PAPER Gastroesophageal Disease and 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 (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- PϽ.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 ( 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 in 6, and Bar- toms of GERD and abnormal results of a rett esophagus in 2). 24-hour esophageal pH study. Upper 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. , 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.

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©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 Ͻ.001 formed all LNF procedures. All preoperative and in- Regurgitation 78 (78) 4 (4) 95 Ͻ.001 traoperative data were collected concurrently. Post- Nausea 33 (33) 7 (7) 79 Ͻ.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 ␹2 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 Ͼ.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.

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©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%). Eight (67%) of the 12 from group A and 4 Regurgitation 1 (14) 7 (8) .15 (24%) of the 17 from group B had abnormal results (P = .02). Cough 3 (43) 3 (3) .003 Two of the 12 patients from group A had postoperative nau- Dysphagia 3 (43) 9 (10) .009 sea, both of whom had abnormal results of gastric empty- ing studies. Of the 17 patients from group B who under- went preoperative gastric emptying studies, 1 patient with hour pH studies. This demonstrates the nonspecific na- a normal result developed nausea postoperatively. These ture of nausea. Since GERD is a relatively common con- data show that, while patients with preoperative nausea were dition, it may coexist with other common conditions that more likely to have delayed gastric emptying, a majority produce nausea, leading to problems in accurate diag- (75%) of patients with preoperative nausea and delayed gas- nosis and treatment of these patients. tric emptying experienced relief of their nausea after LNF. While many studies have demonstrated the effective- ness of LNF in relieving heartburn and regurgitation in pa- COMMENT tients with GERD (Table 5), few studies have examined the effect of the procedure on relief of atypical symptoms. Nausea is a nonspecific, subjective sensation of an im- Moreover, to our knowledge, no study has specifically ex- pending urge to vomit. It can be a dominant symptom amined the effectiveness of LNF in relieving nausea in pa- or a minor symptom in patients with GERD. Nausea can tients with GERD. In Hunter and coworkers’ review11 of also be a symptom of other disease processes, such as pep- 300 patients undergoing laparoscopic antireflux surgery, tic ulcer disease, , gastrointestinal tract ma- 89% of patients had typical reflux symptoms (heartburn lignant neoplasm, intestinal obstruction, and intracra- and regurgitation), while 64% also had atypical symp- nial disease. In a small retrospective series by Brzana and toms (chest pain, cough, hoarseness, and asthma) and 11% Koch,24 10 patients with chronic intractable nausea un- had atypical symptoms only. Treatment by LNF was found responsive to empiric therapies were found to have GERD to be very effective, with improvement of 93% of typical on the basis of esophagogastroduodenoscopy, 24-hour and 81% to 91% of atypical symptoms. Preoperative nau- pH study, or a positive Bernstein test. All experienced reso- sea was seen in 18% of their patients. Postoperatively, nau- lution of nausea after treatment with omeprazole (7 pa- sea was present in 4% of patients at 6 weeks and 6% of pa- tients), cisapride or ranitidine hydrochloride (2 pa- tients at 1 year. However, it was not clear whether any tients), or open Nissen fundoplication (1 patient). That patients without preoperative nausea developed nausea af- study emphasized the important relationship between ter LNF. In addition, the characteristics of the patients with GERD and nausea, as well as the effectiveness of antire- preoperative and postoperative nausea