Lesser Curvature Tubular Gastroplasty with Partial Plication for Gastroesophageal Reflws: Manometric and ph-metric Postoperative Studies

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1 Lesser Curvature Tubular Gastroplasty with Partial Plication for Gastroesophageal Reflws: Manometric and ph-metric Postoperative Studies Adolfo Benages, M.D., Francisco Paris, M.D., Manuel T. Ridocci, M.D., Vicente Tarazona, M.D., Ramon Molina, M.D., Francisco Mora, M.D., Antonio Canto, M.D., Maximiliano Lloret, M.D., and Guillermo Garrido, M.D. ABSTRACT Thirty-four patients with sliding hiatal hernia, gastroesophageal reflux, or both were treated by lesser curvature gastroplasty with partial gastric plication, using a surgical stapler. Before operation, esophageal manometric studies were performed in 33 patients and during the early postoperative period (1 to 3 months), in 34. The esophageal ph test was performed before operation in 22 patients, shortly after discharge in 27, and later in 30 patients. The clinical results were considered satisfactory in 30 patients (88%) after follow-up ranging from 18 to 33 months (average, 23 months). Before the procedure, the abdominal compression test was positive in 25 of 30 patients (83%). n early postoperative studies it was positive in 1 out of 34 patients (3'/0), but in the second series of postoperative studies it was positive in 9 out of 32 (28%). After instillation of hydrochloric acid into the stomach, the esophageal ph test was considered positive in 17 out of 22 patients in preoperative studies (77%). n early postoperative studies the test was positive in 3 out of 27 patients (11%) and one year later, in 7 out of 30 (23%). The later postoperative studies showed a higher number of positive reflux tests than the early studies, 28 and 23% positive in manometric and ph tests, respectively. Gastroesophageal reflux is the principal problem of patients with sliding hiatal hernia. ts prevention should be the primary objective of surgical repair [211. From January, 1975, to May, 1976, we operated on a series of patients with this abnormality and used a surgical procedure From the Services of Thoracic Surgery, Radiology, and Gastroenterology, Hospital La Fe, and the Esophageal Laboratory, University Hospital, Valencia, Spain. Accepted for publication Feb 10, Address reprint request to Dr. Paris, Servicio de Cirugia Toracica, Departamento de Cirugia, Hospital La Fe, Avda Alferez Provisional 21, Valencia 9, Spain. [18] that includes parts of three antireflux operations: the Collis gastroplasty 161, the Nissen plication [13], and the Belsey Mark V repair [211. Material and Method Thirty-four consecutive patients were treated by the antireflux procedure to be described. Thirty-two patients had a sliding hernia, 1 after recurrence of a Nissen repair, and 2 had gastroesophageal reflux without hernia. The most common clinical symptoms were the following: heartburn, 30 patients (88%); dysphagia, 18 patients (53'/0), severe in 4; reflux into the throat, 16 patients (47%); and hematemesis, melena, or severe anemia, 7 patients (21%). Eight patients had esophageal stricture-4, the severe type and 4, the mild type-diagnosed by barium swallow and esophagoscopy. n 5 patients with concomitant diffuse esophageal spasm, an esophageal myotomy in combination with the antireflux operation was performed as proposed by Brindley [4], Bombeck and associates [31, and Cross and Jones [71. Gastroduodenal ulcer was present in 7 patients, who had an additional vagotomy, and l patient with gallstones had a cholecystectomy. All 34 patients had a barium swallow examination before they were discharged and, at the time of writing, had been followed for 18 to 33 months after operation. A new roentgenographic study was made either if the patient reported recurrence of gastroesophageal reflux or at the last postoperative visit (at least 18 months after surgical treatment). Esophageal manometric studies were performed in 33 patients before operation and during the early postoperative period (1 to 3 months) in 34. A second series of studies was carried out (12 to 24 months following operation) in 32 patients. Manometric studies were by Adolfo Benages

