Nissen Hiatal Hernia Rep& Problems of Recurrence &d R. D. Henderson, M.B. Continued Symptoms ABSTRACT The standard Nissen operation is the most effective method of reflux control. However, the procedure can result in continuance of symptoms, particularly dysphagia, which presents considerable diagnostic difficulty. Experience gained in the management of 17 patients with continued recurrent symptoms following standard Nissen repair has allowed more specific definition of the nature of these problems. The anatomical defect has been categorized as follows: (1) tight repair (tight fundoplication or tight diaphragmatic repair); (2) anatomical recurrence with and without reflux; and (3) intussusception recurrence. Each patient has been evaluated by history, manometry, ph reflux, acid perfusion, radiology, and endoscopy. At the time of corrective operation, the previous repair was carefully dissected to allow confirmation of the type of defect. Correlation is made between symptoms, investigative findings, and the anatomical problem at operation. Many operations have been designed for reflux control. However with each procedure, there is a significant incidence of anatomical recurrence. With most operative designs, when recurrence takes place, reflux occurs again and is responsible for recurrence of symptoms [3,151. The Nissen fundoplication totally wraps the lower esophagus with fundus of the stomach [3, 6, 131. This unique operative design is the most effective method of reflux control. Total fundoplication effectively controls reflux whether the high-pressure zone is below or above the diaphragm [2, 9, 161. Because of its effectiveness in reflux control, the operation has gained considerable popularity. There are specific problems with the Nissen fundoplication From the Department of Surgery, University of Toronto, and Women s College Hospital, Toronto, Ont, Canada. Presented at the Fifteenth Annual Meeting of The Society of Thoracic Surgeons, Jan 15-17, 1979, Phoenix, AZ. Address reprint requests to Dr. Henderson, Women s College Hospital, 76 Grenville St, Toronto, Ont, Canada M5S 1B2. that can result in severe symptoms [l, 4, 5, 101, but because of diagnostic difficulties, particularly with radiological display of the defect, they often remain unrecognized. In the present study, patients with a Nissen fundoplication had symptoms either immediately following operation or at a variable interval after effective reflux control. From the results of the preoperative and intraoperative investigation it is possible to more clearly define the mechanisms involved, categorize the anatomical defects, and correlate the operative findings with the preoperative investigations. Materials and Methods Seventeen patients, 5 men and 12 women with an average age of 47.6 years (range, 26 to 71 years), were investigated and operated on for continued or recurrent symptoms following a standard Nissen fundoplication. All patients were evaluated by history, radiology, manometry, acid perfusion, and endoscopy prior to operation. At the time of operation, the previous hiatal hernia repair was carefully dissected free to establish the nature of the anatomical defect. History was obtained using a prepared format, which allowed documentation of past operations, symptom relief, recurrence of pain, its distribution, and the various precipitating and relieving factors. Reflux, night aspiration, eructation, hiccup, water brash, nausea, vomiting, and dysphagia were also evaluated. Manometry was carried out using fine-bore polyethylene catheters with side openings and with constant water infusion from a modified Harvard pump. Manometric data were recorded using an ultraviolet Honeywell 1508 Visicorder. The ph reflux studies and an acid perfusion study were obtained during manometry using a Beckman probe. Reflux was tested by the installation of decinormal hydrochloric acid into the stomach and recording the ph, 5 cm above the high-pressure zone. 587 0003-49751791120587-07$01.25 @ 1978 by R. D. Henderson
