 1/5 2/50 7/104

7%

* Two of the 20 splenectomies were associated with concomitant operations. t Systemic antibiotics were frequently administered in the peri-operative period.

Judgmental errors also contribute significantly. Three patients who underwent laparotomy clearly would have had more adequate reconstruction and repair by the transthoracic approach; the reverse was recognized in one patient. On 6 occasions, ill-advised complementary procedures produced one early and 6 late complications. All procedures were vagotomy and drainage performed without clear-cut evidence of intractable duodenal ulcer disease. One of these patients represents the worst nonfatal complication in the series, his digestive disturbance leading to total disability after a variety of remedial operations. Failure to add myotomy in the presence of clear signs of disorders of esophageal motility mandated a secondary procedure in one patient. Major Problems

Aside from those patients subjected to multiple, associated operations on a single occasion, major disasters accompanying fundoplication for hiatal hernia have only been associated with unintentional injury to the spleen, mobilization of an acutely inflamed esophagus, and other visceral injury. A principal reason that a more conservative aproach to superficial splenic injuries has been taken in recent patients is that the only subphrenic abscesses in this series followed splenectomy for what seemed to be minor trauma. One patient had a very long course with the first manifestation of his undrained abscess being atrial fibrillation.5 Indeed, the final component of this particular patient's abscess was drained through the left lower quadrant, necessitating a three-month hospitalization. Since the two deaths associated with early operation for severe edematous, weeping esophagitis (vide infra), the three additional patients with this disease were treated by insertion of a small nasal tube and a continuous antacid drip to induce relative healing of the acutely inflamed organ. Resolution of the inflammatory process has alway been demonstrated on repeated study

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within a week when the antacid is given faithfully. Within another week, operation can be undertaken with sufficient resolution of the inflammatory process to make handling of the acutely inflamed organ surgically safe. Another special problem concerns the management of the patient with Schatzki ring formation.10 Such apparent ring formation in most patients is spastic, unassociated with an organic obstruction, and readily disappears following operative control of the reflux. However, in none of the four patients requiring excision of a fibrotic ring have we experienced particular difficulty approaching the excision of the fibrotic ring by high gastrotomy. Esophageal fistula relating to excision of a fibrotic Schatzki ring through an esophagotomy has occurred. The obvious lesson is that such lesions should be dealt with by transversely placed proximal gastrotomy just below the esophagogastric junction. The diaphragmatic narrowing can be prolapsed into the stomach, excised readily, and esophageal mucosal continuity restored if this is the preference; simple healing occurs regularly without mucosal suture, provided reflux is terminated. Hospital Deaths Of the three patients who died, the first was a 55-yearold man with disabling severe reflux esophagitis producing intractable pain. An acutely weeping esophagus was identified endoscopically, and barium study disclosed an active duodenal ulcer. This patient also had severe rheumatoid arthritis, treated with systemic corticosteroids. He underwent a transabdominal exploration which confirmed the presence of a duodenal ulcer. During excision of a segment of the posterior vagus, the acutely inflamed peri-esophageal tissue began to bleed, and an opening in the posterior aspect of the esophagus was made. The esophagus was then gently mobilized downward, but in doing so an additional rent was made in the esophagus. Bleeding from the left gastric artery was encountered and controlled. Fundoplication was completed and esophageal repair buttressed with the plication at the sites of injury. Pyloroplasty and gastrostomy were also added. The patient developed signs of bilateral bronchopneumonia in the presence of prior co-existing chronic obstructive emphysema. Although alimentary function was normal, he developed a fulminant gram negative pneumonitis. Present-day respiratory support was not available, and despite tracheostomy and repeated bronchoscopy the patient died of progressive pneumonitis. In retrospect, the duration of operation required because of injury to the acutely inflamed esophagus certainly prolonged anesthesia. At no time did the local problem associated with his severely inflamed esophagus appear to contribute to his death.

