Gastroplasty with Partial or Total Plication for Gastroesophageal Reflux: Manometric and ph-metric Postoperative Studies

Gastroplasty with Partial or Total Plication for Gastroesophageal Reflux: Manometric and ph-metric Postoperative Studies Francisco Paris, M.D., Manuel Tomas-Ridocci, M.D., Adolfo Benages, M.D., Angel G. Zarza, M.D., Ramon Molina, M.D., Jose Padilla, M.D, Francisco Mora, M.D. Jose M. Borro, M.D., and Eduardo Moreno, M.D. ABSTRACT From January, 975, to December, 980, 83 patients with sliding hiatal hernia, gastroesophageal reflux, or both were treated using a modified Collis gastroplasty associated with either partial or total gastric application. When partial plication was used, the five-year clinical results were considered satisfactory in 27 out of 35 patients (77%). When total plication was used, the results were satisfactory in 4 out of 46 patients (89%) after follow-up ranging from 2 to 60 months (average, 36 months), but no symptoms of gastroesophageal reflux reappeared in any patient. In patients undergoing partial plication, the mean preoperative high-pressure zone of.20 f 8.9 mm Hg increased after operation to 7.3 f 0.50 mm Hg, but in the second postoperative studies the value decreased to 3.69 5 7.24 mm Hg. When 360 degree plication was used, the preoperative value of the high-pressure zone-9.36 f 4.80 mm Hg-increased after operation to 7.70 f 7.53 mm Hg but did not decrease significantly in the second postoperative studies: 6.46 f 7.99 mm Hg. When partial plication was used, the positivity of the abdominal compression test was 9 and 28% in the early and late postoperative studies, respectively. Using total plication, the percentage of positivity in the early and late postoperative periods was 0 and 2%, respectively. Concerning the acid reflux test, when partial plication was used, the test was positive in 3 out of 27 patients (%) in the early postoperative studies and in 7 out of 30 (23%) one year later. For the total plication procedure, the percentage of positive tests was null in the first control and 3% in the second postoperative studies. From the Service of Thoracic Surgery, Hospital La F6, and the Esophageal Laboratory, University Hospital, Valencia, Spain. Accepted for publication Nov 5, 98. Address reprint requests to Dr. Paris, Servicio de Cirugia Toracica, Departamento de Cirugia, Hospital La Fe, Ava. De Campanar 2, Valencia 9, Spain. It is well known that control of reflux esophagitis is the main objective of any surgical repair proposed for patients with a sliding hiatal hernia, incompetence of the lower esophageal sphincter, or both conditions. From January, 975, to December, 980, we operated on 83 patients with this abnormality, using a modified Collis gastroplasty associated with either partial or total gastric plication (Table ). Methods and Material Surgical Techniques Two operative procedures were used: () lesser curvature tubular gastroplasty with partial plication (35 patients), as reported previously [l, 2, and (2) gastroplasty with total plication (48 patients) (Fig ). Preparation of the lesser curvature tube was similar in both surgical methods. A thoracic approach was used in all patients save 2 undergoing total plication who were operated on by a transabdominal approach. The thoracic route allowed adequate liberation of the esophagus. Mobilization of the gastroesophageal junction was achieved by division of the phrenoesophageal membrane as well as by division of the peritoneal reflection, the short gastric vessels, and the upper end of the gastrohepatic omentum. The fully free proximal stomach was brought up through the hiatus into the thorax in 4 patients having partial plication and in 34 having total plication. An anterolateral circumferential incision of the diaphragm was used as an alternative method of exposure as necessitated by anatomical circumstances (2 patients having partial plication and 2 having total plication). The next step was to perform the gastroplasty. A surgical stapler was applied on the lesser curvature, which had been adjusted to a No. 54 Maloney bougie. The bougie was introduced perorally into the stomach. When the 540 0003-4975/82/060540-09$0.25 @ 98 by The Society of Thoracic Surgeons

