A tailored surgical approach for gastro-oesophageal reflux disease: the Nottingham experience.

OBJECTIVE

The objective was to assess the results which can be achieved by tailoring the anti-reflux procedure to the anatomical and functional situation of the patient with gastro-oesophageal reflux disease (GORD).

PATIENTS AND METHODS

Two hundred and seventy six patients undergoing a primary tailored anti-reflux procedure between 1986 and 1996 were evaluated. An anti-reflux procedure was selected on the basis of the anatomical and functional findings assessed by means of barium video, endoscopy, manometry and prolonged pH monitoring. The operations performed were Nissen fundoplication (77), total fundoplication gastroplasty (TFG; 140) and Belsey Mark IV (BMIV; 59). The unit policy is for life-long follow-up. The symptoms at review were assessed and graded according to previously published criteria (Orringer MB, Skinner DB, Besley HR. Long-term results of the mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972;63:25-31). Patients with recurrent symptoms were fully re-investigated.

RESULTS

Mean hospital stay was 8.2 days (5-32 days). There was one hospital death (0.36%). Mean follow-up was 6.7 years (range, 2.2-13.1 years). Overall excellent or good results were achieved in 247 (89.5%) patients (92.2% in Nissen, 90.7% in TFG and 83.1% in BMIV group, P=0.1). In patients without oesophagitis (n=72), the success rate was 93.1%, while for patients with grade IV oesophagitis (n=89) this was 87.6% (P=0.2). Kaplan-Meier freedom from recurrent or new, operation-induced, symptoms at 10 years was 88.1% (89.5% in Nissen, 87.4% in TFG and 73.8% in BMIV groups, P=0.08).

CONCLUSIONS

These data suggest that where the appropriate anti-reflux procedure is selected, surgery can achieve satisfactory mid- and long-term success rates across the spectrum of GORD. When oesophageal shortening is evident, or merely suspected, we favour a TFG. In the presence of impaired motility and no evidence of oesophageal shortening, a BMIV is the preferred approach. The Nissen procedure is used for uncomplicated cases.