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The second patient was a 62-year-old man with an 18-year history of esophageal reflux with severe esophagitis unresponsive to prior vagotomy and pyloroplasty. Preoperative evaluation showed an acutely weeping, inflamed esophagus with apparent shortening. Transthoracic operation disclosed the particularly tenuous nature of the esophagus. Although the esophagus was not injured, gentle handling did induce bleeding in the peri-esophageal tissues and a lengthy dissection up to the aorta to the left chest was undertaken to restore the esophagogastric junction to its subdiaphragmatic position. Fundoplication was otherwise completed normally. The patient did well for three days but then became profoundly ill. Chest films showed evidence of fluid and air in the left chest. A clinical diagnosis of esophageal disruption was made and immediate reoperation undertaken. Dissolution of about two-thirds of the circumference of the lower third of the esophagus was found. This distal esophagus at the level of the diaphragm was transected and a gastrostomy inserted. The remaining esophagus was excised, the residual stump drained, the chest closed and a cervical esophagostomy constructed. However, the patient died within 24 hours of operation from the effect of uncontrolled infection despite aggressive management with fluids, antibiotics, and a full range of supportive methods. The third patient, known to have arteriosclerotic heart disease, sustained a fatal myocardial infarct on his eighth postoperative day.

Incomplete Relief of Symptoms Among results which represent less than the maximal benefit expected from the operation, the most impressive is the patient who had the right operation for the wrong illness. Despite the stringent nature of our indications for operation, we are convinced in retrospect that operations on at least two occasions were performed for individuals with diseases other than reflux esophagitis. A classic example was a businessman who had presented with angina-like syndromes and had had three normal coronary arteriograms. Clinical signs of reflux became more noticeable with the classic increase in discomfort associated with reclining, leaning over, or increasing intra-abdominal pressure. Subsequent studies indicated that acid perfusion of the distal esophagus did produce the electrocardiographic abnormalities associated with his earlier signs of cardiac ischemia, a syndrome described by Morris and associates.7 He underwent an uneventful operative repair and a benign postoperative course. An obstructive episode occurred on the eighteenth postoperative day, and although this episode resolved, the patient experienced continuing chest pain. He was readmitted to the hospital a year postoperatively with a documented myocardial infarct. He is also the only pa-

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tient who continues to have late dysphagia. Radiographic studies show rotation of the plication, initial emptying of the esophagus into the plicated fundus and only subsequently, in ruminant fashion, into the rest of the stomach. Careful studies still have not explained this problem totally. However, this subsequent myocardial infarct, although well tolerated and associated with a return to work, makes the risk of revision measurable, all the more so because he has learned to tolerate the complication. This individual represents an adverse outcome from the confusion of coronary artery disease with reflux esophagitis. There are four other individuals who were evaluated for reflux esophagitis following careful cardiologic evaluation and normal coronary arteriogram. All were documented to have reflux esophagitis and have subsequently been entirely relieved of their complaints following fundoplication. Alleged Problems Six per cent of our patients have complained of upper abdominal fullness and discomfort after eating in the early postoperative period, consistent with the "gas bloat" syndrome described by Woodward and colleagues.13 In all of these patients but one, symptoms disappeared within 3 months. Most patients who are ill of reflux esophagitis learn to swallow repeatedly to facilitate the acid-clearing mechanism.12 Incident to repeated swallowing, the patients became aerophagic. However, when it continues after gastroesophageal competence is restored, gaseous distention of the upper abdomen ensues. Among the 18 patients so afflicted, in only one did this problem persist more than 3 months, and he has had mild but continuing discomfort over a period of 5 years. The gas bloat syndrome has occurred much less frequently than described by Woodward and colleagues,13 although we have been unable to define the reason. Perhaps it is not related to the size of the esophageal lumen but rather to the looseness and the freedom with which the fundoplicated segment lies about the restored intra-abdominal esophagus. In this series, at least two fingers, and in some cases the surgeon's entire hand, could be passed underneath the plication alongside the esophagus. This loosely applied fundic wrap probably allows most patients to belch after a short time postoperatively; more tightly constructed fundoplications may not.

Other Problems Dealing with a stenotic esophagus secondary to reflux esophagitis continues to be a major challenge. Hollenbeck and Woodward4 have found that fundoplication employed as an onlay graft to widen the narrowed esophagus is highly efficacious. However, as pointed out

previously,4 the so-called Nissen-Thal operation8 has been a uniform disaster for us. A limited trial was undertaken because of greater risk reported for intestinal interposition, despite superb long-term physiologic results of this later procedure. However, we have now reverted to the management of the patient with fibrous stricture byjejunal interposition after the method of Merendino and Dillard6 because of our inability to match Woodward's results in these difficult cases. We continue to treat most soft or pliable strictures by dilatation and fundolication. Among 13 such patients, dilatation one to three times has always been sufficient if the reflux is controlled effectively by the plication. Esophageal shortening that is so apparept in some patients with reflux esophagitis proves real in only a minority; in only 10 patients was the apparent shortening genuine. This represents a relative indication for the transthoracic approach allowing thorough mobilization of the esophagus. In the past, we have left the plication about the esophagus in the thorax and accepted evidence that it was not essential, although desirable, to restore the esophagogastric junction to the abdomen in every instance. We believed that plication was so efficacious in preventing reflux that restoration of abdominal esophageal length was unnecessary. Our attempts in four patients have been unsatisfactory. Accordingly, every effort is now made in these circumstances to restore the esophagogastric junction to an infradiaphragmatic position. Discussion This presentation describes both real and imagined difficulties with fundoplication, using a substantial experience to define ways to avoid or preclude the seeming misadventures. The technical maturity achieved with the operative procedure is such that relative risks of these procedures can be defined narrowly. Morbidity in the last 100 patients has declined from 14 to 5%, and no deaths have occurred among the last 158 patients under-