588 The Annals of Thoracic Surgery Vol 28 No 6 December 1979 All patients had esophagogastroduodenoscopy and, when indicated, a 60F Maloney bougie was passed at the completion of this investigation for esophageal dilatation. Barium esophagograms, including water siphon investigation for reflux, were obtained on all patients. A barium sandwich was used to identify obstruction by solids when necessary. Following completion of the investigation and after careful intraoperative evaluation, the patients were classified as follows: a tight repair (tight fundoplication or tight diaphragmatic repair), anatomical recurrence, or intussusception recurrence. The investigative and operative findings are described using these diagnostic categories. Results Tight Repair HISTORY. In the 6 patients with a tight repair (Fig l), dysphagia was present immediately after operation and persisted without significant change. The dysphagia involved both liquids and solids and occurred with each meal in all patients. In 4 patients it was associated with intermittent regurgitation of material that tasted like food. Dysphagia was the dominant symptom. Heartburn, present before the original operation, was eliminated in all patients, although some retrosternal pain was present and was associated with food sticking. None of these patients had symptomatic reflux to the throat. All patients complained of an inability to eructate. Nausea was intermittently present in 3 patients, but there was no associated vomiting. Fig 1. Tight diaphragmatic crural repair. A Nissen fundoplication that is either too tight or too long, acts as a barrier to the descent of the food bolus. --Tight Diaphragm Too Tight Fundoplication One patient was able to retch, but could not vomit. None of the others described attempted vomiting. Weight loss averaged 5.45 kg (range, 4.54 to 22.68 kg) and was present in4 of the 6 patients. RADIOLOGY. In each patient, radiology showed no evidence of hernia recurrence and no reflux. For each patient, previous radiological studies had been reported as normal. When a barium sandwich was swallowed, it was possible to demonstrate obstruction at the gastroesophageal junction. MANOMETRY AND ACID PERFIJSION. Mano- metrically, the tone of the high pressure zone averaged 17.3 cm H,O (range, 14 to 22 cm H,O). Disordered motor activity in the lower half of the esophagus averaged 34.3%) ((range, 6 to 50%). Acid perfusion studies were clone on all patients, and in 4, pain was reproduced similar to that occurring with food obstruction. There was no demonstrable reflux. ENDOSCOPY. For endoscopy, the highpressure zone was considered to be below the diaphragm. The endoscope passed into the stomach without recognizable resistance. There was no evidence of reflux and, in particular, no ulceration of the esophagus. A 60F bougie was passed without resistance in all patients. Although some transient improvement was present following bougienage, no patient had major relief and the improvement lasted a maximum of three days. OPERATION. A thoracoabdoniinal approach was used for surgical repair. The esophagus was mobilized above and below the diaphragm. In 4 patients it was possible to demonstrate a tight fundoplication and in 2 patients, a tight diaphragmatic repair. In both of these patients, there was evidence of reaction to the suture material. This reaction consisted of granulation tissue and local srnall sterile abscesses around the material. This could be suture reaction or the end result of a local fistula. Re-repair in 5 patients was by total fundoplication gastroplasty [7, 8, 121 (Fig 2) and in 1, by partial fundoplication gastro plilsty [ll]. A thoracoabdominal incision, allowing dissection above and below the diiaphragm, is used routinely in patients with a recurrent
589 Henderson: Nissen Hiatal Hernia Repair A Fig 2. Total fundoplication gastroplasty. (A) The intrathoracic esophagus and fundus are mobilized and the crurae are approximated with interrupted sutures. A 6OF bougie is passed, and a gastroplasty tube is cut from the lesser cuwature of the stomach. The tube and fundus are closed. (B) The fundus is fixed to the 5 cm gastroplasty tube and the distal 2 cm of the esophagus. The total length of the fundoplication is 21k cm at completion of the procedure. hiatal hernia. Once the intrathoracic esophagus and fundus of the stomach are mobilized, the crurae are approximated with interrupted No. 1 silk sutures. A 60F bougie is passed and a gastroplasty tube, 5 cm in length, is cut from the lesser curvature of the stomach. The tube and fundus are closed with 00 chromic and 000 silk suture. The 60F bougie is passed again to ensure that no tightness has been produced in the gastroplasty tube. Following preparation of the gastroplasty tube, the fundus of the stomach is passed posterior to the tube and lower esophagus. Interrupted mattress 00 silk sutures are placed, fixing the fundus to the 5 cm gastroplasty tube and to the distal 2 cm of esophagus. The fundus is passed