2 575 Benages et al: Postoperative Manometric Studies after Gastroplasty performed through pressure transducers (Hewlett-Packard 1280-C) using two polyvinyl water-filled, open-tipped esophageal catheters (1.5 mm in diameter). Readings were taken simultaneously at two points 5 cm apart with the direct writing Hewlett-Packard Model 7754A. For yield pressure, the catheters were continuously perfused by a Harvard 975 pump at a rate of 1.2 ml per minute. The resting and swallowing pressures were recorded every 0.5 cm as the catheters were withdrawn through the gastroesophageal junction and at intervals of 1 cm in the esophagus. Finally, the pressures were recorded every 0.5 cm at the pharyngoesophageal junction. The abdominal compression test (common cavity test) was done as described by Butterfield and associates [5]: if abdominal compression increased the esophageal pressure to at least 50% of the value reached in the stomach, the test was considered positive. The esophageal ph test was performed before operation in 22 patients, early after discharge in 27, and later in 30 patients. We used the electrode radiometer GK 282C and the ph-meter radiometer PHM 28 with direct-writing recording in the Hewlett-Packard model using the 8803A amplifier. The ph electrode was placed 3 to 4 cm above the high-pressure zone of the esophagus after instillation of 250 ml of 0.1 N hydrochloric acid into the stomach. Esophageal ph was studied when the patient performed the Valsalva and Muller maneuvers in the supine and in the Trendelenburg position [25] and when manual abdominal compression was done. Gastroesophageal reflux was considered to be present if the ph in the lower esophagus dropped to less than 4.0. Surgical Technique A left lateral thoracotomy is made through the sixth rib interspace. The procedure is carried out either through the hiatus without opening the diaphragm or by an anterolateral detachment of the diaphragm, depending on anatomical circumstances. After exposure of the gastroesophageal junction, the upper gastrosplenic vessels are divided, and a surgical stapler is placed on the lesser gastric curvature, with a perorally intro- duced Ewald rubber stomach tube (external diameter, 14 mm; internal diameter, 7 mm) in place. The mechanical staplers used were the TA 55 and the TA 90 (Auto-Suture nstruments, USA) and the UTL (Medexport, Moscow, USSR). A gastric tube is fashioned, as shown in Figure la, without sectioning the stomach. The gastric body is plicated 270 degrees round the tube with two layers of nonabsorbable sutures, and the fundus is wrapped around two-thirds of the esophagus. Finally, the two halves of the right diaphragmatic crus are approximated behind the esophagus, and the diaphragm is reinserted if it is detached. When esophageal shortening is present, a longitudinal incision in the proximal portion of the gastric tube is made. This allows restoration of the stomach below the diaphragm without any tension (Fig 1B). When there is severe fibrous stricture, Hegar dilators are passed up through a gastrostomy as described by Pearson and associates [ZO]. Results Clinical Results There was no postoperative mortality. Air distention of the stomach due to difficulty in belching, the so-called gas bloat syndrome of Woodward and colleagues [25], was not a problem. t appeared in only 1 patient and lasted forty-eight hours. Dysphagia was a common postoperative symptom that decreased spontaneously. Twelve patients with no esophageal stricture complained of mild postoperative dysphagia at the time of discharge. Dysphagia was present in 7 of these 12 when the early postoperative studies were carried out and remained in only 1 patient 3 months after operation. Of 4 patients with severe dysphagia produced by an esophageal stricture, 2 were asymptomatic when discharged and 2 complained of mild dysphagia but had no heartburn. Several months later, 1 of the symptomatic patients became asymptomatic while the other was handicapped by recurrence of progressive gastroesophageal reflux. Of the 2 asymptomatic patients, l remained asymptomatic but the other had dysphagia again because of late recurrence

3 576 The Annals of Thoracic Surgery Vol 26 No 6 December 1978 Fig 1. The surgical procedure used in (A) patients without esophageal fibrosis and (B) patients with fibrous stricture, shortening of the esophagus, or both. Dilation of thc stricture and gastric section are done before the gastroplica tion. of gastroesophageal reflux and peptic stricture of the esophagus. The early postoperative results with regard to heartburn and reflux to the throat were excellent in 33 patients, but 1 had occasional mild heartburn. After follow-up of at least 18 months (range, 18 to 33 months; mean, 23 months), the total clinical results were the following: 26 asymptomatic patients; 3 patients with symptoms not related to gastroesophageal reflux; 1 improved but still experiencing mild heartburn when bending down; and 4 requiring a second operation because of symptoms due to gastroesophageal reflux. The operative results were considered satisfactory in 30 of the 34 patients (88 '/o). No symptoms of gastroesophageal reflux reappeared in any of the 5 patients who under- went an additional esophageal myotomy because of concomitant diffuse esophageal spasm. Early roentgenographic