Effect of Nissen fundoplication on competence of the gastro-oesophageal junction.

Abstract

SUMMARYThe changes produced by the Nissen fundoplication were measured in 12 patients, who required surgery to control their reflux oesophagitis. The gastro-oesophageal junction of each patient was studied before and three months after operation by station pullthrough manometry and prolonged pH monitoring of the distal oesophagus. All patients were free from reflux symptoms post-operatively. The Nissen fundoplication resulted in a significant increase in the pressure, but not the length, of the lower oesophageal high pressure zone. A greater proportion of this zone was situated in the abdomen postoperatively. Prolonged pH monitoring showed a significant improvement in all the measured indices of acid reflux. Nissen fundoplication restores competence to the gastro-oesophageal junction as judged by manometry and pH monitoring. This kind of study should be performed to document the efficiency of other anti-reflux procedures.Although the precise nature of the mechanism which prevents abnormal reflux of gastric contents into the lower oesophagus is not clearly defined and may be dependent upon more than one factor,l 23 it is now well recognised that failure of this mechanism may occur independently of the anatomical abnormality of a sliding hiatal hernia.45 Consequent upon this understanding of the pathophysiology of gastro-oesophageal reflux has come the reappraisal of the aim of surgery in the treatment of those patients whose symptoms and oesophagitis are unresponsive to conservative therapy.When the cause of the symptoms of heartburn and regurgitation were correctly attributed to gastrooesophageal reflux," it was assumed that this reflux was made possible by the presence of a sliding hiatal hernia. It was further assumed that, if this hernia were repaired according to the general principles of hernia repair, then the abnormal reflux would be prevented and the patient cured. Unfortunately, anatomical repair of the hiatus frequently did not prevent further reflux, however meticulously the operation was carried out and by whatever method it was performed.7 8

Esophageal Manometry and Clinical Outcome After Laparoscopic Nissen Fundoplication

“…12 Furthermore, in a small series of patients studied previously using video manometry, we also found a weak correlation between dysphagia for solid food and lower esophageal sphincter residual relaxation pressure (r=0.37, p=0.04). 13 Previous studies have also shown that laparoscopic Nissen fundoplication is followed by an increase in lower esophageal sphincter resting and residual relaxation pressures, 14,15 and the results of our current study are consistent with these findings. Other studies, including randomized trials, have shown that the increase in lower esophageal sphincter resting pressure is less after various anterior partial fundoplication procedures, and this is associated with a lower incidence of dysphagia.…”

Results of Elective Nissen Fundoplication for Gastro-Oesophageal Reflux in Selected Patients

“…Although SART is a less sensitive and specific method for measuring reflux, than 24-hour pH monitoring [24], the former pH-metric assessment was effective enough to provide good corre lation in most cases. As in other series [4,6,[8][9][10]23] manometric data confirm that Nissen fundoplication results in a significant increase of the average LES pres sure up to normal values. However, in some patients LES pressure remains below the normal value without any effect on the clinical result [10,23].…”

“…As in other series [4,6,[8][9][10]23] manometric data confirm that Nissen fundoplication results in a significant increase of the average LES pres sure up to normal values. However, in some patients LES pressure remains below the normal value without any effect on the clinical result [10,23]. Such data rein force the concept that LES is not necessarily the most important factor in preventing reflux [8,24], Long-term effectiveness of the procedure is more con troversial.…”

Serum Gastrin Levels and Lower Oesophageal Sphincter Pressures in Infants with Congenital Hypertrophic Pyloric Stenosis

“…The disappearance of projectile vomiting following pyloromyotomy seems to be related to the improvement oflower oesophageal function as weB as better passage through the postoperative pylorus. Some authors (5)(6)(7)(8) have investigated the barrier to refl ux of gastric contents at the gastroesophageal junction by oesophageal manometry. In the present study we used oesophageal manometry to examine the lower oesophageal function before and after pyloromyotomy.…”