forward and sutured to give a total fun- doplication. Completion of the fundoplication provides a total length of 3 cm. Follow-up is complete in all patients and includes clinical and radiological evaluation. Average follow-up is 31 months (range, 3 to 72 months). Five patients are asymptomatic, and 1 has residual epigastric fullness well controlled with metachlopramide. Anatomical Recurrence HISTORY. All 6 patients had a satisfactory response to the standard Nissen fundoplication with resolution of prior reflux symptoms. Recurrent symptoms developed at variable intervals, 6 months to three years following operation (Fig 3). Epigastric and retrosternal burning discomfort recurred in all patients, and in 2 patients was referred to the middle of the back. Reflux to the throat was present in 4 of the 6 patients (absent in the 2 patients with no radiological reflux). Nausea was present in 3 patients, intermittent vomiting in 1 and eructation in 3. Intermittent dysphagia was present in all 6 patients. It involved solids in 6 and liquids in 1,
590 The Annals of Thoracic Surgery Vol 28 No 6 December 1979 Intact Fundoplication No Reflux Fig 3. Anatomical recurrence with a standard Nissen operation. If the fundoplication remains intact, reflux may be controlled; if the fundoplication breaks down, reflux is likely to occur. and regurgitation occurred occasionally in 3. The dysphagia was never severe. Weight loss averaged 2.38 kg (range, 0 to 9.98 kg) and was present in 3 of the 6 patients. RADIOLOGY. There was radiological evidence of recurrence of an anatomical hernia in all 6 patients. In 4, radiological reflux was present, and in 2 there was no evidence of reflux using the water siphon test. MANOMETRY AND ACID PERFUSION. The average tone of the high-pressure zone was 11.7 cm H20 (range, 9 to 19 cm HzO). Disordered motor activity in the lower part of the esophagus averaged 40.7% (range, 5 to 100%). Acid perfusion reproduced typical heartburn in all patients, and reflux was demonstrated in 4. These were the same 4 patients who had reflux on radiological examination. ENDOSCOPY. One patient had a gastric phytobezoar from pyloric obstruction. The remaining patients had chronic stage I epithelial changes with no ulceration of the esophagus. OPERATION. Each patient was treated surgically by a thoracoabdominal total fundoplication gastroplasty because of intractable symptoms. Follow-up averaged 22.3 months (range, 10 to 32 months). All patients were evaluated by history and radiology. Four patients are asymptomatic, 1 has persistent moderate wound pain, and 2 have minor epigastric pain related to bile gastritis from a previous radical Billroth I1 gastrectomy. In none of these patients are the residual symptoms severe. Intussusception Recurrence This form of recurrence is defined as migration of the stomach through an intact fundoplication (Fig 4) [14]. As it migrates, because of the bulk of the stomach wall, the lumen of the migrating stomach is progressively narrowed, producing obstruction. Symptomatically and radiologically intussusception recurrence is difficult to separate from a tight repair; however, the intussusception usually occurs at some time after the primary operation and is rarely an immediate postoperative symptom. HISTORY. Five patients with intussusception recurrence were studied. Three had epigastric and retrosternal pain. In 1 of them, the pain was referred to the back. Pain occurrecl only when food stuck. There was no described reflux in 3 patients, but 2 had very occasional recognizable reflux to the throat. Only 2 of thlese patients could burp. Three had nausea, none vomited, and 1 described an inability to vomit. Dysphagia was the dominant symptom in all patients and occurred with liquids and solids in 3, with only solids in 1, and with only liquids in 1. Regurgitation of material tasting like food occurred in 4. The dysphagia was severe and was experienced with each meal. Four of the 5 patients lost weight, average 10.94 kg (range, 4.08 to 19.05 kg:i. RADIOLOGY. In all patients, the results of radiological examination were described as normal, with no evidence of recurrence or re- Fig 4. Standard Nissen intussusception recurrence. (HPZ = high-pressure zone.) 1 1 1 - HPZ Stomach Intact Fundoplication
