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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