54 Paris et al: Gastroplasty with Partial or Total Plication for Gastroesophageal Reflux Table. Clinical Data on 83 Patients Undergoing Collis Gastroplasty with Fundoplication Variable Diagnosis Gastroesophageal reflux + hiatal hernia Gastroesophageal reflux - hiatal hernia Recurrence after previous operation Complications Esophageal reflux stricture Esophageal reflux ulceration Herniated sac ulcer Recurrence from previous repair Nissen repair Lortat-Jacob repair Pexy of teres ligament Collis + partial plication Associated pathological condition Gastroduodenal ulcer Gallbladder stones Esophageal motor disordersb ac0.5 cm diameter. bneeding esophageal myotomy. Partial Plication 32 2 9 (severe, 5)a 2 7 5 Total Plication 39 4 5 2 (severe, 9)a 3 0 2 0 esophagus was relatively normal, the gastric tube was fashioned by stapling, without sectioning the stomach (27 patients having partial plication and 33 having total plication). When esophageal shortening was present, a longitudinal incision of the gastric tube was made in order to lengthen the esophagus (Fig 2). This maneuver allowed restoration of the stomach below the diaphragm without any tension. When there was a fibrous stricture of the esophagus, the dilation was carried out with a Maloney bougie or through a retrograde approach using Hegar dilators passed up through a gastrotomy. We excluded from this series a patient with gastroesophageal reflux due to Thevenards disease plus alcoholism and diabetes. The esophageal stricture was perforated during intraoperative dilation, and subsequently, esophageal resection and reconstruction were performed. For the partial plication procedure, the gastric body was plicated 270 degrees around the gastric tube. In total plication, a wrapping of 360 degrees was used. The gastric tube and its gastric plication were reduced below the hiatus by placing and tying four mattress sutures through the hiatus, fundus, and esophagus. This resembled the second row of sutures used in the Belsey Mark IV procedure (see Fig ). Finally, the two halves of the right diaphragmatic crus were approximated and the diaphragm was reinserted if detached. A vagotomy was performed in 7 patients having partial plication and in 2 undergoing total plication. An accidental vagotomy was done in 2 other patients in the latter group. Material From January, 975, to May, 976, 35 consecutive patients were treated using gastroplasty and partial plication [l, 2. Nine patients had esophageal stricture, 5 severe and 4 mild (see Table ). From May, 976, to December, 980, another 48 consecutive patients were treated with gastroplasty and total plication. Twentyone of these patients had esophageal stricture, 9 severe and 2 mild (Fig 3). In 77 out of the 83 patients, esophageal manometric studies were performed prior to operation and in 78 during the early postoperative period. A second study was carried out 2 to 24 months later in 32 of the patients who had partial plication and in 44 who had total plication. The manometric studies were performed using two polyvinyl water-filled, open-tipped catheters and a Hewlett-Packard 280-C pressure transducer. Readings were taken simultaneously at two points 5 cm apart. For yield pres-

542 The Annals of Thoracic Surgery Vol 33 No 6 June 982 Fig. Surgical procedure used in patients without esophageal shortening. T h e gastric tube was stapled but the stomach w a s not cut. Fig 2. Procedure used in patients with fibrous stricture and shortening of the esophagus. Dilation of the stricture and gastric section are done before the gastroplication.

543 Pans et al: Gastroplasty with Partial or Total Plication for Gastroesophageal Reflux A B C D Fig 3. Preoperative roentgenograms of a patient who had a severe but short stricture of the esophagus (< 0.5 cm in diameter and < 2 cm in length). sure, constant water infusion from a Harvard 975 pump at a rate of.2 ml per minute was used. The resting and swallowing pressures were recorded every 0.5 cm through the gastroesophageal junction and at intervals of cm in the body of the esophagus. The abdominal compression test, the so-called common cavity test, was practiced as described by Butterfield and co-workers [3]. If abdominal compression increased the esophageal pressure by at least 50% of the value reached in the stomach, the test was considered positive. The ph reflux studies were recorded using a Radiometer GK 282C electrode and a Radiometer PHM ph-meter with a Hewlett-Packard direct-writing recorder using an 8803 amplifier. Reflux was tested after instillation of 250 ml of 0. N hydrochloric acid into the stomach and recording the ph 3 to 4 cm above the highpressure zone of the cardia. The esophageal ph was studied when the patient was performing the Valsalva and Muller maneuvers in the supine and the Trendelenburg positions and when undergoing manual abdominal compression. Gastroesophageal reflux was considered present if the ph in the lower esophagus dropped to less than 4.0. The esophageal ph tests were performed before operation in 6 patients, early after discharge in 69, and later in 68. Results Partial Plication The clinical results of both series are shown in Tables 2 and 3. When partial plication was used (35 patients), gas bloat syndrome was not a real problem. At the time of discharge, mild dysphagia was common but it decreased spontaneously. When early postoperative studies were carried out, dysphagia remained in 7 out of 30