591 Henderson: Nissen Hiatal Hernia Repair flux. When solids were added to the barium swallow, obstruction was noted. MANOMETRY AND ACID PERFUSION. All patients underwent esophageal manometry, acid perfusion, and ph reflux studies preoperatively. The tone of the high-pressure zone averaged 15.3 cm H,O (range, 8 to 27 cm H,O). Lower esophageal disordered motor activity averaged 31% (range, 22 to 50%). Acid perfusion studies were positive in 4 out of 5 patients and produced epigastric and retrosternal pain. There was no evidence of reflux. ENDOSCOPY. Although endoscopy showed no evidence of reflux, gastric mucosa was seen pouting into the thorax above the point of anatomical competence in 2 patients. In l of these patients, who underwent endoscopy three times in 6 months, the mucosa was noted to progressively migrate proximally above the point of reflux competence. Bougienage with a 60F produced no improvement or minor and transient (less than three days) improvement in the dysphagia symptoms. OPERATION. All patients were treated by a thoracoabdominal total fundoplication gastroplasty. The intussusception defect was confirmed at the time of operation. Follow-up averaged 18.8 months (range, 5 to 31 months). All patients have been followed by history and radiology; 4 are symptom-free and none show evidence of radiological recurrence or reflux. One patient has residual minor dysphagia, but is much improved since operation. Comment In any patient with continuing or recurrent symptoms following hiatal hernia repair, it is necessary to establish the correctness of the original diagnosis, to confirm that a marked problem is present, and, when possible, to accurately define the nature of the disorder. Evaluation of patients following the standard Nissen repair is complicated by the fact that the radiological examination may be considered normal. Then, in the absence of positive findings, such patients might be considered functional and treated inappropriately. Anatomical recurrence is more readily recog- nizable because reflux symptoms occur and a radiological abnormality is present. Manometry is important to exclude previously misdiagnosed motor disorders and endoscopy, to evaluate reflux damage, and to exclude gastric or duodenal disease and malignancy. Intussusception recurrence or a tight repair are more difficult to evaluate and correctly diagnose. As a result, misdiagnosis is common and there is a delay in treatment. History is important in differentiating between these two categories. With a tight repair, although reflux symptoms are corrected, there is immediate and unremitting dysphagia as soon as the patient returns to a normal diet. With intussusception recurrence, the symptoms are similar, but the onset of dysphagia is delayed. Unless solids are added to the radiological examination to demonstrate obstruction, the investigation may be considered normal. Endoscopy often is considered normal because a mechanical obstruction is not recognized. Bougienage to 60F may give temporary relief, but the symptoms usually return within two to three days. Occasionally, endoscopically, gastric mucosa can be seen above the point of competence, and this is helpful in recognizing the presence of intussusception. Manometry is important to exclude primary motor disorders and can demonstrate a hightone sphincter. In general, these changes are not sufficiently specific to confirm the diagnosis. In patients with a tight repair or with intussusception recurrence, the symptoms of dysphagia may be the most positive findings. They can be confirmed by radiologically demonstrating obstruction to solids. Manometry and endoscopy are mandatory to exclude other diseases. A history of dysphagia and the presence of radiological obstruction confirm the presence of either of these disorders; however, the delayed onset of symptoms with intussusception must be recognized to make this diagnosis. Operative management of anatomical recurrence after a Nissen repair is necessary when vigorous conservative treatment fails. With intussusception recurrence or a tight repair, conservative treatment is ineffective and if the