going such operations. Whether the criteria for this operation have been too rigid and too narrow is a constant concern. As the operation has proved itself, perhaps it deserves wider applicability. Certainly a determinant of the relative indication for any operation is its risk-to-reward ratio. However, as long as dysphagia does not supervene, we believe that the patient with mild reflux esophagitis is best managed nonoperatively; only those patients who have persistent complaints unresponsive over long periods warrant operative intervention. References 1. DeMeester, T. R. and Johnson, L. F.: Evaluation of the Nissen Antireflux Procedure by Esophageal Manometry and Twentyfour Hour pH Monitoring. Am. J. Surg., 129:94, 1975.

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2. DeMeester, T. R., Johnson, L. F. and Kent, A. H.: Evaluation of Current Operations for the Prevention of Gastroesophageal Reflux. Ann. Surg., 180:511, 1974. 3. Hardy, J. D. and Yelverton, R. L.: "Spontaneous Rupture" of the Spleen: One Mechanism. Routine Splenectomy Challenged. Arch. Surg., 87:468, 1963. 4. Hollenbeck, J. I. and Woodward, E. R.: Treatment of Peptic Esophageal Stricture with Combined Fundic Patch-fundoplication. Ann. Surg., 182:472, 1975. 5. Kirkpatrick, J. R., Heilbrunn, A. and Sankaran, S.: Cardiac Arrhythmias: An Early Sign of Sepsis. Am. Surg., 39:380, 1973. 6. Merendino, K. A. and Dillard, D. H.: The Concept of Sphincter Substitution by an Interposed Jejunal Segment for Anatomic and Physiologic Abnormalities at the Esophagogastric Junction. Ann. Surg., 142:486, 1955. 7. Morris, J. C., III, Shelburne, P. F. and Orgain, E. S.: Coronary Disease and Hiatal Hernia. An Example in Support of the Existence of a Viscerocardiac Reflex. JAMA, 183:788, 1963.

8. Nissen, R. and Pfeiffer, K.: Zwerchfellhernien. Klinik Indikation Chirurgie Technik. Bern and Stuttgart, Verlag Hans Huber, 1968. 9. Polk, H. C., Jr. and Zeppa, R.: Hiatal Hernia and Esophagitis: A Survey of Indications for Operation and Technic and Results of Fundoplication. Ann. Surg., 173:775, 1971. 10. Schatzki, R. and Gary, J. E.: Dysphagia due to a Diaphragmlike Narrowing in the lower Esophagus ("Lower Esophageal Ring"). Am. J. Roentgenol. Radium Ther. Nucl. Med., 70:911, 1953. 11. Skinner, D. B. and Belsey, R. H. R.: Surgical Management of Esophageal Reflux and Hiatus Hernia: Long-term Results with 1,030 Patients. J. Thorac. Cardiovasc. Surg., 53:33, 1967. 12. Skinner, D. B. and Booth, D. J.: Assessment of Distal Esophageal Function in Patients with Hiatal Hernia and/or Gastroesophageal Reflux. Ann. Surg., 172:627, 1970. 13. Woodward, E. R., Thomas, H. F. and McAlhany, J. C.: Comparison of Crural Repair and Nissen Fundoplication in the Treatment of Esophageal Hiatus Hernia with Peptic Esophagitis. Ann. Surg., 173:782, 1971.

DISCUSSION

This is an incapacitating problem, and in this athletic age, with some of these women playing tennis, even on forehand shots they'll lose gastric content. The Nissen fundoplication is a superb procedure for this control, and we have used that, I think, with a greater degree of efficacy than in any other cohort of patients on whom we have applied this procedure. One more point: We are a bit slower than Dr. Polk to operate, I would guess, since he has accumulated now somewhat over 300 patients, and when he left Miami we were at the figure that he had given you. We're still operating on about one out of every hundred patients who has demonstrated reflux in our institution. Perhaps it's because we deal with a very large cohort in our community of well-intentioned and talented gastroenterologists, who control these patients very effectively; so that when we see the patients, we have two problems: Uncontrolled reflux, or esophagitis.

