What can be expected from posterior fundoplasty in treatment of gastroesophageal reflux?
V. Guarner (Mexico City)
The Nissen fundoplication has a high rate of undesirable side effects. In 1969, after a long experimental evaluation fl] we introduced another antireflux procedure that we conventionally called: the posterior fundoplasty, which is essentially a modification of the Nissen procedure but not a hemifundoplication [2].
As was demonstrated for the first time in 1975 [3], the side effects with this late procedure were, from the beginning, considerably less frequent than with the Nissen.
In 1980, a comparative study was published [4] with a 10-year follow-up of 135 patients, who had been operated on using the posterior fundoplasty method, compared with 40 patients who were operated on employing Nissen fundoplication. The 10-year evaluation was done clinically, with endoscopy, radiology and manometric studies in both groups.
Technique
Either a right transverse or a vertical midline incision is performed. The left lobe of the liver is retracted without sectioning the left triangular ligament. The spleen is protected with a large sponge, previously rolled. Both crura of the diaphragm are dissected and closed behind the esophagus.
The upper part of the anterior wall of the fundus, in the area in which there are
Figure 1. .Left: the right hand passes the anterior wall of the fundus to the right side of the esophagus; middle: the fundus does not wrap around the esophagus, but forms a 110° angle with the wall of the esophagus; right: the esophagus is sutured to the anterior wall. (Reprint from Surg Gynecol Obstet 1990;170:451-452. ©1990, by The Franklin H. Martin Foundation.)
no vasa brevia (so the omentum does not need to be transected), is passed behind the esophagus to its right side, forming more or less a 110° angle between the esophagus and the fundus, as seen in Fig. 1. This angle does not refer to the degree in which the stomach wraps around the esophagus, as it is often misinterpreted. The clue to the operation (and the reason for insisting on the technique) is the amount of fundus that is passed to the right side of the esophagus. It is precisely the internal part of this portion of the fundus which is attached with interrupted stitches of three or four zero silk to the esophagus (Fig. 1).
The difference between our technique and the Toupet [5] is that, in the latter procedure, the operation is done with both the anterior and the posterior walls of the fundus.
|
Clinical evaluation |
Preoperative |
Postoperative |
||||
|
Posterior fundoplasty |
Nissen |
Posterior fundoplasty |
Nissen |
|||
|
Substernal burning |
135 |
40 |
7 (5.1%) |
2 (5%) |
||
|
Regurgitation |
135 |
40 |
7(5.1%) |
2 (5%) |
||
|
Dysphagia |
9 |
0 |
0 |
5 (12.5%) |
||
Table 2..
|
Postoperative clinical evaluation |
Fundoplication |
Posterior fundoplasty |
||
|
Vomiting block |
24/40 (60%) |
3/135 (2.2%) |
||
|
Difficulties in belching |
14/40 (35%) |
4/135 (2.9%) |
||
Table 1..
Discussion
This operation accomplishes three purposes. First, it elongates the abdominal esophagus even more than does the Nissen procedure and as it has been demonstrated by many authors, this is an important point. Secondly, it forms a fold or a type of valve on the left side of the esophagus, which prevents gastric content to reach the esophagus. Thirdly, it also creates, as other procedures, a posterior bag with the stomach in which the gastric acid finds an easier access.
In 1980, we published a 10-year comparative evaluation between 135 cases operated with posterior fundoplasty and 40 patients with classical Nissen fundoplication. Both procedures had the same effectiveness in the control of gastroesophageal reflux, however, dysphagia was lower with our procedure (2.9 vs. 12.5%), inability to vomit 2.2 vs. 60%, difficulties in belching, 2.9 vs. 35% (Tables 1 and 2; Fig. 2).
Sliding of the fundoplication that occurred in one patient, and produced occlusion of the esophagogastric junction, was not seen after fundoplasty, because in this technique the fundus is fixed all its way to the abdominal esophagus. By the same fact, the length of the lower sphincter is manometrically longer with posterior fundoplasty compared to the Nissen (Fig. 3).
From 1966 until 1992, we have operated on more than 1,500 patients with the technique of posterior fundoplasty. The evaluation of long-term results are 90% excellent, with the same low average of side effects.
Figure 2..
Figure 3. .Length of the lower esophageal sphincter before and after surgical treatment.
References
2. Skinner DB. In: Atlas of Esophageal Surgery. New York: Churchill Livingstone, 1991
3. Guarner V. A new antireflux procedure in the esophagogastric junction Arch Surg 1975;110:101-106.