were not studied. flux therapies in relief of nausea caused by GERD. In contrast, the prospective study by So et al3 of 150 In the series reported herein, preoperative nausea patients undergoing LNF demonstrated that typical symp- was the most common atypical symptom of GERD and toms of GERD, such as heartburn, were reduced by 93% was found in 33% of patients with proved GERD. Lapa- after surgery, compared with only 56% reduction in atypi- roscopic Nissen fundoplication was more effective in re- cal symptoms. The authors concluded that the relief of atypi- lieving typical symptoms (heartburn and regurgitation) cal symptoms attributed to gastroesophageal reflux by LNF of GERD than atypical symptoms. Patients with preop- is less satisfactory and more difficult to predict than relief erative nausea were more commonly female and were of heartburn and regurgitation. However, nausea was not more likely to have delayed gastric emptying but not poor included as an atypical symptom in that study. Nausea can esophageal contraction pressures. Heartburn and regur- also be a postoperative complication of LNF. In a retro- gitation were equally common in patients with and with- spective study by Swanstrom and Wayne25 of 82 patients out preoperative nausea. Early postoperative nausea oc- undergoing LNF, postoperative nausea immediately after curred in 7 patients. Persistent cough and/or dysphagia surgery was present in 12 patients (15%). Of these 12 pa- were more common in patients with postoperative nau- tients, 8 developed nausea only after their operation. sea. All patients with early postoperative nausea experi- In our series, esophageal motility studies failed to de- enced no nausea at longer-term follow-up. tect differences between patients with and without nau- The precise number of patients with GERD who ex- sea. Unfortunately, gastric emptying studies (although re- perience nausea is unknown. Of 304 patients with a va- sults were more often abnormal in patients with nausea) riety of esophageal and extraesophageal symptoms who were not done on enough patients to fully elucidate a pos- underwent 24-hour pH monitoring for possible GERD, sible cause and effect. A review by Scarpignato26 summa- 166 had pathological results of pH monitoring indica- rized the results of 30 studies regarding gastric emptying tive of reflux.4 Nausea was present in 38% of these pa- of different meals in adult patients with GERD. In all stud- tients but also occurred with similar frequency (32%) in ies reviewed, gastric emptying of liquid was normal. How- the remaining 138 patients with normal results of 24- ever, delayed gastric emptying of solid or semisolid meals

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Table 5. Studies Examining the Efficacy of Antireflux Surgery in Relieving Symptoms Secondary to GERD*

Symptom Prevalence Preoperatively, % Symptom Reduction After LNF, % No. of Median Source Patients Heartburn Atypical Nausea Heartburn Aytpical Nausea F/U, mo Hunter et al11 300 89 75† 18 93 87 6 12 Peters et al13 100 82 NA NA 96 NA NA 21 Jamieson et al9 135 100 NA NA 99 NA NA 3 Hinder et al14 198 82 5-30‡ 15 NA§ NA§ 8 6-32§ So et al3 35 86 100࿣ NA 93 56 NA 22 Johnson et al15 118 NA 53 NA NA 86 NA 3 Deveney et al19 13 77 100¶ NA NA 73# NA 11 Wetscher et al21 21 100 86** NA 95 67 NA 6 Allen and Mehran22 199 84 68** NA 93 83 NA 6 Present study 100 86 70 33 95 21 7 1.5

*GERD indicates gastroesophageal reflux disease; LNF, laparoscopic Nissen fundoplication; F/U, follow-up; and NA, not available. †Atypical symptoms included chest pain, cough, hoarseness, and asthma. ‡Nausea or vomiting was present in 15% of patients. §Only 100 patients had follow-up ranging from 6 to 32 months; 92% were free of reflux symptoms and nausea. ࿣Only patients with atypical symptoms (cough, chest pain, asthma, pharyngolaryngeal symptoms) were studied. ¶Chronic persistent laryngeal lesions. #Seventy-three percent had resolution of symptoms and laryngoscopic changes of acute inflammation. **Chronic cough.

