J Gastrointest Surg (2009) 13:61–65 DOI 10.1007/s11605-008-0688-3
Laparoscopic Fundoplication in Patients with a Hypertensive Lower Esophageal Sphincter Peter J. Lamb & Jennifer C. Myers & Sarah K. Thompson & Glyn G. Jamieson
Received: 9 July 2008 / Accepted: 20 August 2008 / Published online: 7 September 2008 # 2008 The Society for Surgery of the Alimentary Tract
Abstract Background A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. Material and Methods Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP ≥30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0–10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. Results Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30–55). Median follow-up after fundoplication was 99 (12–182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P=0.541), dysphagia (2.7 vs. 3.1, P=0.539), and satisfaction (7.4 vs. 7.6, P=0.546). Five patients required revision for dysphagia compared to no control patients (P=0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P=0.036). Conclusion Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate. Keywords Lower esophageal sphincter . Antireflux surgery . Gastroesophageal reflux
Introduction The finding on esophageal manometry of an isolated hypertensive lower esophageal sphincter (LES), in the absence of other motility abnormalities, has been recognized for many years.1 Reports evaluating treatment for these patients are limited by small numbers and a lack of consistency in the manometric criteria used for its definition. Recent guidelines propose a pressure greater than 45 mm Hg
P. J. Lamb : J. C. Myers : S. K. Thompson : G. G. Jamieson (*) Discipline of Surgery, University of Adelaide, Level 5, Eleanor Harrald Building, North Terrace, Adelaide, South Australia 5005, Australia e-mail:
[email protected]
in mid-respiration, with appropriate sphincter relaxation on swallowing and normal esophageal body motility.2 However, most published studies evaluating the condition have used less stringent criteria and a lower cutoff, between 26 and 35 mm Hg, mid respiration.3–5 Chest pain and dysphagia were initially reported to be the most common symptoms associated with a hypertensive LES, and treatment was directed at reducing sphincter pressure, by medical or surgical techniques.6,7 Although some patients fit this algorithm, it is now recognized that there is another group who present primarily with heartburn and are proven to have gastroesophageal reflux.8,9 A hypertensive LES is diagnosed incidentally in these patients. This association appears paradoxical, as reflux is more commonly associated with a hypotensive, incompetent sphincter. The optimal surgical strategy is unclear, as there is concern about inducing dysphagia with a fundoplication, while a myotomy might worsen reflux. The aim of this study was to evaluate the long-term outcomes of laparoscopic fundoplication in these patients.
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Material and Methods Between October 1991 and December 2006, all patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease at the Royal Adelaide Hospital, Flinders Medical Centre or associated private hospitals with preoperative esophageal manometry were identified from a prospective database. Patients undergoing revisional antireflux surgery were excluded. Those undergoing repair of a large paraesophageal hernia (>50% of stomach in the chest) were also excluded, as the high-pressure zone might be due to extrinsic compression from adjacent tissues rather than the sphincter itself. The preoperative esophageal manometry was reviewed to identify patients with hypertensive LES. A control group of patients with non-hypertensive LES was also identified from the database. Study patients were individually matched to the next suitable patient in the database according to sex, age (within 5 years), year, and type of fundoplication and the degree of preoperative dysphagia. Esophageal manometry was performed using a water perfused eight-channel esophageal motility catheter (Dentsleeve Pty. Ltd, Adelaide, Australia), introduced transnasally. The catheter comprised of six proximal channels spaced 5 cm apart, a 6-cm sleeve sensor, and one gastric channel. The LES was located by the station pull-through technique, and then the catheter was firmly taped with the sleeve sensor positioned across the sphincter for continuous measurement of LES pressure. Manometric measurements were recorded during a 5-min rest period, and a series of ten water swallows. We have previously demonstrated this technique to give reproducible measurements of LES pressure. 10 The criteria used to define the findings of esophageal manometry are given in Table 1. Basal LES pressure (millimeters of mercury) was the resting pressure sampled during the 5-min rest period (mean end expiratory pressure referenced to basal intragastric pressure). Traces for patients with a hypertensive LES were also retrospectively re-evaluated to determine the mean LES pressure at midrespiration. The residual relaxation (nadir) pressure (milli-
meters of mercury) was the lowest pressure recorded during swallow-induced sphincter relaxation. Laparoscopic fundoplication was offered to patients with proven reflux [endoscopic evidence of esophagitis or a positive 24-h pH study (pH 4% of study)], who were not controlled or unable to tolerate antireflux medication. The type of fundoplication performed was determined by surgeon preference in a similar manner in each group. For patients undergoing 360° fundoplication, a loose 2-cm-long wrap was constructed over a 52F intraesophageal bougie, without routine division of the short gastric vessels. The techniques for 360° fundoplication, anterior 180°, and anterior 90 fundoplication have been described previously in detail.11–13 A follow-up was conducted using a standardized structured questionnaire, which evaluated symptom scores for heartburn, dysphagia for liquids and solids, and overall satisfaction with the outcome of surgery. This was administered by post or telephone by an independent nonclinical investigator preoperatively, 12 months following surgery, and annually thereafter until December 2007, allowing a minimum of 12 months follow-up. The presence or absence of heartburn and dysphagia was graded using an analogue scale from 0 to 10 (0–3, none or mild; 4–6, moderate; 7–10, severe). Patient satisfaction was also measured (0–3, unsatisfied; 4–6, satisfied; 7–10, highly satisfied). The most recent follow-up data was included for each patient, and outcomes were compared to those of the control group. Statistical evaluation was performed using the Statistical Package for the Social Sciences (SPSS) statistical package (SPSS version 12, SPSS, Chicago IL, USA). Data are reported as the mean [95% confidence interval (CI)] or median (range). Chi-squared test was used to compare categorical data sets. Mann–Whitney U test was used for independent samples and Wilcoxon test was used for related samples to compare continuous data sets. Statistical significance was accepted at P
