Surgical treatment of reflux stricture of the oesophagus

Abstract

The choice of surgery in patients with reflux-induced oesophageal stricture remains controversial. From 1976 to 1990, a total of 65 patients underwent fundoplication (36 patients), Collis gastroplasty plus fundoplication (ten), total duodenal diversion (four) and oesophageal resection (15). The postoperative mortality rate was 5 per cent (three patients): necrosis of the colon transplant in two patients and acute pancreatitis in one. The median follow-up was 25 (range 6-120) months. After conservative surgery, the median number of dilatations per patient per year significantly decreased (P < 0.001). Nine patients (25 per cent) complained of persistent or recurrent symptoms after standard fundoplication and six required reoperation. Clinical results were satisfactory in patients who underwent Collis fundoplication, total duodenal diversion and oesophageal resection. It is concluded that the causes of failed fundoplication are irreversible stricture or persistent gastro-oesophageal reflux; the latter may be caused by inefficacy or deterioration of the partial fundoplication wrap. A subtle degree of oesophageal shortening is probably underestimated in such patients and this may explain the better results obtained with the Collis fundoplication. Total duodenal diversion is a good therapeutic option in patients who have undergone previous oesophagogastric surgery. Oesophageal resection should be reserved for patients with tight strictures unresponsive to dilatation or those with scleroderma, multiple previous operations or severe dysplasia in Barrett's oesophagus.

Gastroesophageal reflux strictures in children, management and outcome

“…Reflux strictures are usually diagnosed late and management requires dedicated and long-term treatment. Although the therapeutic approach to pathological gastroesophageal reflux is well established, there are differences in opinion regarding the management of complicating strictures namely, bouginage with medical therapy, fundoplication without dilatation, pre-operative dilatation followed by fundoplication with intra-operative and post-operative dilatations or resection and interposition grafting [2][3][4][5][6][7]. This difference in management is mainly due to the nature of the narrowing, whether it is a stenosis (an inflammatory lesion) or a true stricture.…”

Tratamento cirúrgico da doença de refluxo gastroesofágico na esclerose sistêmica

“…Acometimento esofágico foi observado em 86.7% dos pacientes esclerodérmicos na experiência dos autores, cursando com significativa morbidade (27) . Recomendações quanto à ressecção esofágica (28) , receio na confecção de uma válvula num esôfago hipotônico (17) e a falta de dados científicos objetivos levaram a maioria dos cirurgiões gástricos a evitar a cirurgia anti-refluxo em pacientes com ES. A evolução a curto prazo com a ressecção esofágica apresenta uma morbidade significativa, a despeito da melhora clínica (29,30) .…”

Indikation zur Antirefluxchirurgie des Oesophagus

“…75 % deutlich schlechter als bei Patienten mit Refluxoesophagitis oder Barrett-Oesophagus [4,36]. Die konservative Therapie mit hochdosierten Protonenpumpenhemmern und wiederholter endoskopischer Bougierung bietet hier deutliche Vorteile und stellt damit derzeit bei peptischen Stenosen die primäre Therapie der Wahl dar [37].…”

“…Die in der Literatur angegebenen Erfolgsraten der Fundoplicatio bei diesen Patienten schwanken zwischen 50 und 90 % [4,11,38] und stehen in engem Zusammenhang mit der aufgebrachten Sorgfalt in der Diagnostik des ursächlichen Zusammenhangs zwischen Symptomatik und gastrooesophagealem Reflux. Beim objektiven Nachweis einer zeitlichen Korrelation zwischen Symptom und Säurereflux, Dokumentation einer posterioren Laryngitis und gutem Ansprechen auf medikamentöse Säuresuppression kann jedoch als Alternative zur medikamentösen Dauertherapie eine Fundoplicatio mit guter Aussicht auf Erfolg empfohlen werden [11].…”