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Are ulcers of the antireflux valve characteristic of the Nissen procedure?
C.G. Bremner (Los Angeles)
Gastric ulceration following the Nissen fundoplication occurs either distal to the wrap, proximally within the wrap, or in the chest associated with an intrathoracic Nissen fundoplication. Krupp and Rossetti first described an antral ulcer and two fistulae near the wrap in a series of 524 Nissen fundoplication operations [1], Sifers et al. reported on ten gastric ulcers in a series of 381 operations which they described as the reefing method of fundoplication [2]. Specific attention was drawn to the association of gastric ulcer after the Nissen fundoplication by Bushkin et al. [3] and Bremner [4,5]. Since then, numerous reports have appeared.
Gastric ulceration occurring distal to the wrap of a Nissen fundoplication
(Table 1)
Gastric ulcer occurring distal to a Nissen fundoplication has been reported in approximately 2.8% of 1,756 operations [1 - 14], The ulcer is usually on the lesser curve of the stomach or in the antrum, but there is one report of a greater curve ulcer following the procedure. The interval between the Nissen fundoplication operation and the first symptoms of the ulcer is variable and is between 1 month and 7 years, with a median interval of 15 months from reported series [3,4,7]. There is no agreement as to the possible pathogenesis of these ulcers. Bushkin et al. suggests that the prime problem was gastric stasis with hypergastrinemia, because four of their patients had gas bloat [3]. Bremner found alkaline duodenal gastric reflux in his patients and could not show evidence of delayed gastric emptying or hypergastrinemia [4]. It is also possible that these patients would have developed ulceration despite the Nissen operation. No studies have been reported, for example, of a possible association with Helicobacter pylori. Herrington suggested that vagal entrapment could be a cause, but gave no objective evidence that such an event altered gastric physiology or secretion [7]. In his article, he gives a detailed description of how to avoid incorporation of the vagal trunks in the Nissen fundoplication. Unrecognized truncal vagotomy would also lead to gastric stasis and possible ulceration. Anti-inflammatory drugs were the cause of antral ulceration after
Table 1. .Gastric ulceration occurring distal to the wrap of a Nissen fundoplication
|
Author(s) |
Date |
Number gastric ulcerations |
Number antireflux operations |
||
|
Krupp, Rossetti [1] |
1966 |
3 |
524 |
||
|
Sifers [2] |
1976 |
10 |
381 |
||
|
Bushkin [3] |
1976 |
5 |
160 |
||
|
Bremner [4] |
1977 |
4 |
43 |
||
|
Maher [6] |
1982 |
2 |
|
||
|
Herrington [7] |
1982 |
5 |
158 |
||
|
Campbell [8] |
1983 |
13 |
|
||
|
O'Rourke [9] |
1985 |
5 |
|
||
|
Fleming [10] |
1986 |
23 |
|
||
|
Low [11] |
1988 |
6 |
|
||
|
Tissot [12] |
1989 |
1 |
|
||
|
Bonaldi [13] |
1989 |
1 |
|
||
|
Houdelette [14] |
1989 |
1 |
|
||
a supradiaphragmatic Nissen in Maher's series [6]. Treatment of these cases poses a particular problem. Medical treatment has been used successfully in some reported cases, but antrectomy, wedge resection and wrap take-down with pyloroplasty and partial gastrectomy have all been reported [3,4,7,18]. Tissot (see p. 622) suggests that the treatment should be total gastrectomy if medical treatment fails [12]. One patient in the author's series perforated a lesser curve gastric ulcer about 4 years after the Nissen operation and the attending surgeon in another district operated and oversewed the ulcer. The patient has subsequently been symptom- and ulcer-free for a further 5 years. Of interest, this patient had histological gastritis prior to the Nissen operation.
Gastric ulceration occurring within the wrap of an intra-abdominal Nissen fundoplication (Table 2)
Ulceration occurring within the wrap of a Nissen is reportedly less common than ulceration occurring distal to the wrap, and it occurred in 16 reported cases [15-19]. These ulcers may fistulate and develop several days after surgery, suggesting a
Table 2. .Gastric ulceration occurring within the wrap or proximal to an intra-abdominal Nissen fundoplication
|
Author(s) |
Date |
Number of cases |
Number in series |
Proposed causes |
||
|
Launois [15] |
1990 |
8 |
|
Gastric stasis, alkaline reflux |
||
|
Pennell [16] |
1981 |
3 |
200 |
|
||
|
Burnett [17] |
1977 |
1 |
|
|
||
|
Scobie [18] |
1979 |
3 |
100 |
Mechanical |
||
|
Deschamps [19] |
1990 |
1 |
|
Ischemia |
||
different pathogenesis such as ischemia, handling of the stomach with forceps, or devascularization of the fundus. Suturing the wrap with silk sutures has a potential for ulceration. Such ulcers may present with pain and bleeding and may be difficult to diagnose [8]. Double contrast radiological studies and endoscopy usually confirm the diagnosis [20]. A double-lumen esophagus was evident at endoscopy in one patient who had developed an esophagogastric fistula [10]. No clear guidelines are included in the literature as to how these cases should be treated. Conservative management has resulted in healing in a few reported cases, but gastric resection may be necessary. One of Scobie's cases relapsed after medical healing and required resection [18].
