Clinical surgery Acid normalization and improved esophageal motility after Nissen fundoplication: equivalent outcomes in patients with normal and ineffective esophageal motility Narayanasamy Ravi, F.R.C.S.I., Nael Al-Sarraf, M.B., Tracey Moran, M.A.G.I.P., James O’Riordan, A.F.R.C.S.I., Suzanne Rowley, B.Sc., Patrick J. Byrne, Ph.D., John V. Reynolds, F.R.C.S.I.* University Department of Surgery, St James’ Hospital, Dublin 8, Ireland Manuscript received December 9, 2004; revised manuscript May 2, 2005 Abstract Background: Severe gastroesophageal reflux disease may result in acquired esophageal dysmotility. The correct surgical approach to associated gastroesophageal reflux disease and dysmotility is controversial, in particular whether the “gold-standard” total fundoplication of Nissen is appropriate compared with partial fundoplication. Our unit has performed total fundoplication for all patients, irrespective of esophageal motility, and this article describes that experience. Methods: Ninety-eight patients undergoing antireflux surgery were divided into 2 groups. Group 1 (n  60) consisted of patients with normal esophageal motility, and group 2 (n  38) had dysmotility. All patients underwent preoperative and postoperative manometry, 24-hour pH testing, symptom scoring, and quality-of-life assessment. Results: The median postoperative acid score was not significantly different between groups 1 and 2. Eighty-eight percent of patients with normal motility and 89% of patients with dysmotility had no symptoms or minor symptoms, with a significant improvement in quality of life 6 months after surgery. There was a significant increase in esophageal wave amplitude in both groups, and 20 patients (53%) in the dysmotility group reverted to normal motility after surgery. Recurrent symptoms were associated with postoperative abnormal pH profiles in 5 patients from group 1 and 3 from group 2. Conclusions: Preoperative dysmotility is not a contraindication for total fundoplication. Postoperative acid control is associated with improved esophageal clearance and symptoms. © 2005 Excerpta Medica Inc. All rights reserved. Keywords: Dysmotility; Nissen; Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire; Reflux Medical management remains the standard initial therapy for patients with symptomatic gastroesophageal reflux disease (GERD) [1,2]. Control of reflux symptoms with medical ther- apy is not always corroborated by physiologic evidence of control of acid reflux, and symptoms can be completely absent in the presence of high acid exposure [3,4]. In contrast, Nissen fundoplication provides control of reflux in addition to excel- lent long-lasting relief of symptoms, and the advent of the laparoscopic era has shifted the paradigm toward early consid- eration of antireflux surgery in patients with severe reflux [5]. A byproduct of successful surgery may be an improvement in reflux-acquired motility disturbances of the esophagus [6]. The choice of surgery in the presence of reflux-associated dysmo- tility is controversial as to whether to perform the 360° wrap of a total (Nissen) fundoplication and theoretically increase the risk of postoperative dysphagia or to perform a partial wrap with decreased risk of dysphagia but a higher likelihood of treatment failure [7,8]. The policy in our unit has been to perform a total fundoplication on all patients with reflux- acquired dysmotility. The report highlights the lessons learned from this experience. Patients and Methods Study population and design A prospective database (Microsoft Excel) on patients with reflux disease was established in our unit in 1996. The * Corresponding author. Tel.: 353-01-453-7479; fax: 1-353-01- 4546534. E-mail address: reynoljv@tcd.ie The American Journal of Surgery 190 (2005) 445– 450 0002-9610/05/$ – see front matter © 2005 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.05.040