was reported in 60% of the gastric emptying studies. Since 2. Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesophageal reflux: inci- dence and precipitating factors. Dig Dis Sci. 1976;21:953-956. Scarpignato’s review, other European studies using real- 3. So JBY, Zeitels SM, Rattner DW. Outcomes of atypical symptoms attributed to time ultrasound and electrogastrography have found in- gastroesophageal reflux treated by laparoscopic fundoplication. Surgery. 1998; creased incidence of delayed gastric emptying in patients 124:28-32. 27,28 4. Klauser AG, Schindlbeck NE, Muller-Lissner SA. Symptoms in gastro- with GERD. However, this finding could not be vali- oesophageal reflux disease. Lancet. 1990;335:205-208. dated by a number of US studies, which demonstrated de- 5. Rattner DW, Brooks DC. Patient satisfaction following laparoscopic and open an- layed gastric emptying in only 6% to 12% of the pa- tireflux surgery. Arch Surg. 1995;130:289-294. 29-31 32 6. DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesopha- tients. Furthermore, in the study by Schwizer et al, geal reflux disease. Ann Surg. 1986;204:9-20. delayed gastric emptying occurred with equal frequency 7. Hill LD. An effective operation for hiatal : an eight-year appraisal. Ann Surg. 1967;166:681-689. in patients with or without reflux. In our series, 6 of 8 pa- 8. Boutelier P, Jonsell G. An alternative fundoplicative maneuver for gastroesopha- tients with preoperative nausea and delayed gastric emp- geal reflux. Am J Surg. 1982;143:260-264. tying experienced complete resolution of nausea at 6 weeks 9. Jamieson GG, Watson DI, Britten-Jones R, Mitchell PC, Anvari M. Laparoscopic Nissen fundoplication. Ann Surg. 1994;220:137-145. after operation, and the remaining 2 patients were free of 10. Peters JH, Heimbucher J, Kauer WKH, Incarbone R, Bremner CG, DeMeester TR. nausea when questioned 6 months later. It is known that Clinical and physiological comparison of laparoscopic and open Nissen fundo- antireflux surgery enhances gastric emptying, as shown plication. J Am Coll Surg. 1995;180:385-393. 33 34 11. Hunter JG, Trus TL, Branum GD, Waring JP, Wood WC. A physiological ap- by the work of Hinder et al and Viljakka et al. It is pos- proach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann sible that this effect led to the resolution of nausea. Surg. 1996;223:673-687. 12. Trus TL, Laycocke WS, Branum G, Waring P, Mauren S, Hunter JG. Intermedi- In conclusion, nausea is a common symptom of pa- ate follow-up of laparoscopic antireflux surgery. Am J Surg. 1996;171:32-35. tients with GERD, occurring in one third of patients. Lapa- 13. Peters JH, Demeester TR, Crookes P, et al. The treatment of gastroesophageal roscopic Nissen fundoplication is effective in relieving reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with “typical” symptoms. Ann Surg. 1998;228:40-50. nausea in this group of patients, with 79% symptom re- 14. Hinder RA, Filipi CJ, Wetscher G, Neary P, Demeester TR, Perdikis G. Laparo- duction at 6 weeks after surgery and complete resolu- scopic Nissen fundoplication is an effective treatment for gastroesophageal re- tion after 6 months. Although the efficacy of LNF is not flux disease. Ann Surg. 1994;220:472-483. 15. Johnson WE, Hagen JA, DeMeester TR, et al. Outcome of respiratory symptoms as dramatic in curing atypical symptoms of GERD, it is after antireflux surgery on patients with gastroesophageal reflux disease. Arch still highly effective and more effective in relieving nau- Surg. 1996;131:489-492. 16. DeMeester TR, O’Sullivan GC, Bermudez G, Midell AI, Cimochowski GE, O’Drobinak sea than cough or dysphagia. The patient with nausea and J. Esophageal function in patients with angina-type chest pain and normal coro- reflux should anticipate a good outcome after antireflux nary angiograms. Ann Surg. 1982;196:488-498. surgery. 17. Perrin-Fayolle M, Gormand F, Braillon G, et al. Long-term results of surgical treatment for gastroesophageal reflux in asthmatic patients. Chest. 1989;96: 40-44. Presented at the 107th Scientific Session of the Western Sur- 18. Larrain A, Carrasco E, Galleguillos F, Sepulveda R, Pope CE. Medical and surgi- gical Association, Santa Fe, NM, November 16, 1999. cal treatment of nonallergic asthma associated with gastroesophageal reflux. Chest. 1991;99:1330-1335. Reprints: Edward H. Phillips, MD, 8635 W Third St, 19. Deveney CW, Benner K, Cohen J. Gastroesophageal reflux and laryngeal dis- #795W, Los Angeles, CA 90048 (e-mail: [email protected]). ease. Arch Surg. 1993;128:1021-1027. 