DOES ESOPHAGEAL MOTOR FUNCTION IMPROVE WITH TIME AFTER SUCCESSFUL ANTIREFLUX SURGERY - RESULTS OF A PROSPECTIVE, RANDOMIZED CLINICAL-STUDY

Main objective - There is a continuing debate whether motor abnormalit ies associated with gastro-oesophageal reflux disease (GORD) are prima ry phenomena or occur as a consequence of repeated injury caused by in flammation. To get new insights into mechanisms involved, patients wer e studied before and three years after effective and durable reflux co ntrol induced by two types of fundoplications. Patients and methods - Thirty three consecutive patients with chronic GORD entered the trial. All patients had a clinical history of GORD assessed symptomatically, endoscopically, and by use of 24 hour pH-metry. Eighteen were randomi sed to a 180 degrees semifundoplication (Toupet) and 15 to a total fun dic wrap (Nissen-Rossetti). Manometry was done preoperatively, six mon ths, and three years after the operation assessing motor function in d efined areas of the tubular oesophagus and lower oesophageal sphincter . Results - All patients had a proper control of GORD both when object ively and clinically assessed. Postoperatively, the resting tone of th e lower oesophageal sphincter was significantly higher in the Nissen-R ossetti group (p<0.05), and the intra-abdominal portion of the lower o esophageal sphincter was of identical length in the two groups. A sign ificant increase in peristaltic amplitude in the middle and distal thi rd of the oesophagus was recorded at long term follow up compared with the preoperative findings (p<0.05), but there was no corresponding ef fect on propagation speed and duration of contraction. However, an inc rease in peristaltic amplitude and, as a tentative consequence, a sign ificant decrease (p<0.05) in the frequency of primary peristalsis was found only in patients operated on with a total fundic wrap. Conclusio n - Despite adequate and durable reflux control after fundoplication i n patients with chronic GORD, no change was found in oesophageal motor function with time. The higher contraction amplitude and decreased fr equency of failed primary peristalsis seen in patients having a total fundic wrap were thus most likely due to a mechanical outflow obstruct ion in the gastro-oesophageal junction. These results could therefore be interpreted in favour of the hypothesis that GORD is pathogenetical ly linked to a primary defect in oesophageal motor function.