Background Nissen fundoplication is a surgical procedure used to tighten the lower esophageal sphincter and thus prevent gastroesophageal reflux in gastroesophageal reflux disease (GERD) patients not responding to standard medical therapy. The aims of this study were to 1) evaluate the clinical effectiveness of Nissen fundoplication by comparing pre- and postoperative gastroesophageal reflux symptoms; 2) to observe the effects that fundoplication has on gastric emptying time (GET); and 3) to determine if preoperative gastric emptying could predict changes in postoperative symptoms.
Patients and Methods The study included 21 patients (6 M, 15 F, mean age 50 years), all who have had Nissen fundoplication at the University of Kansas Medical Center by a single surgeon between November 1998 and August 2003. All patients had pre- and postoperative gastric emptying studies, at which time a 255 kcal test meal consisting of Egg-Beaters prepared with technetium, 2 slices of bread, and one-half cup of water was consumed. Anterior and posterior images of the stomach were obtained immediately after eating, and again at 1 hour, 2, 3, and 4 hours to determine the percent of gastric retention. Patients also completed a survey which evaluated the severity of the following reflux symptoms: heartburn, regurgitation, dysphagia, nausea, abdominal bloating, epigastric pain, fullness, early satiety, weight loss, diarrhea, constipation, and atypical chest pain (no symptoms = 0, mild = 1, moderate = 2, severe = 3).
Results The severity of all symptoms decreased postoperatively except for early satiety and weight loss. 9 patients lost the ability to vomit. Average global improvement in symptoms was 56% with 14 patients having greater than 50% improvement compared to only 7 with less than 50%. Preoperative gastric emptying showed 9/21 patients (42.8%) were slow compared to 6/21 (28.6%) after. Mean gastric retention of isotope at 4 hours was similar both pre- and postoperatively at 12% and 16% respectively.
Conclusions 1) In patients who have failed standard medical management, specifically those patients who experience nocturnal regurgitation, Nissen fundoplication is an effective treatment option. 2) GET should be obtained routinely prior to surgery so postoperative dyspepsia and gas-bloat syndrome can be interpreted. 3) Slow GET is not resolved by Nissen fundoplication and will need to be treated during the long-term medical management of these patients. 4) Upper GI symptom assessment could not reliably predict the subset of patients with either pre- or postoperative delayed GET.
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