592 The Annals of Thoracic Surgery Vol 28 No 6 December 1979 dysphagia is severe, surgical repair is necessary. Bougienage gives only transient relief since it simply stretches healthy muscle which then returns to its normal resting tone. With anatomical recurrence, symptoms can be corrected by re-repair provided the initial diagnosis is correct and evaluation has excluded other disease involvement. Similarly, with tight repair or intussusception recurrence, if the previous operation is dissected and fully mobilized, then repair by any standard method will successfully relieve the symptoms. Because of the high incidence of further recurrence, a total fundoplication gastroplasty (Collis-Nissen or total fundoplication gastroplasty) was chosen as the method of choice. The thoracoabdominal incision allows careful dissection under direct vision of both the intrathoracic esophagus and the subdiaphragmatic fundoplication. Using this approach, damage to the muscle wall or devascularization of the stomach is minimized. In the present group of patients there were no notable postoperative complications. The combination of gastroplasty with total fundoplication was used because it minimizes the risk of further reflux and almost eliminates the risk of further recurrence. In my present experience with 400 consecutive patients undergoing total fundoplication gastroplasty, the mortality is 0, anatomical recurrence is 0.25'/0, and continued reflux is 0 with a follow-up of 6 months to four years. Using this operative approach has produced satisfactory results in the present study. References Bahadorzadeh K, Jordan PH Jr: Evaluation of the Nissen fundoplication for treatment of hiatal hernia: use of parietal cell vagotomy without drainage as an adjunctive procedure. Ann Surg 181:402, 1975 Bettex M, Kuffer F: Fundoplication in hiatal hernia-results after 10 years. Prog Pediatr Surg 1025, 1977 Bushkin FL, Neustein CL, Parker TH, et al: Nissen fundoplication for reflux peptic esophagitis. Ann Surg 185:672, 1977 DeMeester TR, Johnson LF: Evaluation of the Nissen antireflux procedure by esophageal manometry and twenty-four hour ph monitoring. Am J Surg 129:94, 1975 5. Dilling EW, Peyton MD, Cannon JP, et al: Comparison of Nissen fundoplication and Belsey mark IV in the management of gastroesophageal reflux. Am J Surg 134:730, 1977 6. Henderson RD: Motor Disorders o j the Esophagus. Baltimore, Williams & Wilkins, 19715 7. Henderson RD: Reflux control following gastroplasty. Ann Thorac Surg 24:206, 1977 8. Henderson RD: The gastroplasty tube as a method of reflux control. Can J Surg 21:264, 1978 9. Henderson RD, Lind JF, Feaver 13: Invagination for control of reflux after esophagogastric anastomosis. Can J Surg 14:195, 1971 10. Mokka RE, Punto L, Kairaluoma ME, et al: Surgical treatment of axial hiatal hernia-reflux complex by Nissen fundoplication: a cineradiologic and manometric study. Acta Chir Scand 143965, 1977 11. Orringer MB, Sloan H: Complications and failings of the combined Collis-Belsey operation. J Thorac Cardiovasc Surg 74:726, 1977 12. Orringer MB, Sloan H: Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 25:16, 1978 13. Polk HC Jr, Zeppa R: Fundoplicaiion for complicated hiatal hernia: rationale and results. Ann Thorac Surg 7202, 1969 14. Siewart R, Lepsien G, Weiser HF et al: The telescope phenomenon: a complicai ion possibility following fundoplication. Chirur*g 48:64, 1977 15. Skinner DB, Belsey RH: Surgical management of esophageal reflux and hiatus hernia: long-term results with 1,030 patients. J Thorac Cardiovasc Surg 53:33, 1967 16. Woodward ER: Sliding esophageal hiatal hernia and reflux peptic esophagitis. hdayo Clin Proc 50:523, 1975 Discussion DR. F. HENRY ELLIS, JR. (Boston, MA): The introduction of any new operative proced,ure is usually greeted with great enthusiasm and is widely applied, often to conditions that are inapprop~iate. A number of years must pass before it becomes apparent that there are problems associated with the new procedure and a period of reevaluation takes place. It is essential, therefore, that we analyze from time to time potential shortcomings of new procedures. That is what Dr. Henderson has done, and I think he is to be commended. I would like to discus!; some of my experiences with these problems and to ask a few questions. I have seen 19 patients who had problems after a Nissen procedure. Only a few of thein had been operated on by me. I have categorized these problems somewhat differently than Dr. Henderson. Dysphagia was the most common, occurring in 11 pa-