~~ ~ 544 The Annals of Thoracic Surgery Vol 33 No 6 June 982 Table 2. Preoperative and Late Postoperative Symptoms Partial Plication Total Plication Symptom Preop Postop Preop Postop Heartburn 30 6 42 0 Regurgitation 6 29 0 Dysphagi a Mild 4 2 9 5 Severe 5 3 4 3 Bleeding 7 0 Gas bloat syndrome Mild 0 2 0 4 Severe 0 0 0 0 Satiety 0 3 0 3 Incisional pain Mild 0 0 0 2 Severe 0 0 0 0 Table 3. Clinical Postoperative Results Category Satisfactory Excellent; asymptomatic Symptoms not related to reflux (patient satisfied) Poor Symptoms not related to reflux but patient dissatisfied Symptoms of gastroesophageal reflux Recurrence of reflux stricture Nondilatable reflux stricture needing resection + colon interposition Partial Plication Total Plication :I 0 (%) 3 546 patients, without a tight preoperative esophageal stricture. Five years later this symptom was present in only 2. Of 5 patients with severe dysphagia and tight esophageal stricture before operation, 2 were asymptomatic when discharged and 3 complained of dysphagia but had no heartburn. Some months later, of these symptomatic patients became asymptomatic and the other 2 became progressively impaired because of recurrence of gastroesophageal reflux. Of the 2 asymptomatic patients, remained asymptomatic and the other experienced recurrence of dysphagia on the recurrence of gastroesophageal reflux and peptic stricture. Two patients died late, of acute pneumonitis (8 months postoperatively) and the other of heart infarct (two years after operation). With reference to the symptoms of heartburn and reflux to the throat, the early results were satisfactory in 33 patients. After a follow-up of at least five years (range, 60 to 77 months), the total clinical results were as follows: 23 were asymptomatic; 4 had symptoms not related to gastroesophageal reflux; and 8 had complaints of reflux (see Tables 2,3). Five patients needed a second operation. The clinical results were considered satisfactory in 27 out of the 35 (77%) patients. The first postoperative roentgenograms demonstrated a new gastroesophageal junction and the disappearance of spontaneous positional reflux in 32 of 33 patients studied [l, 2. The

545 Paris et al: Gastroplasty with Partial or Total Plication for Gastroesophageal Reflux Fig 4. Postoperative roentgenogram of the patient shown in Figure. The gastric tube is surrounded by the gastroplication and the esophageal stricture has disappeared. second postoperative roentgenograms (2 to 24 months later) showed gastroesophageal reflux in 9 out of 34 patients studied. Total Plication When total plication was used (48 patients), gas bloat syndrome was more frequent than in patients who had partial plication (see Table 2). When the early postoperative studies were done ( to 3 months after operation), dysphagia was present in 20 out of the 47 patients and gas bloat syndrome in 4. Of 2 patients with esophageal stricture preoperatively, 4 were asymptomatic after the operation. In 4 the symptom disappeared after esophageal dilation with Maloney bougies postoperatively. The other 3 needed colon interposition, although no symptoms of reflux recurrence were present. With reference to the symptoms of heartburn and reflux to the throat, the early postoperative result was excellent in every patient. After a follow-up of 2 to 60 months (average, 36 months), no symptoms of gastroesophageal reflux reappeared in any patient. Roentgenograms made postoperatively demonstrated the presence of the gastric tube sur- rounded by the gastroplication, and improvement of the stricture if one had been present previously (Fig 4). Spontaneous positional reflux disappeared in every patient; the stricture did not disappear (Fig 5) in 3 patients whose roentgenograms showed no evidence of gastroesophageal reflux. One patient died 2Y2 months postoperatively of a perforation at the most proximal site of the row of staples. The patient was an obese, 65- year-old man, in whom there occurred postoperative migration of the gastric tube and its plication into the thorax. He died of sepsis despite reintervention and intravenous alimentation. Manometric Studies and ph Reflux Test In patients who had gastroplasty with partial plication, the mean preoperative high-pressure zone (maximal yield pressure) of.20 k 8.9 mm Hg increased after operation to 7.3 k 0.50 mm Hg (Fig 6). In the second postoperative studies, the value decreased to 3.69 +. 7.24 mm Hg. The difference between the preoperative and early postoperative studies by paired t test was statistically significant (p < 0.0). There was no significant difference between the preoperative and second postoperative studies. When 360-degree plication was used, the preoperative value of the high-pressure zone of

