Tailoring antireflux surgery: A randomized clinical trial

A hypothesis has been formulated that mandates the adjustment of antireflux surgery to either a total or a partial wrap depending on the motor functio n of the esophagus to avoid dysphagia and other obstructive complaints. Thi s hypothesis has been tested in a randomized, clinical trial where 106 chro nic gastroesophageal reflux patients were allocated to either a total Nisse n-Rossetti (n = 53) or a Toupet partial posterior (n = 53) fundoplication, irrespective of their preoperative esophageal motor function. All patients were followed at least 3 years, during which time none had a relapse of mod erate to severe reflux symptoms. Motor dysfunctions defined as peristaltic amplitude less than or equal to 30 mmHg in the distal third and failed prim ary peristalsis with or without >20% simultaneous contractions were noted i n 67 patients preoperatively, but these patients did not have a specific sy mptom profile (e.g., dominated by obstructive symptoms) nor did seven patie nts with "aperistaltic esophagus." The incidence of dysphagia decreased fro m 20% preoperatively to 8% (mild) at 3 Sears after the operation with no di fference between the surgical procedures. We were unable to demonstrate a r elation between preoperative manometric findings and postoperative symptoms when assessed in the total group or when subdivided by the type of fundopl ication (r < 0.3). Flatulence occurred more frequently among those with a t otal fundic wrap (p < 0.01). When patients representing motor dysfunction ( see above) were specifically analyzed, we again observed no difference in o utcome between those having a total or a partial fundic wrap. In conclusion , the concept of tailoring antireflux surgery based on the preoperative mot or function of the esophagus in patients with chronic gastroesophageal refl ux disease was not supported by the results of this clinical trial.