A more physiological alternative to total fundoplication for the surgical correction of resistant gastro-oesophageal reflux

Abstract

The incidence of mechanical complications associated with the Nissen fundoplication has prompted evaluation of an anti-reflux procedure designed to be simpler and more physiological, and encompassing a broader view of the many factors involved in the anti-reflux mechanism. Preliminary assessment of the first 100 patients with a mean follow-up of 3.5 years showed symptomatic improvement in 96 per cent and complete relief in 85 per cent. A further 100 patients were studied using formal symptom scoring, endoscopy, manometry and pH monitoring performed before operation and 3 months after operation. Similar clinical results were accompanied by improvement in endoscopic oesophagitis in 95 per cent, complete healing in 74 per cent and restoration of the pH profile to physiological levels in 84 per cent. Troublesome mechanical complications comprised a 2 per cent incidence of dysphagia, but there was no gas bloat or inability to belch or vomit, which may relate to the restoration of lower oesophageal sphincter characteristics close to those of 30 asymptomatic controls. The procedure is simpler to perform than total fundoplication, is well tolerated and is applicable to patients with reflux stricture and impaired oesophageal body motility. The results of this study support the hypotheses that effective reflux control can be achieved without total fundoplication by attention to several factors of known relevance to the anti-reflux mechanism, and that restoration of characteristics of the lower oesophageal sphincter close to physiological levels results in a lower incidence of mechanical complications.