A clinical, endoscopical, and functional analysis

Of 46 patients who had Nissen fundoplication for proved gastro-oesophageal reflux, 25 were available for follow up after a median of 20 years, 15 had died of unrelated causes, and six could not be traced. All 25 patients in the follow up study were personally interviewed: 21 consented to an endoscopy, 14 to 24 hour recording of oesophageal pH and manometry, and 15 to radionucide transit test. Repeat fundoplication for recurrent reflux was performed in two cases during the study. Heartburn and regurgitation were significantly lessened (p<0005), but the incidence of dysphagia was slightly increased. Endoscopy showed six of 21 fundic wraps to be defective. Erosive oesophagitis was seen in two patients, and Barrett's oesophagus (histologically confirmed) in one of them and six other patients. Total reflux time was abnormal in four of 14 patients. No patient with an intact fundic wrap seen on endoscopy, only two of seven with Barrett's oesophagus, and one of four with abnormal reflux had oesophagitis. Fundoplication in itself did not affect oesophageal motility or transit, provided that the wrap was intact. It is concluded that Nissen fundoplication gave a reasonably good longterm effect in chronic reflux disease, with the state ofthe fundic wrap as the main determinant of outcome. (Gut 1993; 34: 1015-1020) Department of Clinical Medicine, University of Tampere, Tampere and Departments of Surgery, Clinical Physiology, Internal Medicine, and Diagnostic Radiology, Tampere University Hospital, Tampere, Finland M Luostarinen J Isolauri J Laitinen M Koskinen 0 Keyrilainen H Markkula E Lehtinen A Uusitalo Correspondence to: Dr M Luostarinen, Department of Clinical Medicine,TampereUniversity, PO Box 607, SF-33101 Tampere, Finland. Accepted for publication 24 November 1992 Good longterm results of Nissen fundoplication' have been reported, with disappearance of reflux symptoms in 80-97% of cases.'-6Postfundoplication symptoms such as dysphagia, gas bloat, and epigastric pain may occur in variable degree,3 7-10 however, sometimes in a substantial number of patients. Previous studies on longterm results of fundoplication were based mainly on questioning patients, with only sporadic endoscopical examinations.2A46 Only a few reports concerned the fate of oesophagitis, and then with relatively short follow up," 12 although the typical patient is young or middle aged and thus has a life expectancy of several decades. While shortterm evaluation after fundoplication, as a rule, shows normal values of 24 hour oesophageal pH measurements,'3'4 rise of lower oesophageal sphincter pressure'3"' and probably correction of reflux induced disturbances of motility,'6 17 little is known of the longterm effects of fundoplication on oesophageal function. The purpose of this study was to evaluate the longterm clinical and endoscopical effects of Nissen fundoplication performed for reflux, including assessment of oesophageal function. Patients and methods