Reflux control by fundoplication: a clinical and manometric assessment of the Nissen operation.

Ninety-two Nissen fundoplications were performed for relief of symptoms of reflux in patients without stricture and in whom the wrap was left in the abdomen. Of these, 25 were reoperations. Reflux secondary to a hypotensive lower esophageal sphincter was associated with a sliding esophageal hiatus hernia in 61 patients, and surgical or other manipulative maneuvers were responsible for a hypotensive lower esophageal sphincter in 5 patients. No obvious cause could be determined in the remaining patients. The operation was transabdominal in 74 patients and by thoracotomy in 18 patients. Fifteen patients required ancillary operative procedures. Follow-up studies averaged 5 3/4 years in 82 patients and revealed permanent control of reflux in 74 of them (90.2%). Eighty percent of the patients were able to belch after operation. Overall patient satisfaction was achieved in 67 patients (81.7%). Among those who underwent operation for the first time, 84.5% achieved satisfactory results, whereas only 75% of those who underwent reoperation were benefited. Poorest results were caused by too tight a wrap, a complication that became rare after the size of the indwelling stent was increased to 42F. Esophageal manometry documented effective and significant augmentation of the amplitude and length of the lower esophageal sphincter from preoperative values of 7.2 +/- 0.5 mm Hg and 2.4 +/- 0.1 cm to postoperative values of 15.6 +/- 0.6 mm Hg and 4.1 +/- 0.1 cm (p less than 0.001). We conclude that if patients are properly selected and the wrap loosely fashioned, permanent control of reflux can be achieved by the classic Nissen fundoplication in 90% of patients with relatively few complications and a high degree of patient satisfaction.