Life Long Experience Treating and Preventing Gastro-Esophageal Reflux

Opinion

For over 60 years, we have operated upon several hundred patients suffering from gastroesophageal reflux and its complications. Three separate procedures have been devised, tested, applied, and followed for many years, both in the presence or surgical absence of the patient’s cardia. Our interest in esophageal surgery spans over 60 years. To judge the results of our operations we have been guided by Mr. Ronald Belsey’s edict: The correction of an anti-reflux procedure should be judged after no less than ten year follow-up, 9 (R. Belsey, personal communication, 1968).

Fundoplication for correction of gastroesophageal reflux, introduced by Raloph Nissen, had become an important breakthrough for the correction of hiatal hernia Opinion [1]. Recurrence followed frequently enough due to slippage. Collis, in 1957, introduced a lengthening gastroplasty and fundoplication [2]. Since then, lengthening by transecting and suturing the cut edges prior to fundoplication because a widely accepted procedure [3].

We introduced stapling of the fundus instead of transecting and suturing (Figure 1). Stapling saves time and is less likely to lead to leakage of the sutured edges. Figure 2 shows a partial fundoplication in a patient with abnormal esophageal peristalsis. Figure 3 shows the multiple advantages of the stapled, uncut gastroplasty. Our 24 years experiences with 161 patients with severe reflux and/or stricture revealed only one death, an emergency operation, and two symptomatic occurrences (Figure 4&5).

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The Mayo Clinic has used this gastroplasty as the main procedure for reflux and its complications, (S. Payne, personal conversation, 1989). Our gastroplasty has been used through the chest or abdomen [4, 5]. A group of 24 patients were successfully operated upon using the video assisted technique [6].

The second procedure devised by us concerns recurrent achalasia with reflux and stricture. In three such patients we performed a Y-V Plasty and partial Fundoplicaton (Figures 6 & 7). This technique had been previously employed by Moschel and coworkers to correct pyloric stenosis, 8. Five year follow-up by our three patients revealed no dysphagia, reflux or esophagitis [7].

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Our third anti-reflux procedure concerns patients with surgical absence of the cardia. Skinner and Belsey declared that “recurrent gastroesophageal reflux and stenosis is the most important late complication to follow reconstruction by intrathoracic esophagogastrostomy [8]. In fact, Wang and associates followed 368 patients after esophagogastrostomy and found that 5% if patients had succumbed fatally to pulmonary aspiration and 26% more suffered severely from reflux and aspiration [9].

We thought a muscular pedicle around the esophagogastrostomy might provide protection form reflux. In my early resident years, I assisted our mentor, William J. Poth, construct a thigh muscular pedicle inserted subcutaneously around the anus to correct anal incontinence in young children [10, 11]. Indeed, an intercostal myo- nuerovascular pedicle did the work of a new cardia in patients with esophagogastrostomy, (Figure 8).

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Technically, the pedicle procedure takes about 15 minutes to dissect thus adding very little to the much longer esophagogastrectomy, 17. The resulting pictures on the esophagus, Figure 5, are convincing as to the result of the pedicle. Certainly the 24-year study of our patients is convincing [12, 13, 14, 15, 16, 17].

We believe that it’s not all pedicle, at least the majority of them continue to be viable. In one patient, dying of heart disease two years after the pedicle operation, the autopsy biopsy of the pedicle revealed viable muscle, nerves and vessels. Moreover, nanometric studies performed three years postoperatively active sphincteric pressure and acid to neutral pH changes at the “new cardia” level (Figure 9).

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In my retirement, I can that we now have procedures to treat and protect our patients from the suffering of acid gastroesophageal reflux and its catastrophic or disabling complications.