593 Henderson: Nissen Hiatal Hernia Repair tients. Another common underlying feature was esophageal aperistalsis, which was present in 5 patients with either achalasia or scleroderma. This reemphasizes something that I have mentioned before, namely, that an antireflux procedure, particularly of the total wrap variety, is inappropriate when there is no peristalsis. Dysphagia developed in 6 other patients immediately after operation. Four patients had reflux postoperatively, 1 as late as four years after operation, because the sutures pulled out of the total wrap. I have not been concerned about anatomical recurrences if there is competence, and I would like to ask Dr. Henderson why reoperation is required for an anatomical recurrence of a hernia if there is gastroesophageal competence. The only postoperative hernia that I consider hazardous is a paraesophageal hernia. It occurred twice in my series and can lead to obstruction and incarceration. Two patients had a gas bloat syndrome. I reviewed the manometry of these 2 patients and of the 6 who experienced immediate postoperative dysphagia, because I thought, as Dr. Henderson did, that perhaps the wrap was too tight or that the length of the wrap was excessive. The level of pressure at the high-pressure zone in these 12 patients averaged 18 mm Hg, which is the same as in our patients with a successful Nissen procedure; and the length of the wrap was not excessive, being between 3 and 4 cm, which was also the length in the patients with a successful operation. Dr. Henderson said that the length of the wrap was important, yet he didn t show any manometric evidence that his patients with dysphagia had an excessively long wrap. I would like to ask him how long the high-pressure zone was in those patients in whom dysphagia developed. DR. NICHOLAS J. DEMOS (Short Hills, NJ): I have always learned something from the in-depth presentations of Dr. Henderson and from his excellent book on esophageal physiology. I have learned also from Dr. Ellis. I would like to urge use of the uncut gastroplasty, as Dr. Spencer Payne recently called the procedure. In this operation, the stomach is stapled during the gastroplasty, not cut. Because of the anatomical continuity of the plicated stomach and the plicated fundic segment, there is no recurrence from intussusception. The gastroplasty can be done lower down in the fundus if there is a short esophagus and, therefore, the plicated segment can be transfixed easily under the diaphragm. No sutures are taken on the esophagus at all; therefore, they subsequently cannot be pulled out and lead to recurrence or fistula. We have performed the uncut gastroplasty on more than 64 patients in the last seven years. There has been no anatomical recurrence and no mortality. Three patients have mild dysphagia. The more recent experience of Dr. Payne and Dr. John Evangelist enforce our trust in our procedure. DR. HENDERSON: I would like to thank Drs. Ellis and Demos for their comments. Dr. Ellis made some excellent points, and we seem to be mostly in agreement. His first question was why one should operate if the recurrence is present and competent. In constructing this paper, I included patients who were treated only surgically and did not include patients seen with recurrence after a Nissen repair who were not treated surgically. The 2 patients with competence who required operation were 2 out of a group of several with competence who had minor or no symptoms. These 2 had nausea and vomiting as dominant symptoms, which were related to the anatomical recurrence. I would agree with Dr. Ellis that most patients with a competent, total recurrence after a Nissen fundoplication do, in fact, have a satisfactory result and do not require re-repair. I agree entirely that if there is scleroderma or some other reason for a very low pressure profile in the body of the esophagus, the Nissen fundoplication should be very much modified; otherwise, excess dysphagia would be produced. The length of the fundoplication in patients with dysphagia was demonstrated primarily at the time of operation, and each was carefully taken down and measured anatomically. We can take those measurements back to our manometric traces and compare them. The critical length was around 4 cm, and fundoplication above this length seems to produce a degree of dysphagia that is unacceptable. I would like to thank Dr. Demos for his comments. There is controversy as to whether to use a cut or uncut total fundoplication tube at the time of gastroplasty, and of course this is important. I am very aware of this controversy and know that others, including Dr. Payne, are using the uncut method. I have no particular problem with the cutting of gastroplasty tubes. It takes very little extra time and does not add morbidity. There are published reports of breakdown of uncut tubes with recurrence of reflux, and I believe this should be avoided if possible. For this reason and because I believe that the fundoplication with a cut tube is superior, I have cut and will continue to cut the tubes.