Abstracts
1997 Digestive Disease Week

Collis gastroplasty plus fundoplication is more effective than bougienage plus acid-suppressive therapy in the treatment of reflux-induced strictures of the esophagus.

M Anselmino, G Zaninotto, M Costantini, C Boccu', D Molena, E Ancona. Department of Surgery, University of Padova, Padova, Italy.

Esophageal peptic stricture represents the end-stage of gastroesophageal reflux disease and its treatment is still challenging surgeons and gastroenterologists. The effects of two different treatment modalities (Collis gastroplasty plus fundoplication or bougienage plus acid-suppressive therapy) were studied in 39 patients (27 M and 12 F, median age 61 y., range 19-77) with peptic stricture of the esophagus. Patients were evaluated by scored symptom assessment, esophagography, endoscopy, esophageal manometry and 24-hour pH monitoring, before and after treatment. Fourteen patients (36%) underwent Collis gastroplasty plus fundoplication with intraoperative esophageal dilatation, whereas the remaining 25 (64%) underwent conservative treatment with a median number of 3 (r.1-12) dilatations with Savary bougies plus high doses of acid-suppressive therapy. Before treatment, esophageal stricture caliber and symptom score were similar in the two groups of patients. Failure of conservative therapy, i.e. recurrence of stricture and dysphagia, was observed in 10 patients (40%) after a median time of 4 months (r.2-33) and a median of 2 (r.1-12) dilatations/patient. These patients were shifted to surgery and the surgical group [Group A] was therefore eventually formed by 24 patients, whereas the group treated with bougienage plus medical therapy [Group B] included 15 patients. After a median follow-up of 14 months (r.1-91) for Group A and 17 months (r.3-50) for Group B, p=n.s., symptom-free patients were 71% (17/24) in Group A and 33% (5/15) in Group B, p<0.05. Recurrent dysphagia was recorded in 4/24 patients (16.6%) treated with surgery and in 9/15 (60%) of those treated with multiple dilatations (p<0.01). A positive score for symptoms other than dysphagia was recorded in 4/24 patients (16.6%) in Group A and in 7/15 (46.6%) in Group B, p<0.05. In Group A, post-operative manometry showed a significant increase in the LES pressure [15.4 (r.7-28) vs 7.8 (r.3-20), p<0.05]. This finding was associated with an overall decrease in the total % esophageal pH < 4 (p<0.01). Eleven of these patients (46%) were able to discontinue acid-suppressive drugs, whereas all 15 patients treated with bougienage continued medical therapy, p<0.001. During a period of over 12 months, the need for further dilatation amounted to 12.5% (3/24) in Group A and 67% (10/15) in Group B; a total of 4 dilatation sessions (mean:1.3/patient) were required in Group A as opposed to 27 sessions (mean: 2.7/patient) in Group B, p<0.05.

Surgical treatment of esophageal peptic stricture using Collis gastroplasty plus fundoplication is more effective than multiple dilatations plus medical therapy, and enables acid-suppressive therapy to be discontinued in 46% of cases versus 0% of those treated with dilatation. The need of further dilatation is greater in patients after bougienage than after surgery; moreover, in the event of recurrent disabling dysphagia, the number of dilatations required to stabilize esophageal caliber is significantly lower in patients treated with surgery.