postoperative studies revealed a new gastroesophageal junction (Fig 2) and disappearance of spontaneous positional reflux in 32 of the 33 patients studied. Later roentgenographic postoperative examinations revealed gastroesophageal reflux in 8 of 34 patien ts. Manometric Studies and ph Reflux Test Although manometric studies do not directly measure gastroesophageal competence or reflux, they allow one to study the intraluminal high-pressure zone before and after treatment [8, 11, 121 as well as the percentage of positive results with the abdominal compression test. n the patients who underwent operation the mean preoperative high-pressure zone (maximal yield pressure) of f 8.19 mm Hg was less than that obtained from 38 control subjects (18.11 f 7.76 mm Hg). This preoperative value increased in the first postoperative studies to k mm Hg, including readings from

4 577 Benages et al: Postoperative Manometric Studies after Gastroplasty s R rnmhg 30 E 20 3 v) v) w [r 10 (3 0 F RST SECOND PREOP POSTOP POSTOP n. 28 n. 34 n.32 tig 3. Mean and standard deviation values of the highpressure zone in preoperative and in first and second postoperabve studies (n = number of patients). n the preoperative period, this pressure was not calculated in 5 patients because the catheter could not be passed through the hiatus to the portion of stomach resting in the abdomen. n the late postoperative studies, 2 asymptomatic patients refused further tests. tig 2. Postoperative roentgenogram of the gastroesophageal junction when the patient was in the Trendelenburg position and swallowed, and manometric studies of the high-pressure zone. ( = pneumograph; e = expiration; i = inspiration; 0 = 0 mm Hg.) the 5 patients who underwent an additional myotomy. n the second series of postoperative studies the value decreased to f 7.24 mm Hg (Fig 3). The difference in values between the preoperative and early postoperative studies by paired t test was statistically significant (p < 0.01), but it was not statistically significant between the preoperative and late postoperative studies (p > 0.05). n the patients who had additional myotomy, the mean of the maximal values for the highpressure zone changed from a preoperative level of _ 8.28 mm Hg to levels of _ 9.03 in the first postoperative studies and f 9.41 mm Hg in second postoperative studies. The average length of the high-pressure zone before operation (4.89 f 1.97 cm) exceeded the value (3.07 f 0.57 cm) obtained from control subjects. t did not increase significantly after operation, when it was 5.59 k 1.58 cm, although it did change in form. The highpressure zone has a first segment that corresponds to the gastric tube, followed upward by the true sphincter, which is marked by an acute increase of pressure (see Fig 2). The length of the high-pressure zone shortened in the late postoperative studies, with a mean value of 4.24 k 1.32 cm. Before operation the abdominal compression test was carried out in 30 patients and was considered positive in 25 (83%) as shown in Fig 4. The test was performed in 21 control subjects and was negative in all. n the early postoperative studies, the abdominal compression test was done in 34 patients and was considered negative (Fig 5) in all but 3 (9%). n the later postoperative studies, the test was positive in 9 out of 32 patients (28%); 3 of the 9 patients had clinical recurrence of gastroesophageal reflux and 6 were asymptomatic. Disordered esophageal motor activity was found by manometry in 9 patients before operation. n these patients, not less than 40% of swallowing waves were found to be of higher amplitude and longer duration than normal waves. There was also a greater incidence of simultaneous or repetitive nonperistaltic waves or a combination of these. Five of the 9 patients underwent esophageal myotomy, and the swallowing wave pressures were noticeably lower after operation. This occurs also in idiopathic diffuse esophageal spasm [17]. On the other hand, after performance of the antireflux op-

5 578 The Annals of Thoracic Surgery Vol 26 No 6 December 1978 COMMON CAVTY TEST C- percent of positives E S O P H f i ~ Preoperative 25/30 83 % 1 1, ' C First postop 3/34 9% STOM. 1 Second postop '/32 28% abdominal compression PH ACD REFLUX TEST 8- Preoperative 11/22 77 % First postop 3/27 11 % 2- :\ 2 23% 0- Second postop 7/30 fig 4. On the left are examples of positive manometric (see text) and ph reflux tests. On the right are the percent of positive results in the preoperabve studies and the first and second postoperative studies. Fig 5. Lxample of a postoperative negative common cavity test. Manual abdominal compression does not increase the esophageal pressure or produce reflux of barium from the stomach to the esophagus.

