Gastroplasty and fundoplication in the management of complex reflux problems.

Between 1963 and 1976, 220 patients with complex reflux problems were managed by combining a modified Collis gastroplasty with a Belsey type of partial fundoplication. All patients had one or more of the following complicating conditions considered indications for the combined operation: peptic stricture (104), esophagitis and shortening without stricture (25), one or more prior hiatal repairs (65), massive herniation (33), and motor disorders associated with reflux (26). Ninety-six percent of the patients were evaluated by personal interview from 1 to 15 years after repair. The operative mortality rate was 0.5 percent. The incidence of significant symptomatic reflux requiring medical therapy was 3 percent and the incidence of troublesome dysphagia was 11 percent. No patient has required further operation for the relief of recurrent symptomatic reflux. Two patients required additional operation for severe residual dysphagia. Twenty patients managed by this repair were evaluated by preoperative, intraoperative, and sequential postoperative esophageal pressure studies. The mean postoperative pressure of 21.4 mm. Hg was more than double the preoperative value. Two publications from other centers reported on similar groups of patients managed by gastroplasty and partial fundoplication, evaluated by preoperative and postoperative esophageal pressures. In these latter publications, the percentage increase in postoperative lower esophageal pressure was significantly less than in our study, and a much higher incidence of symptomatic reflux was recorded. We suggest that the differences in postoperative pressures observed in account for the pronounced differences in the quality of results obtained.