Antireflux anastomosis following oesophagectomy

Reflux of duodeno-gastric fluid is a significant problem after oesophagectomy with gastric conduit reconstruction. It can impact considerably upon the patient's quality of life and can induce oesophagitis and Barrett's metaplasia in the remnant oesophagus.

The aim of the present study was to describe the use of a modified fundoplication in controlling reflux after oesophagectomy.

Patients undergoing subtotal oesophagectomy at the Royal Adelaide Hospital were identified. Clinical and operative details were obtained from hospital records. All patients had an end oesophagus to side stomach anastomosis. Two cohorts were identified - one with a standard anastomosis only and the other in whom a modified fundoplication had been added. A structured phone interview was used to assess reflux in the two groups with a minimum of 6 months follow up. The interviewer was blinded to the operative details.

The operative technique is described. A total of 44 patients were assessed, 33 having the fundoplication type anastomosis and 11 the standard anastomosis. Operative morbidity was not different between the groups. Symptoms of reflux were better controlled in patients with the fundoplication anastomosis than in patients with a standard anastomosis. Of those with a fundoplication, 14 of 33 patients (42%) were asymptomatic with respect to reflux compared to only one of 11 patients (9%) in the standard anastomosis group. Only four of the 33 patients (12%) with a fundoplication anastomosis had symptoms of severe reflux while seven of the 11 patients (63%) with a standard anastomosis had severe reflux symptoms.

This initial evaluation of a modified fundoplication as an antireflux manoeuvre after oesophagectomy suggests that the technique is effective in controlling post-oesophagectomy reflux in the majority of patients. It is simple to perform and may have benefits in improving quality of life and preventing oesophagitis and metaplastic changes in the remnant oesophagus. A more detailed prospective study of the technique is warranted.