6 579 Benages et al: Postoperative Manometric Studies after Gastroplasty Postoperative Motor Activity of the Esophageal Body in Patients Without Preoperative Motor Disorders" Percent of First Studies Second Studies Abnormal Swallowing No. of No. of Waves Patients Percent Patients Percent < 40 18/ /24 8 4/ > 60 2/ "Excluding 9 patients who had preoperative manometric hypermotility disorders (40% of abnormal waves) and 1 who did not have preoperative manometric studies. eration described, motor disorders of the esophageal body appeared in patients who had not had preoperative disordered motor activity (Table). After instillation of hydrochloric acid into the stomach and when the patient performed the Valsalva or Muller maneuvers [22] or was subjected to abdominal compression, the esophageal ph test was considered positive in 17 out of 22 patients who had preoperative studies (77%). n the early postoperative studies, the test was positive in 3 out of 27 patients (119'0) and a year later in 7 out of 30 (23%) (see Fig 4). The esophageal ph test was performed in 21 control subjects and was positive in 2 (10%). Comment Long-term follow-up of patients who have undergone procedures to correct gastroesophageal reflux indicates some recurrence of this condition, according to Donnelly [lo] and Orringer [15] and their co-workers. For this reason Urschel and associates [24] suggested the combined Collis-Belsey operation for patients with high risk of postoperative recurrence of reflux. Factors conducive to recurrence include obesity, older age, pulmonary disease, and previous hiatal hernia repair. This approach was proposed previously by Pearson and co-workers [20], who added the Belsey hiatus hernia repair to the Collis gastroplasty [6] in the management of peptic stricture with acquired short esophagus. Urschel [23], Orringer and Sloan [16], and Payne [19] considered this surgical procedure the primary op- eration to be used in all patients with gastroesophageal reflux. n 1977 Orringer [141 stated that control of reflux after the Collis gastroplasty is better when a 360-degree fundoplication is used rather than a partial gastric wrap. n our technique the gastric tube is made with a stapler, and without any section of the stomach, in patients with esophageal shortening. Demos and colleagues [9] also have used the mechanical stapler without sectioning the stomach. However, they added a Nissen fundoplication of 360 degrees and left the plicated segment above the diaphragm when necessary. n our procedure we make a plication with the body of the stomach of 270 degrees around the unsectioned gastric tube and finish the operation with a partial fundoplication. WE never leave the valvoplasty above the diaphragm; if the esophagus is short, we section the proximal portion of gastric tube to replace the new junction below the diaphragm. Manometric studies and the esophageal ph test are the measures most widely used to study gastroesophageal reflux. Belsey [l] has emphasized the importance of these tests in diagnosis and evaluation of surgical results in patients with gastroesophageal reflux. We have drawn some conclusions based on the results of our proposed surgical procedure. After operation, air distention of the stomach was not a problem and voluntary eructation was possible. Early postoperative dysphagia, when present, generally disappeared 3 months after the operation. t persisted or reappeared in only 3 patients; in 1 it was related to the antireflux procedure and in the other 2, to recurrence of gastroesophageal reflux. The early postoperative results were satisfactory. Early postoperative manometric studies showed an increase in the high-pressure zone relative to preoperative values. After surgical treatment, the high-pressure zone depended on the lower esophageal sphincter tone and the abdominal pressure acting over the gastric tube with subsequent fundoplication. The immediate effects of the antireflux mechanism created by the proposed operation are confirmed by the high percentage of unaltered manometric and esophageal ph figures when maneuvers increasing intraabdominal pressure are performed.

