Stefan J. M. Kraemer

The gastroesophageal flap valve: in vitro and in vivo observations

BACKGROUND This study was performed to confirm the presence and significance of a gastroesophageal flap valve. METHODS The pressure gradient needed to induce reflux across the gastroesophageal junction and the level of a high-pressure zone were determined in 13 cadavers. On inspection in the cadavers, a mucosal flap valve at the entrance of the esophagus into the stomach was seen through a gastrostomy. This valve was deficient or absent in cadavers with a hiatal hernia. The valve was inspected in controls and in patients with reflux with a retroflexed endoscope. RESULTS In cadavers with no hiatal hernia, a gradient across the gastroesophageal junction was present in nearly all cadavers. The gradient could be increased by surgically accentuating the valve without a concomitant rise in pressure in the high-pressure zone. Reduction of the hiatal hernia in the cadaver and anchoring of the gastroesophageal junction to the normal attachment to the preaortic fascia restored the valve and the gradient as seen through a gastrostomy. Control subjects had a prominent fold of tissue that extended 3 to 4 cm along the lesser curve of the stomach and tightly grasped the shaft of the endoscope. This was diminished or absent in reflux patients. Inspection of the valve in control subjects and subjects with reflux allowed for a grading system with Grades I through IV. This grading system was applied to a cohort of patients with and without reflux. The appearance of the flap valve was a better predictor of the presence or absence of reflux than was lower esophageal sphincter pressure. Endoscopic viewing of the valve during surgery can confirm that a competent valve has been reconstructed. CONCLUSIONS Grading of the gastroesophageal valve is simple, reproducible, and offers useful information in the evaluation of patients with suspected reflux undergoing endoscopy.

Early results with the laparoscopic hill repair

The open Hill repair is established as a highly effective and durable antireflux procedure. At the present time, we have multi-institutional experience with over 140 laparoscopic Hill repairs. Detailed follow-up on the first 40 patients at our institution is described. All patients had well-documented reflux or esophagitis preoperatively, 7 patients had evidence of peptic stricture or Schatzkis ring, 11 had large hiatal hernia, and 10 weighed more than 200 lb. There were no serious complications and no reoperations. There was 1 death during the follow-up period that was not attributable to the repair. Hospital stay averaged 2.8 days with return to normal activity in 7 to 14 days. Postoperative manometry has been obtained in 24 of the 39 patients available for follow-up (62%) and 24-hour pH studies in 23 of the 39 (59%). Thirty-nine patients were evaluable at a mean follow-up of 10 months and a median follow-up of 8 months (range: 4 to 20 months), with 36 (92%) subjectively rating results as good or excellent. Only one of the three remaining patients has objective evidence of reflux, yielding 97% clinical control of reflux. Mean lower esophageal sphincter pressure (LESP) was raised from 10.7 mm Hg, preoperatively, to 25 mm Hg, postoperatively. Postoperatively, 33 of the 39 patients (85%) are now free of medications referable to the esophagus or upper gastrointestinal tract. This early follow-up experience with the laparoscopic Hill repair leads us to conclude that it is safe, widely applicable, and highly effective as an antireflux operation. Its special features give it certain advantages over the laparoscopic Nissen repair, and we recommend it as the procedure of choice.

Laparoscopic Hill repair

Gastroesophageal reflux disease, with its attendant symptoms and complications of heartburn, esophagitis, dysphagia, and upper gastrointestinal bleeding, is the most common disorder of the upper gastrointestinal tract. The open Hill repair, which has been utilized in more than 2000 patients, is best defined as restoration of the anti-reflux barrier. The anti-reflux barrier includes the gastroesophageal valve, lower esophageal sphincter, and diaphragm. The Hill repair has now been done laparoscopically in 17 patients (10 men and 7 women) who have been entered into a detailed protocol, including pre-operative evaluation, intra-operative monitoring, and post-operative evaluation. Results have been excellent, with correction of reflux in all patients. Duration of follow-up ranges from 1 to 18 months, with a mean of 10.5 months. No mortality or serious complications have occurred. Extensive post-operative testing in 13 patients, including complete symptom evaluation, standard acid reflux testing, and 24-hour pH monitoring, has shown no recurrence of reflux; lower esophageal sphincter pressure has been restored to a mean of 28 mm Hg, and gastroesophageal valve status to grade 1. Because the laparoscopic procedure is similar to the open Hill repair, expectations for good long-term results are very high.

The Hill antireflux repair at 5 institutions over 25 years.

BACKGROUND Long-term (> 5 years) studies of antireflux operations are needed. This study evaluates long-term results of the open Hill repair at multiple institutions. METHODS This is a retrospective cohort study of open Hill repairs from 1972 to 1997 at 5 North American medical centers with a mean follow-up of 10 years. Objective data and standardized clinical outcomes were collected at a central site. Subjective results, medication use, and satisfaction scales were obtained through scripted phone interview. Results between 2 Hill-trained centers and 3 independent centers were compared. RESULTS One thousand one hundred eighty-one patients met the inclusion criteria. Symptomatic improvement was found in 97% and good to excellent results in 93%. Medication use was markedly reduced. Hiatal hernia recurrence was found in 77 (6.9%); the reoperation rate was 1.9%. Differences in outcomes between Hill centers and independent centers were minor. CONCLUSIONS Excellent results with the open Hill repair are durable beyond 10 years and are reproducible. Anatomic recurrence and reoperative rates are low.