PAPER Gastroesophageal Disease and Nausea Does Fundoplication Help or Hurt? Thomas T. Hui, MD; Steven M. Fass, MD; Dan I. Giurgiu, MD; Atsushi Iida, MD; Sumito Takagi, MD; Edward H. Phillips, MD Hypothesis: Nausea associated with gastroesophageal Results: Nausea was the most common atypical symp- reflux disease is cured by laparoscopic Nissen fundopli- tom of gastroesophageal reflux disease, occurring in 33 cation (LNF). patients (33%). There were no differences in esopha- geal manometry or 24-hour pH results between groups. Design: Prospective cohort study of unselected pa- There was a female preponderance in group A (55% vs tients who underwent LNF from January 1, 1995, through 33%; P = .003). Patients in group A had a higher preva- March 31, 1999. Patients were followed up by a physi- lence of preoperative dysphagia (P = .02). Patients with cian for 6 to 36 months. persistent postoperative nausea had a higher prevalence of cough (P = .003) and dysphagia (P = .009). The LNF Setting: A large community teaching hospital. was more effective in reducing heartburn (95% reduc- tion) and regurgitation (95% reduction) than cough Patients: One hundred consecutive patients with gas- and dysphagia (60% reduction). There was a 79% re- troesophageal reflux disease who underwent LNF; all pa- duction in the number of patients with nausea (33 to 7; tients were followed up. Patients were grouped accord- P,.001). ing to the presence (group A, n = 33) or absence (group B, n = 67) of preoperative nausea. Interventions were LNF, Conclusion: Laparoscopic Nissen fundoplication is ef- esophageal manometry, 24-hour pH monitoring, and fective in eliminating nausea associated with gastro- nuclear gastric emptying studies. esophageal reflux disease and is not contraindicated in these patients. Main Outcome Measures: Resolution of symptoms after LNF. Arch Surg. 2000;135:545-549 YPICAL SYMPTOMS of gastro- RESULTS esophageal reflux disease (GERD) include heartburn Of the 100 patients, 60 were male and 40 and regurgitation. It is esti- female, with average age 50 years (range, mated that 7% to 10% of the 11-96 years). Indications for operation in- US population suffer from heartburn cluded gastroesophageal reflux symp- T1,2 daily. However, patients with GERD of- toms refractory to medical therapy in 47 ten present with atypical symptoms such patients and complications of GERD in 53 as chest pain, asthma, coughing, and nau- patients (esophagitis in 30, stricture in 9, sea.3 In the study by Klauser et al,4 nausea esophagitis and stricture in 6, esophagi- was present in 38% of patients with symp- tis and Barrett esophagus in 6, and Bar- toms of GERD and abnormal results of a rett esophagus in 2). 24-hour esophageal pH study. Upper gastrointestinal tract endos- Laparoscopic Nissen fundoplication copy was performed preoperatively in 81 (LNF) has been shown in nearly all pub- patients and demonstrated esophagitis in lished studies to be highly effective in re- 42 (52%), stricture in 12 (15%), and Bar- lieving typical symptoms of GERD, specifi- rett esophagus in 8 (10%). Barium swal- cally heartburn and regurgitation, when low performed in 45 patients demon- caused by reflux.5-14 It is less clear whether strated reflux in 26 (58%) and stricture in the same results can be achieved with atypi- 6 (13%). A 24-hour pH study was per- cal symptoms. While several series15-22 have formed in 73 patients and showed abnor- From the Department of investigated the effectiveness of LNF in im- mal acid reflux in all of them. Surgery, Cedars Sinai Medical Center, Los Angeles (Drs Hui, proving chronic cough and asthma, to our Esophageal manometry was per- Fass, Iida, Takagi, and knowledge, no study to date has addressed formed in all patients. There were no dif- Phillips), and Kaiser the effect of LNF on relief of nausea in pa- ferences in esophageal motility between Permanente, San Diego tients with GERD. The present study was groups. The average lower esophageal (Dr Giurgiu), Calif. undertaken to consider this issue. sphincter resting pressure was 12 mm Hg. ARCH SURG/ VOL 135, MAY 2000 WWW.ARCHSURG.COM 545 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Table 1. Effects of Laparoscopic Nissen Fundoplication PATIENTS AND METHODS on Symptoms of Gastroesophageal Reflux Disease A retrospective review was conducted on 100 con- Preoperative, Postoperative, secutive unselected patients who underwent laparo- No. (%) No. (%) % (n = 100) (n = 100) Reduction P scopic antireflux surgery between January 1, 1995, and March 31, 1999. A single surgical team per- Heartburn 86 (86) 4 (4) 95 ,.001 formed all LNF procedures. All preoperative and in- Regurgitation 78 (78) 4 (4) 95 ,.001 traoperative data were collected concurrently. Post- Nausea 33 (33) 7 (7) 79 ,.001 operative data were collected by physician interview. Cough 30 (30) 12 (12) 60 .002 Data selected for analysis included patients’ age, Dysphagia 25 (25) 10 (10) 60 .005 sex, preoperative symptoms, preoperative evalua- tions, indications for operation, and postoperative symptoms. All patients had at least 1 preoperative study demonstrating pathological gastroesophageal Table 2. Age, Sex, and Esophageal Manometry in Patients reflux, and all patients underwent esophageal ma- With (Group A) and Without (Group B) Preoperative Nausea nometry before operation. For purposes of analysis, patients were divided Group A Group B into 2 groups on the basis of the presence (group A) (n = 33) (n = 67) P or absence (group B) of preoperative nausea. Nau- Age, y, average 54 47 .09 sea was defined as the subjective sensation of the need Sex, % F 55 33 .003 to vomit. Frequency and severity of nausea were not Lower esophageal sphincter pressure, 12.3 11.8 .77 used to further define patients in group A. Preopera- mm Hg, mean tive and postoperative symptoms were compared be- Upper esophageal body contraction 72 64 .41 tween the 2 groups. In addition, postoperative symp- amplitude, mm Hg, mean toms were compared for patients with and without Lower esophageal body contraction 62 72 .16 amplitude, mm Hg, mean persistent nausea at 6 weeks after operation. LaparoscopicNissenfundoplicationwasperformed using a standard technique.23 The short gastric vessels were routinely divided in all patients. The esophagus wasmobilizedfullytoensureanadequatelengthofintra- Table 3. Symptoms of Gastroesophageal Reflux Disease abdominal esophagus. The crura were closed and a 360° Before and After Fundoplication in Patients With (Group A) and Without (Group B) Preoperative Nausea wrap, 2 to 4 cm in length, was created. All patients underwent follow-up examina- tions at 6 weeks after operation. Patients who had per- No. (%) sistent nausea at this visit were interviewed at 6 to Group A Group B P 36 months. Parametric and nonparametric data were Symptom (n = 33) (n = 67) (1 vs 2) analyzed with t test and x2 analysis, respectively. Heartburn Preoperative 27 (82) 59 (88) .40 Postoperative 1 (3) 3 (4) .74 % Reduction 96 95 .77 Lower esophageal sphincter relaxation was normal or too Regurgitation Preoperative 27 (82) 51 (76) .52 low to measure in all patients. Esophageal peristalsis was Postoperative 1 (3) 3 (4) .74 normal in every patient. Twenty-six patients had mean % Reduction 96 94 .68 esophageal body contraction pressures less than 50 mm Hg: Cough 9 (27%) in group A and 17 (25%) in group B (P = .77). One Preoperative 9 (27) 21 (31) .67 patient (3%) in group A and 3 patients (4%) in group B Postoperative 3 (9) 7 (7) .83 had mean esophageal body contraction pressures of less than % Reduction 67 67 ..99 30 mm Hg. There was no significant difference in 24-hour Dysphagia Preoperative 13 (39) 12 (18) .02 pH study results between groups A and B. The number of Postoperative 3 (9) 9 (13) .53 reflux episodes (78 vs 64; P = .23) and the percentage of % Reduction 77 25 .009 reflux episodes that were symptomatic (21% [16 epi- sodes] vs 17% [11 episodes]; P = .37) in the lower esopha- gus were similar. Symptoms before and after the opera- commonly found in patients with preoperative nausea tion are summarized in Table 1. All symptoms were and was more effectively relieved after LNF in this group reduced significantly by LNF. The 2 typical symptoms of of patients. Furthermore, of all atypical symptoms, pre- GERD—heartburn and regurgitation—were more effec- operative dysphagia was the most likely to persist post- tively relieved by LNF than were the atypical symptoms. operatively. Cough was more effectively relieved in pa- Data for patients with and without preoperative nau- tients without preoperative nausea. Table 4 summarizes sea are compared in Table 2. Age and manometric vari- the postoperative symptoms of patients with and with- ables were similar, but patients with preoperative nau- out postoperative nausea. Patients with persistent post- sea were more often female. operative nausea had a higher prevalence of postopera- Symptoms of the 2 groups before and after LNF are tive atypical symptoms, such as cough and dysphagia, than compared in Table 3. Preoperative dysphagia was more those without nausea. ARCH SURG/ VOL 135, MAY 2000 WWW.ARCHSURG.COM 546 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Seven patients complained of nausea when seen at 6 weeks after operation. Nausea had been present preopera- Table 4. Persistence of Other Symptoms tively in 5 of them and had developed after operation in 2. of Gastroesophageal Reflux Disease in Patients With and Without Early Postoperative Nausea Longer follow-up (6-36 months) of the 7 patients with nau- sea at 6 weeks demonstrated that all patients were free of No. (%) nausea and were using no antinausea medications. Preoperative gastric emptying studies were per- Symptoms Nausea (n = 7) No Nausea (n = 93) P formed in 12 group A patients (36%) and 17 group B pa- Heartburn 1 (14) 3 (3) .15 tients (25%).