546 The Annals of Thoracic Surgery Vol 33 No 6 June 982 Fig 5. Preoperative roentgenogram of a patient with a severe and long stricture of the esophagus, which did not disappear with the Collis-Nissen procedure and postoperative dilations. 30 ~ 20 0 0-0 270' gastroplasty I 360' I + p~icatian I O.O I NS7 n 28 n4 n 34 n 40 n 32 n 39 PREOP FIRST SECOND POSTOP POSTOP Fig 6. Values of lower esophageal sphincter (LES) pressure in the preoperative and first and second postoperative studies (mean f standard error). In some patients the catheter could not be passed to the abdominal stomach (peptic stricture, voluminous hernia); some patients refused the exploration. (n = number of patients in whom the lower sphincter pressure was calculated in all three explorations.) 9.36 k 4.80 increased after the surgical procedure to 7.70 k 7.53 mm Hg but did not decrease significantly in the second postoperative studies, 6.46 k 7.99 mm Hg. The difference between the preoperative and the second postoperative studies by paired t test was statistically significant ( p < 0.0) (see Fig 6). When partial plication was used, the positivity of the abdominal compression test (Fig 7) was 9% in the early postoperative studies and 28% in the late postoperative studies. Using total plication, the percentage of positivity in the early and late postoperative periods was 0 and 2%' respectively. With regard to the acid reflux test (Fig 8), when partial plication was used, the test was positive in 3 out of 27 patients (ll0/o) in the early postoperative studies and in 7 out of 30 (23%) one year later. For the total plication procedure, the percentage of positive tests was null in the first control and 3% in the second postoperative studies. Comment Long-term follow-up results of patients who have undergone antireflux procedures for gastroesophageal reflux indicate some recurrence of this condition. For this reason, Urschel and colleagues [4] suggested using the combined Collis-Belsey operation proposed by Pearson

547 Paris et al: Gastroplasty with Partial or Total Plication for Gastroesophageal Reflux GASTROPLASTY + PLlCATlON 270' 360' Preoperative '5,30 83% 'O.44 00% Example of positive First postop (-3 months) 3/34 9% O44 0% Second postop (2-24 months) 9/32 28% - PCO.05-44 2% % of positives Example of negative Fig 7. Results of common cavity test (manometric abdominal compression): On the left are examples of positive and negative manometric tests. On the right are percentages of positive results in the preoperative studies and in the first and second postoperative studies when partial or total plication was performed. In the second postoperative studies, the difference between partial and total plication procedures (xz = 0.8360) was statistically significant ( p < 0.05). Preoperative GASTROPLASTY + PLlCATlON 270' 360' 77% 37,3s 95% 8 Example of positive 7 First postop 3/27 % 0/42 0% (.3 months) 4 Second Wstop 3m 23% 3% 0 (2-24 months) *ASYMPTOMATIC Example of negative % of positives Fig 8. Results of ph reflux tests: On the left are examples of positive and negative tests. On the right are the percentages of positive results in preoperative and postoperative studies. In the second postoperative studies, the difference between partial and total plication procedures ( x2 = 6.933) was statistically significant (p < 0.05).

