Should reposition of the gastric cardia be attempted in the absence of a hiatus hernia ?
J. Baulieux, A. Bel, C. Ducerf, M. El Riwini (Lyons)
It is now well-known that hiatus hernia is not an essential factor in the pathogenesis of gastroesophageal reflux (GER). In a study of 170 cases operated for GER [4], we noted that gastric cardio-fundal malposition was present in 51 p. cent of the cases, who were thus operated in the absence of a hiatus hernia. This incidence of malposition was higher than that encountered by Ducerf [3] in 112 patients (33 %) or by Teboul [9] in 140 patients (13.6%).
This finding has often been reported in the literature, as in the work of Belsey, Lortat-Jacob [7], Cohen, Harris [2] and Hiebert [5]. The latter clearly demonstrated that GER could develop through a hypotonic, abdominally located lower esophageal sphincter (LES) in the absence of any radiologic evidence of hiatus hernia. It follows that the problem in cases of gastric cardio-fundal malposition is to reestablish sphincteric function. DeMeester and Skinner [8] demonstrated that the length of the LES is directly related to the basal tone of the sphincter and the presence or absence of GER. If the length of the abdominal esophagus is sufficient (4 to 5 cm), any rise in the intra-abdominal pressure will be reflected in the gastric pressure and will result in a rise of the LES pressure [1].
Actually, two operative procedures of completely differing principle can be performed to increase the LES pressure. These are as follows:
The complete Nissen fundoplication
This technique aims to create an active substitute sphincter at the lower esophagus and results in an increase in LES pressure. In a comparative study [4], the preoperative LES pressure was 9.85 mmHg and rose to a mean of 21.4mmHg following the Nissen procedure. Detailed analysis of the results showed that an increased LES pressure developed in 92 p. cent of the patients.
Among the 35 patients showing a hypotonic LES in the preoperative period, 32 (82 %) regained a normal LES pressure following fundoplication, 3 (7.6 %) remained hypotonic, though with complete disappearance of all clinical signs, and 4 (10.4 %) developed a hypertonic LES.
The rise in pressure following fundoplication was more significant (p < 0.02) in patients with a preoperative hypotonic sphincter (gain = + 12.1 mmHg) than in those with a normotonic or a hypertonic LES (gain = + 6.7 mmHg). The development of LES hypertonus following fundoplication was significantly more frequent
(p < 0.02) in patients showing a normal preoperative LES pressure (40 %). It was encountered in only 10 p. cent of patients who presented with preoperative hypotonus.
It should be noted that the typical Nissen operation is performed on a segment of abdominal esophagus, which is relatively easy to bring down into the abdomen. In the absence of this restitution, a « pseudo-Nissen » procedure is performed on a gastric cone, a procedure which is less reliable as regards the correction of the GER.
Posterior gastropexy (Hill operation)
Reposition of the gastric cardia according to the technique of Hill permits posterior fixation of the gastroesophageal junction and reconstitutes an anatomic terminal esophagus [6]. In our experience [4] the mean preoperative LES pressure was 10.59 mmHg and rose to 19.87mmHg following Hill's procedure (gain = + 9.28 mmHg). Detailed analysis of the results showed that an increase in LES pressure occurred in 90 p. cent of patients.
Among the 37 patients presenting a preoperative hypotonic sphincter, 28 (75 %) regained a normal LES pressure following posterior gastropexy, 2 (5 %) remained hypotonic, although only one patient presented a bad clinical result, and 7 (18%) developed moderate hypertonus with an LES pressure not exceeding 30 mmHg, all with satisfactory clinical results. The lower the original LES pressure, the higher was the gain after operation (gain = + 11.1 mmHg for a preoperative hypotonic sphincter, but only 5.2 mmHg for a normotonic sphincter).
Does this comparative study establish the elements of choice between the ideal of simple restitution of abdominal esophageal length (Hill operation) and the creation of an active substitute sphincter with a varying degree of restitution of the abdominal esophagus (Nissen fundoplication) ?
In our view, the Hill procedure should be used whenever the abdominal esophagus can be brought down into the abdomen without excessive traction and posterior gastropexy performed in good conditions. This choice becomes mandatory if the preoperative studies show a hypertonic LES and presence of esophageal dyskinesia, which could be exacerbated if complete fundoplication were performed. Of course, the Nissen (or pseudo-Nissen) procedure could be performed in every case, but its use is only imperative in certain cases when an acquired short esophagus is difficult to bring down into the abdomen.
However, the Nissen procedure carries the considerable risks of splenectomy and many functional sequelae (postoperative dysphagia); hence our cautious attitude towards the Nissen procedure in cases of gastric cardio-fundal malposition.
We reserve this technique for more advanced conditions which are difficult to treat.
Conclusion
To answer this question, it seems proper that whenever a hiatus hernia is absent, the surgical treatment of GER should aim at restoration of a normal length of the abdominal esophagus and that the posterior gastropexy of Hill is the best technique available to achieve this goal.
References
6. Hill LD (1967) An effective operation for hiatal hernia. Ann Surg 4 : 681-692.
7. Lortat-Jacob JL, Giuli R (1977) Les malpositions cardio-tuberositaires. Lyon Chir 68 : 21-24.