20. Pitcher DE, Pitcher WD, Martin DT, Curet MJ. Antireflux surgery does not reli- ably correct reflux-related asthma [editorial]. Gastrointest Endosc. 1996;43: REFERENCES 433. 21. Wetscher GJ, Glaser K, Hinder RA, et al. Respiratory symptoms in patients with gastroesophageal reflux disease following medical therapy and following anti- 1. Locke GR, Talley NJ, Fett SL, Zinsmeister AR, Meiston LJ. Prevalence and clini- reflux surgery. Am J Surg. 1997;174:639-643. cal spectrum of gastroesophageal reflux: a population-based study in Olmstead 22. Allen CJ, Mehran A. Gastroesophageal reflux related cough and its response to County, Minnesota. . 1997;112:5-12. laparoscopic fundoplication. Thorax. 1998;53:963-968.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 23. Peters JH. Laparoscopic Nissen’s fundoplication. In: Phillips EH, Rosenthal RJ, Second question: Did you stratify these symptoms with re- eds. Operative Strategies in Laparoscopic Surgery. New York, NY: Springer- spect to the presence or absence of hiatus hernia, for example, Verlag New York Inc; 1995:115-122. 24. Brzana RJ, Koch KL. Gastroesophageal reflux disease presenting with intrac- sizable type 2 or type 3 hiatus ? Lastly, do you ever per- table nausea. Ann Intern Med. 1997;126:704-707. form gastric emptying studies in conjunction with your fun- 25. Swanstrom L, Wayne R. Spectrum of gastrointestinal symptoms after laparo- doplication? scopic fundoplication. Am J Surg. 1994;167:538-541. 26. Scarpignato C. Gastric emptying and gastroesophageal reflux disease and other J. Bradley Aust, MD, San Antonio, Tex: How do you de- functional esophageal disorders: functional evaluation in esophageal disease. Front fine nausea? How do you grade or measure it? This is critical. Gastrointest Res. 1994;22:223-259. Dr Phillips: We did not identify gastric or duodenal pa- 27. Cucchiara S, Salvia G, Borrelli O, et al. Gastric electrical dysrhythmias and de- thology with greater or lesser frequency in the patients with layed gastric emptying in gastroesophageal reflux disease. Am J Gastroenterol. 1997;92:1103-1108. nausea than in those without nausea. Gastric emptying was by 28. Benini L, Sembenini C, Castellani G, Caliari S, Fioretta A, Vantini I. Gastric emp- nuclear emptying study with solids; we did not test for abnor- tying and dyspeptic symptoms in patients with gastroesophageal reflux. Am J mal emptying of liquids. Is it possible to quantify the delay in Gastroenterol. 1996;91:1351-1354. emptying? Yes, but we chose to analyze the data using abnor- 29. Johnson DA, Winters C, Drane WE, et al. Solid-phase gastric emptying in pa- tients with Barrett’s esophagus. Dig Dis Sci. 1986;31:1217-1220. mal or normal. When is gastric emptying impaired suffi- 30. Shay SS, Eggli D, McDonald C, Johnson LF. Gastric emptying of solid food in ciently to consider pyloroplasty? That is a difficult question to patients with gastroesophageal reflux. Gastroenterology. 1987;92:459-465. which we have given considerable thought without reaching 31. Keshavarzian A. Gastric emptying in patients with severe reflux esophagitis. Am any definite conclusions. To date, our protocol is not to per- J Gastroenterol. 1991;86:738-742. 32. Schwizer W, Hinder RA, Demeester TR. Does delayed gastric emptying contrib- form drainage procedures at the primary operation, waiting in- ute to gastroesophageal reflux disease? Am J Surg. 1989;157:74-81. stead to see whether the fundoplication itself improves emp- 33. Hinder RA, Stein HJ, Bremmer CG, DeMeester TR. Relationship of a satisfactory tying and symptoms. So far, this approach has been successful, outcome to normalization of delayed gastric emptying after Nissen fundoplica- and no reoperations have been needed. This issue is certainly tion. Ann Surg. 1989;210:458-465. 34. Viljakka M, Saali K, Koskinen M, et al. Antireflux surgery enhances gastric emp- of concern, particularly in patients with diabetes or connective- tying. Arch Surg. 1999;134:18-21. tissue disorders resulting in gastroparesis. As to the question of gastric emptying studies being performed postoperatively, DISCUSSION they were done on selected patients with persistent symp- toms, usually for continued heartburn or regurgitation. Two Marco G. Patti, MD, San Francisco, Calif: In this study, the au- patients with nausea and delayed gastric emptying had persis- thors assessed in 100 patients the efficacy of laparoscopic Nissen tence of nausea, but because it eventually improved, they were fundoplication in relieving nausea, which they consider an atypi- not restudied. Clearly, a