548 The Annals of Thoracic Surgery Vol 33 No 6 June 982 and co-workers [5] for patients with a complicated form of hiatal hernia or a high risk of postoperative reflux recurrence. Because of the early favorable results obtained, Urschel [6], Orringer and Sloan [7], and Payne [S] considered this surgical procedure the primary operation to be used in all patients with gastroesophageal reflux. Bingham [9, 0 and Demos and associates [ll] described an operation resembling a combination of Collis gastroplasty and Nissen plication. They used this operation as the standard surgical treatment for hiatus hernia or gastroesophageal reflux or both. In 977, Henderson [2] and Orringer [3] stated that control of reflux after the Collis gastroplasty is achieved better when a 360-degree fundoplication is used rather than a partial gastric wrap. Both have abandoned the gastroplasty with partial plication in favor of gastroplasty combined with total plication. A similar policy has been adopted by Evangelist and co-workers [4], Payne,* and ourselves [l, 2 after reaching the conclusion that lesser curvature tubular gastroplasty with partial plication is not adequate to improve the condition of all patients with gastroesophageal reflux. Although a longer follow-up is required, we emphasize the significant differences between the results of the two surgical procedures we used in this study. They were better when gastroplasty with total plication was employed. The better results obtained with this technique in relation to other operations that involve plicating the gastric fundus around the lower esophagus [5] can be explained by the lower tension on the repair, which is desirable in the effort to avoid recurrence. Also, the sutures are placed in the stronger gastric tissue rather than in the more tenuous altered wall of the esophagus. Finally, the great advantage of gastroplasty with total plication is the possibility of offering the most effective method of surgical repair to almost all patients with gastroesophageal reflux, especially patients with a high risk of recidivism because of panmural esophagitis. Tayne WS: Personal communication, 978. References. Paris F, Benages A, Ridocci MT, et al: Allongement oesophagien avec le "stapler" et valvuloplastie comme operation antireflux. Ann Chir Thorac Cardiovasc 6:335-34, 977 2. Benages A, Paris F, Ridocci MT, et al: Lesser curvature tubular gastroplasty with partial plication for gastroesophageal reflux: manometric and ph-metric postoperative studies. Ann Thorac Surg 26:574-580, 978 3. Butterfield DG, Struthers JE, Showalter JP: A test of gastroesophageal sphincter competence: the common cavity test. Am J Dig Dis 7:45-42, 972 4. Urschel HC, Razzuk MA, Wood RE, et al: An improved surgical technique for the complicated hiatal hernia with gastroesophageal reflux. Ann Thorac Surg 5:443-45, 974 5. Pearson FG, Langer B, Henderson RD: Gastroplasty and Belsey hiatus repair: an operation for the management of peptic stricture with acquired short esophagus. J Thorac Cardiovasc Surg 6:50-63, 97 6. Urschel HC: Discussion of Kannitz VH, Maa LC, Vastola DL, Katz LA: A simple physiological repair of diaphragmatic hernia. J Thorac Cardiovasc Surg 68:53-52, 974 7. Orringer MB, Sloan H: Collis-Belsey reconstruction of the esophagogastric junction: indications, physiology, and technical considerations. J Thorac Cardiovasc Surg 7:295-303, 976 8. 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. Surgery 80:396-404, 976 9. Bingham JAW: Evolution and early results of constructing an antireflux valve in the stomach. Proc R SOC Med 67:4-8, 974 0. Bingham JAW: Hiatus hernia repair combined with the construction of an antireflux valve in the stomach. Br J Surg 64:460-465, 977. Demos NJ, Smith N, Williams D: New gastroplasty for strictured short esophagus. NY State J Med 75:57-59, 975 2. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:206-24, 977 3. Orringer MB: Discussion of Skinner DB: Complications of surgery for gastroesophageal reflux. World J Surg :485-492, 977 4. Evangelist FA, Taylor FH, Alford JD: The modified Collis-Nissen operation for control of gastroesophageal reflux. Ann Thorac Surg 26:07-, 978 5. Tomas-Ridocci M: Reflujo gastro-esofagico y su correccion quirurgica: analisis de diversas t6cnicas. Doctoral thesis, University of Valencia Faculty of Medicine, 98