Reflux and belching after 270 degree versus 360 degree laparoscopic posterior fundoplication

Broeders JA, Bredenoord AJ, Hazebroek EJ, Broeders IA, Gooszen HG, Smout AJ.

To investigate differences in effects of 270 degrees (270 degrees LPF) and 360 degrees laparoscopic posterior fundoplication (360 degrees LPF) on reflux characteristics and belching.

Three hundred sixty degrees LPF greatly reduces the ability of the stomach to vent ingested air by gastric belching. This frequently leads to postoperative symptoms including inability to belch, gas bloating and increased flatulence. Two hundred seventy degrees LPF allegedly provides less effective reflux control compared with 360 degrees LPF, but theoretically may allow for gastric belches (GBs) with a limitation of gas-related symptoms.

Endoscopy, stationary esophageal manometry, and 24-hour impedance-pH monitoring off PPIs was performed before and 6 months after fundoplication for PPI-refractory gastroesophageal reflux disease (n = 14 270 degrees LPF vs. n = 28 360 degrees LPF). GBs were defined as gas components of pure gas and mixed reflux episodes reaching the proximal esophagus. Absolute reductions (Δ) were compared.

Reflux symptoms and the 24-hour incidence of acid (Δ -77.6 vs. -76.7), weakly acidic (Δ -9.4 vs. -6.6), liquid (Δ -59.0 vs. -49.8) and mixed reflux episodes (Δ -28.0 vs. -33.5) were reduced to a similar extent after 270° LPF and 360° LPF, respectively. The reduction in proximal, mid-esophageal and distal reflux episodes were similar in both groups as well. Persistent symptoms were not related to acid or weakly acidic reflux. Two hundred seventy degrees LPF had no significant impact on the number of gas reflux episodes (Δ -3.6; P = 0.363), whereas 360 degrees LPF significantly reduced gas reflux episodes (Δ -17.0; P = 0.002). After 270 degrees LPF, GBs (Δ -29.3 vs. -50.6; P = 0.026) were significantly less reduced and the prevalence of gas bloating (7.1% vs. 21.4%; P = 0.242) and increased flatulence (7.1% vs. 42.9%; P = 0.018) was lower compared to 360 degrees LPF. Twenty-eight patients (67%) showed supragastric belches (SGBs) before and after surgery. The increase in SGBs without reflux (Δ +32.4 vs. +25.5) and the decrease in reflux-associated SGBs (Δ -12.1 vs. -14.0) were similar after 270 degrees LPF and 360 degrees LPF.

Two hundred seventy degrees LPF and 360 degrees LPF alter the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). However, gas reflux and GBs are reduced less after 270 degrees LPF than after 360 degrees LPF, resulting in more air venting from the stomach and less gas bloating and flatulence, whereas reflux is reduced to a similar extent in the short-term.