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Abstract
Reflux oesophagitis is a common clinical problem of multifactorial causes. It is responsible not only for subjective distress and disability but also for significant organic damage to the esophagus and lungs.
It is mainly due to loss of the competence mechanism at the distal esophagus and cardia. Many factors are responsible for the phenomenon of competence and involved in minimizing the frequency and duration of mucosal contact time when reflux does occur. Chief among these factors are length and magnitude of high-pressure zone (LES) and the presence of peristaltic clearing added to the buffering and dilutional effect of saliva.
Reflux oesophagitis may occur as the consequence of poor gastric emptying due to either organic gastric outlet obstruction or a consequence of motility disturbances of the antrum, duodenum, or small bowel. Most patients with reflux oesophagitis, however, do not have a readily definable cause for their condition, although most are found to have an associated sliding hiatal hernia, and many of these will have a hypotensive LES.
An effective treatment of GORD is to reduce gastric acid secretion with either an H2 receptor antagonist or a proton pump inhibitor, with the dosage titrated to the severity of the disease for each patient.
Theoretically, prokinetic drugs increase lower esophageal sphincter pressure, enhance gastric emptying, and improve peristalsis, thereby counteracting some abnormalities that lead to oesophagitis.
Reflux oesophagitis is likely to relapse, thus maintenance acid suppressive therapy is often necessary. Antireflux surgery is an effective mean of controlling chronic reflux disease. Since the advent of laparoscopic antireflux, the two most common procedures are the Nissen fundoplication and the Toupet partial fundoplication. Nissen fundoplication has been the most used technique for the surgical treatment of GORD and hiatal hernia in adults as well as pediatric patients, but it is not free of complications as wrap disruption with recurrence of symptoms, swallowing problems, inability to vomit or blech, gas blot syndrome, early satiety, diarrhea, and dumping. These postoperative problems may occur in as many as 30% of patients.
The accumulated evidence of an association between GORD and gastric emptying disorders (GE) led some investigators to attribute this ”post fundoplication syndrome” to the GE disorders and recommend pylorplasty as adjunctive procedure on selected patients.
Preoperative screening of delayed gastric emptying as well as operative correction of delayed gastric emptying at the time of fundoplication is therefore recommended.
But pyloromyotomy has the advantage of not opening the gastrointestinal mucosa and therefore, potentially less prone to complications such as leak and stricture.
Thirty patients with chronic symptoms of gastric-esophageal reflux disease were studied. The study conducted in the period between October 2002 and October 2005. All patients were randomized to Nissen fundoplication. GORD was documented in all patients clinically and by endoscopy, ambulatory 24-hour monitoring and gastric emptying study using radioactive isotope scanning. Postoperatively, 8 (26.6%) patients still has dysplagia and bloating symptoms, they showed delayed gastric emptying, and these patients showed severe delayed gastric emptying preoperatively. Five patients (16.7%) of them, scheduled for drainage procedure (pyloromyotomy), gastric emptying studies show significant improvement with significant amelioration of their symptoms