prospective analysis utilizing gastric cal symptom of GERD, and heartburn and regurgitation, which emptying studies in all patients would be ideal, as the present are considered the typical symptoms of this disease. At 6 months’ data are insufficient for definitive conclusions. follow-up, nausea resolved in all patients, while heartburn and Before commenting on our preoperative testing, may I em- regurgitation resolved in 95%. Indeed, these are excellent results. phasize that we did only 360° wraps and have abandoned par- I have 2 comments and some questions for the authors. tial fundoplications. We do manometry in all patients and, per- Symptoms such as nausea and vomiting are usually consid- haps inappropriately, will modify the length of the wrap based ered secondary to gastric or small-bowel disease rather than gas- on manometric data. The wrap is always floppy, and we always troesophageal reflux disease. Gastric emptying studies were per- divide the short gastric vessels. When the esophageal body con- formed in only 12 of the 33 patients who had nausea preoperatively. traction pressures are less than 30 mm Hg or peristalsis is less Did identify any gastric or duodenal pathol- than 50% propagated, the wrap is limited to 1 cm in length. Re- ogy in group A patients? garding 24-hour pH studies: we will omit them in selected pa- Eight of the 12 patients had “delayed gastric emptying.” tients with proven GERD such as patients with Barrett’s, GI stric- Was it for liquids, for solids, or for both? ture with regurgitation, or reflux confirmed on esophagram. Can you quantify the delay in emptying? Dr Aust asked our definition of nausea. Like pornogra- In your experience, when is the emptying impaired enough phy, I can’t define it but I know it when I see it. The correct to consider a pyloroplasty? definition, in fact, is “the sensation of an impending urge to Did you repeat the gastric emptying studies postoperatively? vomit.” The second comment has to do with your workup. Ma- Dr Donahue asked about our interview techniques. This nometry was performed preoperatively in all patients, and pH is a critical issue and one with which we’ve become familiar in monitoring in 73%. our outcome studies of other laparoscopic procedures. To avoid Why do you perform manometry in all patients if a 360° bias and patients’ trying to please their doctors, the operating fundoplication is your standard operation even in patients with surgeon must not conduct the interview regarding the pres- severe impairment of esophageal peristalsis? ence of postoperative symptoms and patient satisfaction. In this How did you confirm the presence of GERD in the 27 pa- study, a physician, who was not a member of the operative team tients who did not have preoperative pH monitoring? nor participated in the present or future care of the patient, con- Merril T. Dayton, MD, Salt Lake City, Utah: I was intrigued ducted all of the postoperative interviews. The initial history by the female preponderance of patients complaining of nausea. was performed by the operating surgeon and the endoscopic I am wondering if you studied all of those patients for gastric emp- fellow. We developed an intake survey tool to document pre- tying abnormalities, and did you find that same preponderance operative symptoms prospectively. It is impossible to get an ac- of abnormalities in gastric emptying in the female patients? curate retrospective assessment of a patient’s preoperative symp- Philip E. Donahue, MD, Chicago, Ill: An analysis of post- toms as the patient’s memory is selective at best. operative symptoms like nausea is a very difficult process. Ap- Dr Dayton, thank you for your questions that give me the parently you have been using a standardized tool. opportunity to clarify our patient population. All patients with My first question is about the person doing the assess- partial fundoplications and patients with hiatus hernias greater ment. Most patients do not want to disappoint their surgeons; than 4 cm and paraesophageal hernias were excluded from this there are some notable exceptions. How did you get an objec- analysis. I cannot explain the preponderance of female pa- tive interviewer? Is this a case of the fox guarding the hen- tients in the nausea group. Of note, frequency of abnormali- house that might lead to justified criticism? I am curious about ties in gastric emptying was not related to sex of the patient. how you handled this issue. This question deserves further study.

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