Gastric ulceration occurring in the intrathoracic Nissen fundoplication [21-28]
It is evident from several reports that the intrathoracic Nissen wrap is subject to serious complications such as gastropleural, gastrobronchial, gastropericardial fistula formation and intracardiac rupture [17]. Both Mansour [28] and Richardson [21] argue strongly against the continued use of this operation. On the other hand, Maher et al. [6] have reported on excellent results following a series of 44 intrathoracic Nissen operations. They did experience two antral ulcers following this procedure, but no intrathoracic problems occurred. It is suggested that variations in operative technique may be responsible for poor results reported by others. In a personal communication with Woodward some years ago, the explanation given was that a tight hiatus leads to stasis and that this should be guarded against when performing the intrathoracic procedure. Collard also noted that complications following the intrathoracic wrap were decreased by enlarging the hiatus [24]. This explanation seems plausible, because the perforation occurs at an early stage, suggesting an ischemic basis for the complication.
Not included in the published series of gastric ulcers after Nissen fundoplications are the cases reported by personal communication to Herrington [7]. Polk had experience with two cases in 600 plication procedures; DeMeester had two cases in a series of 200 fundoplications. Menguy and Bombeck had not encountered gastric ulcer as a complication in 150 and 165 cases respectively. Of interest, Hill reported
Table 3. .Gastric ulceration occurring in the intrathoracic Nissen fundoplication
|
Author(s) |
Date |
Number of cases |
Number in series |
Complications |
||
|
Richardson [21] |
1982 |
4 |
600 |
|
||
|
Parikh [22] |
1991 |
1 |
55 |
Pericardial fistula |
||
|
Bianchi [23] |
1991 |
1 |
|
Intracardiac fistula |
||
|
Collard [24] |
1991 |
5 |
31 |
Gastrobronchial fistula |
||
|
Chong [25] |
1990 |
1 |
|
Gastrobronchial fistula |
||
|
Gaensler [26] |
1988 |
1 |
|
Gastrobronchial fistula |
||
|
Gianello [27] |
1985 |
7 |
|
|
||
|
Mansour [28] |
1981 |
3 |
|
Perforation (2 deaths) |
||
to Herrington that he had not encountered a gastric ulcer in his large series of posterior gastropexy antireflux procedures. Bushkin found that gastric ulcer was exclusive to the Nissen procedure and he had also performed 120 Allison operations, 60 Hill procedures, and 13 others [3]. Yuen [20] described four proximal gastric ulcers in a series of 100 Belsey Mark IV procedures and Mullen [29] reported an esophagogastric fistula following a Belsey operation in a patient with scleroderma. Yuen concluded that local ischemia and mechanical trauma are important in the development of the ulceration which can occur as early as 1 week after fundoplication.
Conclusions
Gastric ulceration after antireflux procedures is characteristic of the Nissen operation, although five cases have been reported after the Belsey Mark IV procedure. No cases have been reported after the Hill operation, which suggests that technical factors may be important in the pathogenesis of this complication. Gastric ulceration distal to the wrap probably has a different cause to ulceration and perforation within the wrap and following the intrathoracic procedure. Possible causes of distal ulceration are ischemia, vagal nerve entrapment, duodenal gastric reflux, or a combination of these factors. Ulceration and fistula within the wrap are likely to be due to ischemic factors, whereas fistulation from the intrathoracic Nissen may be related to entrapment of the stomach by a tight hiatus which could cause ischemia. The latter operation should be discontinued in favor of a lengthening procedure (Collis) combined with a Nissen fundoplication.
References
5. Bremner CG. Gastric ulceration after a fundoplication. Surg Gynecol Obstet 1979; 168:62-66.
11. Low DE, Mercer CD, James EC, Hill LD. Post-Nissen syndrome. Surg Gynecol Obstet 1988:167:1-5.
18. Scobie BA. High gastric view after Nissen fundoplication. Med J Aust 1979; 1:609-610,
25. Chong WK, Constant OC. Gastrobronchial fistula. Clin Radiol 1990:41:141-142.