A tailored surgical approach for gastro-oesophageal reflux disease: the Nottingham experience

Objective: The objective was to assess the results which can be achieved by tailoring the anti-reflux procedure to the anatomical and functional situa tion of the patient with gastro-oesophageal reflux disease (GORD). Patients and methods: Two hundred and seventy six patients undergoing a primary tai lored anti-reflux procedure between 1986 and 1996 were evaluated. An anti-r eflux procedure was selected on the basis of the anatomical and functional findings assessed by means of barium video, endoscopy, manometry and prolon ged pH monitoring. The operations performed were Nissen fundoplication (77) , total fundoplication gastroplasty (TFG; 140) and Belsey Mark IV (BMIV; 59 ). The unit policy is for life-long follow-up. The symptoms at review were assessed and graded according to previously published criteria (Orringer MB , Skinner DB, Besley HR. Long-term results of the mark IV operation for hia tal hernia and analyses of recurrences and their treatment. J Thorac Cardio vasc Surg 1972;63:25-31). Patients with recurrent symptoms were fully re-in vestigated. Results: Mean hospital stay was 8.2 days (5-32 days). There was one hospital death (0.36%). Mean follow-up was 6.7 years (range, 2.2-13.1 years). Overall excellent or good results were achieved in 247 (89.5%) pati ents (92.2% in Nissen, 90.7% in TFG and 83.1% in BMIV group, P = 0.1). In p atients without oesophagitis (n = 72), the success rate was 93.1%, while fo r patients with grade IV oesophagitis (n = 89) this was 87.6% (P = 0.2). Ka plan-Meier freedom from recurrent or new, operation-induced, symptoms at 10 years was 88.1% (89.5% in Nissen, 87.4% in TFG and 73.8% in BMIV groups, P = 0.08). Conclusions: These data suggest that where the appropriate anti-r eflux procedure is selected, surgery can achieve satisfactory mid- and long -term success rates across the spectrum of GORD. When oesophageal shortenin g is evident, or merely suspected, we favour a TFG. In the presence of impa ired motility and no evidence of oesophageal shortening, a BMIV is the pref erred approach. The Nissen procedure is used for uncomplicated cases. (C) 2 000 Elsevier Science B.V. All rights reserved.