Gallbladder Function before and after Fundoplication
Abstracts
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BACKGROUND: Despite the proximity of the hepatic branch of the anterior vagus nerve to the esophagogastric junction, no study has reported the impact of gastroesophageal reflux disease (GERD) on gallbladder function. Also, the importance of preservation of vagal gallbladder fibers during antireflux surgery is uncertain. Therefore, we compared pre- and postoperative gallbladder function in patients undergoing fundoplication to determine: 1) whether patients with chronic GERD have pre-existing gallbladder motor dysfunction, and 2) if division of the hepatic branch of the anterior vagus nerve alters gallbladder motility. METHODS: Nineteen patients with documented GERD consented to preoperative cholecystokinin-stimulated technetium hepatobiliary (CCK-HIDA) scan to quantify gallbladder ejection fraction (GBEF). The likelihood of gallbladder motor dysfunction (GBEF < 35%) was compared to a control group of 53 patients having CCK-HIDA in evaluation of presumed biliary dyskinesia. All patients had laparoscopic Nissen fundoplication by one of four surgeons, and intraoperative decision making dictated the treatment of the hepatic branch fibers. One month after fundoplication, 12 patients completed repeat CCK-HIDA determination of GBEF, with comparison to preoperative GBEF. Patients with biliary symptoms, cholecystectomy, fundoplication or vagotomy were excluded. RESULTS: In preoperative patients with GERD, 11 of 19 (58%) had GBEF < 35%. This rate is similar to that in the control group having evaluation for biliary dyskinesia (31 of 53, 60%, p=NS, Fisher's exact test), and exceeds the rate of abnormal GBEF reported in healthy volunteers (3%). In the 12 patients who underwent postoperative CCK-HIDA, there was no association between preservation or division of the hepatic branch of the anterior vagus nerve and postoperative GBEF (p=NS, univariate analysis). Six of 7 patients with low preoperative GBEF demonstrated normal GBEF postoperatively, however this trend failed to achieve statistical significance. CONCLUSIONS: Unexpectedly, 58% of patients demonstrated gallbladder motor dysfunction prior to fundoplication, with improvement to normal occurring in most of those studied postoperatively. These data support controlled trials to determine the effect of chronic GERD and antisecretory therapy on gallbladder and global gastrointestinal smooth muscle function. Preservation of the hepatic branch of the anterior vagus nerve during fundoplication offers no clear benefit with regard to early postoperative gallbladder function. |
