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2006 Abstracts: Patterns of Reflux after Successful Nissen Fundoplication
Back to 2006 Program and Abstracts
Patterns of Reflux after Successful Nissen Fundoplication
Renee C. Minjarez, Eugene Y. Chang, Charles Y. Kim, John G. Hunter, Blair A. Jobe; Department of Surgery, Oregon Health and Science University , Portland , OR

Background: Nissen fundoplication (NF) is thought to provide a mechanical barrier to all forms of reflux, irrespective of pH content. It is this anatomic barrier which is hypothesized to prevent ongoing esophageal injury and progression along the metaplasia-dysplasia-carcinoma sequence. Combined 24-hour pH-impedance is the most sensitive means by which to detect the proximity, content, duration, and pH of reflux events; while reflux patterns have been well-characterized in normal, non-GERD subjects, they have never been examined in patients who have undergone successful NF. We hypothesize that NF creates a barrier to reflux which is more effective than the native barrier in normal subjects. Methods: Satisfied patients who have undergone NF for documented GERD were evaluated with manometry, upper endoscopy, and validated symptom-based questionnaires. Those who had a normal LESP and were completely free of esophagitis, GERD-related symptoms, and fundoplication-related side-effects underwent 24-hour pH-impedance. A normal DeMeester score was required for inclusion in the final analysis. Impedance patterns of reflux were then characterized. Results: Ten patients (mean age 57 yrs) were studied at a mean follow-up of 33 months postoperatively. A total of 299 reflux events were detected, of which 41.8% were acid, 38.8% non-acid, 16% weakly acid, and 3.3% acid re-reflux. Two-thirds of all events were liquid, and the remainder were mixed liquid and gas. Of all reflux events, 48.2% occurred within one hour after meals; of these, 51% were acidic events. Twenty-five percent of reflux events reached 15 cm above the LES. Mean bolus clearance time was 17 seconds (range, 13.6-23.15). Most reflux events (81%) occurred in the upright position. The table shows the median number of reflux events per patient and interquartile range (IQR). Conclusion: Compared with previously published data in healthy subjects which showed a median of 44 reflux events per patient, asymptomatic post-NF patients have fewer reflux events. A substantial proportion of reflux events after NF are non-acidic and would not be detected with pH monitoring alone. A properly performed NF allows physiologic postprandial reflux and, as suggested by the lack of acid re-reflux, does not hinder esophageal clearance. These findings establish the normal reflux profile of a properly performed NF.
Median number of reflux events per 24 hours per patient

 

All Reflux

Acid Reflux

Non-Acid Reflux

Weakly Acid Reflux

Acid Re-Reflux

All positions

13.5 (6.25, 41.5)

1 (0, 11)

9.5 (6.25, 14)

0.5 (0, 4.5)

0 (0, 1.5)

Upright

8.5 (5.25, 33.75)

0.5 (0, 9.5)

6 (4.25, 11.75)

0 (0, 1.75)

0 (0, 1.5)

Supine

3.5 (1.25, 8)

0 (0, 1)

2 (0.25,5.5)

0.5 (0, 1.75)

0 (0,0)


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