Effect of laparoscopic partial fundoplication on reflux mechanisms

OBJECTIVES: Transient lower esophageal sphincter relaxations (TLESRs) are the main mechanism causing gastroesophageal reflux. Since 1994 we have performed laparoscopic partial instead of complete fundoplication as standard surgical treatment for therapy resistant reflux disease to minimize postoperative dysphagia. To better understand the management of gastroesophageal reflux, we conducted a prospective study of the effects of laparoscopic partial fundoplication on TLESRs and other reflux mechanisms.

METHODS: From 1994 to 1999, 65 patients underwent laparoscopic partial fundoplication (180-200 degrees) and 28 of these patients (16 female, 12 male, mean age 43 +/- 2 yr [range, 26-66 yr]) agreed to participate in this prospective study on reflux mechanisms. Before and 6 months after surgery, all patients were evaluated by simultaneous recording of pH and lower esophageal sphincter characteristics, using sleeve manometry.

RESULTS: After partial fundoplication basal LES pressure increased significantly (p < 0.05), from 14.3 +/- 1.2 mm Hg to 17.8 +/- 1 mm Hg. Partial fundoplication significantly (p < 0.05) decreased the number of TLESRs, from 3.4 +/- 0.8 to 1.6 +/- 0.3 per hour in the fasting period, and from 4.7 +/- 0.5 to 1.9 +/- 0.3 per hour postprandially. The percentage of TLESRs associated with reflux also decreased significantly (p < 0.05), from 45 +/- 7% to 27 +/- 6% after operation. The number of reflux episodes decreased significantly (p < 0.05), from 4.1 +/- 0.7 to 1.3 +/- 0.3 per hour postoperatively. The majority of these episodes were associated with TLESRs: 57% and 46%, pre- and postoperatively, respectively.

CONCLUSIONS: Laparoscopic partial fundoplication significantly increased fasting and postprandial LES pressure and significantly decreased TLESR frequency. This resulted in a significant reduction in esophageal acid exposure, with preservation of postprandial LES characteristics.