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Laparoscopic Hill repair in patients with abnormal motility
1Swedish and Virginia Mason Medical Centers, University of Washington School of Medicine, Seattle, USA.
Background:
Gastroesophageal reflux is frequently associated with abnormal motility in the body of the esophagus. Concern for dysphagia has led surgeons to perform less competent procedures in this group, or to avoid surgery altogether. The current study was undertaken to evaluate our experience with the laparoscopic Hill repair in patients with reflux-associated abnormal motility.
Methods:
A retrospective review of 338 laparoscopic Hill repairs was performed; 253 patients had adequate information for analysis, and 8 patients were excluded because of hypertensive motility. The remaining 245 patients were divided into group I (175) with normal esophageal body peristalsis, group IIA (37) with moderate dysmotility, and group IIB (33) with severe dysmotility. All patients underwent standard laparoscopic Hill repair. Follow-up included postoperative manometry and 24-hour pH studies and interview by an independent physician. Dilation for dysphagia was performed when necessary. Statistical analysis was performed using the F test.
Results:
Mean follow-up was 11.0 months (range 1 to 41). Early dysphagia (<3 months) occurred in 4.0% of group I patients and 12.9% of group II patients. Late dysphagia (>3 months) occurred in 1.1% of group I patients and 1.4% of group II patients. Postoperative motility returned to normal in 43% of group IIB patients studied. Twenty-four hour pH evaluation showed fractional pH <4 an average of 4.8% in group I (median 2.1%) and 6.4% in group II (median 4.0%; P = 0.57). Patient rating of results was good to excellent in 91.0% with no statistical difference between the two groups. No patient required reoperation for dysphagia.
Conclusion:
The laparoscopic Hill repair can be safely performed in patients with reflux-associated dysmotility, with excellent results. Even severely disordered motility will return to normal in a high percentage of cases. Manometric control of the repair and secure distal fixation of the gastroesophageal junction are advantages. Abnormal motility may be an indication for, rather than a contraindication to, laparoscopic Hill repair.