DR. THOMAS BOMBECK (Chicago): In Dr. Polk's excellent presentation of a very large series of Nissen fundoplications, I must say that we could not agree more. We have been involved in studying this particular problem for the last eight years at the University of Illinois. We have essentially the same incidence of success with this procedure; that is, it always prevents reflux when it remains intact. We do have an incidence of gas bloat syndrome somewhat higher than he has reported, but lower than that reported by Dr. Woodward. I wish to ask him if he would please describe for us the specific tricks that he uses in preventing gas bloat syndrome in these patients, enabling the patient to belch postoperatively. DR. ROBERT ZEPPA (Miami, Florida): There are a number of points which I think deserve some amplification. The first is: In terms of the splenectomy problem associated with this operation, we have found that in some patients who have particularly short, short gastrics, where the stomach is attached very, very tightly to the spleen, taking those down allows for freedom of the fundus, and allows you to do a very safe wrap without damage to the spleen. Secondly, in terms of the stent in the esophagus-and we use this in particular as a teaching device for our residents. We pass a 46 Maloney dilator into the stomach, and then do the wrap around that, to ensure that they will not cinch up the lower esophageal segment, like Aunt Tillie's girdle, because that's not the purpose of the operation. The purpose of the operation is to obtain the rather salubrious contact between the lower esophageal segment and intragastric

DR. DONALD L. PAULSON (Dallas): I rise to talk about another operation of choice for gastroesophageal reflux; namely, the combined Belsey and Collis gastroplasty procedures. We have no quarrel with the Nissen fundoplastic procedure, and do congratulate Dr. Polk on the excellence of his results. (Slide) We reviewed our experience from 1963 to 1970, in 1971, with 760 cases of a type of fundoplication modified on the Belsey principle. As you see, we had clinical relief of symptoms in about 95% of the patients. As the end of three months, by cinefluorography of the esophagus and the water siphon test, we had a 5% incidence of persisting gastroesophageal reflux, and at a year an additional 4% so-called recurrent reflux. These are all failures, so at a year we might say that we had 90% good results. In following these cases for a period up to seven years, there is a 2% increment of recurrence of gastroesophageal reflux per year. pressure. On the basis of these failures, and appreciating the fact that with This can be accomplished with a very loose wrap around the lower esophageal segment. In fact, we have been able, with the gastroesophageal reflux there is esophagitis in a high percentage of these help of our colleague, Dr. Arvey Rogers in the Department of Medicine, patients, with consequent varying degrees of esophageal shortening, to confirm Dr. DeMeester's elegant findings in terms of the changes and following the lead of Mr. J. Leigh Collis in Birmingham, England, and Pearson in Toronto, we began to use this combined in lower esophageal segment pressure in these patients after surgery. Despite this, a number of our patients do complain of excessive gas procedure. (Slide) As you see, the procedure is simply a lengthening of the over the period of three to four months, when they are becoming accustomed to a rather new gastrointestinal (gastroesophageal) anatomical esophagus by the Collis gastroplasty, using the Maloney bougies, size 50 to 54, in the esophagus, through the esophagogastric junction, relationship. The other point I'd like to make is that, in the last several years, and making a gastric columnar lined tube of the lesser curvature of the magenstrasse of the stomach. This is carefully constructed to make a we have been placed in contact with patients who do not have esophagitis, by any stretch of the imagination; but these are patients tube of the desired diameter, with not too patulous an opening. This division can extend for a distance of 6 cm or more, depending with very, very highly uncontrolled reflux, and we have seen it primarily in women. Age ranges from the late 20's on up into the 60's. In the upon the length of tube desired for lengthening of the esophagus. (Slide) It results in a connecting tube between the esophagus and younger age group, these are women who, having toddlers, bending over to pick them up, will lose breakfast, lunch, or whatever the prior the new esophagogastric junction. Both sides of the gastroplasty are sutured, or the stapler can be used. meal was at the time of picking up these youngsters.

Fundoplication for reflux esophagitis: misadventures with the operation of choice.

Fundoplication for Reflux Esophagitis: Misadventures with the Operation of Choice HIRAM C. POLK, JR., M.D. Fundoplication, whether performed by thora...
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