7 580 The Annals of Thoracic Surgery Vol 26 No 6 December 1978 Nevertheless, after a follow-up of at least 18 months (average, 23 months) the initial good results in 33 of the 34 patients were impaired, giving 12% unsatisfactory results. The later postoperative studies showed a higher number of positive reflux tests than the early studies. n manometric and ph reflux tests the results were 28 and 23% positive, respectively, figures similar to those published by Orringer and Sloan [161. Out of 19 postoperative acid reflux tests performed within 1 to 6 months after the Collis-Belsey operation, they had 5 positive results (26%). We emphasize the differences between the clinical results and the late postoperative manometric and ph-metric tests. They could be related to several factors: (1) variation in patient sensibility, (2) resistance of the mucosa of the esophagus to the effect of gastric juice, (3) quantity and quality of the refluxed material, and (4) duration of the reflux exposure. To evaluate definitive results, long follow-up of a series of patients is required [l, 21. References 1. Belsey RHR: Surgical treatment of hiatus hernia and reflux esophagitis. World J Surg 1:421, Belsey RHR, Skinner DB: Gastroesophageal Reflux and Hiatal Hernia. Edited by DB Skinner, RHR Belsey, TR Hendrix, et al. Boston, Little, Brown, 1972, p Bombeck CT, Battle WS, Nyhus LM: Preoperative manometry in the choice of operation for gastroesophageal reflux. Am J Surg 125:99, Brindley GV: Discussion of Bombeck CT, Battle WS, Nyhus LM, Spasm in the differential diagnosis of gastroesophageal reflux. Arch Surg 104:477, Butterfield DG, Struthers JE, Showalter ]P: A test of gastroesophageal sphincter competence: the common cavity test. Gastroenterology 58:932, Collis JL: An operation for hiatus hernia with short esophagus. Thorax 12:181, Cross FS, Jones RD: Neuromuscular imbalance of the esophagus associated with hiatal hernia. Chest 63:63, Csendes A, Larrain A: Effect of posterior gastropexy on gastroesophageal sphincter pressure and symptomatic reflux in patients with hiatal hernia. Gastroenterology 63:19, Demos NJ, Smith N, Williams D: A gastroplasty for short esophagus and reflux esophagitis. Ann Surg 181:178, Donnelly R], Deverall PB, Watson DA: Hiatus hernia with and without esophageal stricture. Experience with the Belsey Mark V repair. Ann Thorac Surg 16:301, bllis FH ]r, Garabedian M, Gibb SP: Fundoplication for gastroesophageal reflux. Arch Surg 107:186, Moossa AR, Skinner DB: Gastroesophageal reflux and hiatal hernia. Ann R Coll Surg Engl58:126, Nissen R: Eine einfache Operation zur Beeinflussung der Reflux-oesophagitis. Schweiz Med Wochenschr 86:590, Orringer MB: Discussion of Skinner DB, Complications of surgery for gastroesophageal reflux. World J Surg 1:491, Orringer MB, Skinner DB, Belsey RHR: Longterm results of the Mark V operation for hiatal hernia and analysis of recurrences and their treatment. J Thorac Cardiovasc Surg 63:25, Orringer MB, Sloan H: Collis-Belsey reconstruction of the esophagogastric junction. ndications, physiology, and technical considerations. J Thorac Cardiovasc Surg 71:295, Paris F, Benages A, Berenguer J, et al: Pre and postoperative manometric studies in diffuse esophageal spasm. J Thorac Cardiovasc Surg 70:126, Paris F, Benages A, Ridocci MT, et al: Allongement oesophagien avec le "stapler" et valvuloplastie comme opcration antireflux. Ann Chir Thorac Cardiovasc 16:335, Payne WS: Discussion of Pearson FG, Henderson RD, Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty and Belsey hiatus hernia repair. Surgery 80:396, Pearson FG, Langer B, Henderson RD: Gastroplastyand Belsey hiatusrepair: an operationforthe management of peptic stricture with acquired short esophagus. J Thorac Cardiovasc Surg 61:50, Skinner DB, Belsey RHR: Surgical management of esophageal reflux and hiatus hernia. ] Thorac Cardiovasc Surg 5333, Skinner DB, Booth DJ: Assessment of distal esophageal function in patients with hiatal hernia andlor gastroesophageal reflux. Ann Surg 172:627, Urschel HC: Discussion of Kaunitz VH, Maa LC, Vastola DL, et al, A simple physiological repair of diaphragmatic hernia. J Thorac Cardiovasc Surg 68:513, Urschel HC, Razzuk MA, Wood RE, et al: An improved surgical technique for the complicated hiatal hernia with gastroesophageal reflux. Ann Thorac Surg 1543, Woodward ER, Thomas HF, McAlbany JC: Comparison of crural repair and Nissen fundoplication in the treatment of esophageal hiatus hernia with peptic esophagitis. Ann Surg 173:782, 1971