HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christos Alexiou David Beggs Fayek D. Salama Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Alexiou, C. Articles by Knowles, K. R. Search for Related Content PubMed PubMed Citation Articles by Alexiou, C. Articles by Knowles, K. R.

Eur J Cardiothorac Surg 2000;17:389-395
© 2000 Elsevier Science NL

A tailored surgical approach for gastro-oesophageal reflux disease: the Nottingham experience

Cardio-Thoracic Surgery and GI Physiology Unit, City Hospital, Nottingham NG5 1PB, UK

Corresponding author. Tel.: +44-115-969-1169, fax: +44-115-962-7723
e-mail: david.beggs{at}dial.pipex.com

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 
Objective: The objective was to assess the results which can be achieved by tailoring the anti-reflux procedure to the anatomical and functional situation of the patient with gastro-oesophageal reflux disease (GORD). Patients and methods: Two hundred and seventy six patients undergoing a primary tailored anti-reflux procedure between 1986 and 1996 were evaluated. An anti-reflux procedure was selected on the basis of the anatomical and functional findings assessed by means of barium video, endoscopy, manometry and prolonged pH monitoring. The operations performed were Nissen fundoplication (77), total fundoplication gastroplasty (TFG; 140) and Belsey Mark IV (BMIV; 59). The unit policy is for life-long follow-up. The symptoms at review were assessed and graded according to previously published criteria (Orringer MB, Skinner DB, Besley HR. Long-term results of the mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972;63:25–31). Patients with recurrent symptoms were fully re-investigated. Results: Mean hospital stay was 8.2 days (5–32 days). There was one hospital death (0.36%). Mean follow-up was 6.7 years (range, 2.2–13.1 years). Overall excellent or good results were achieved in 247 (89.5%) patients (92.2% in Nissen, 90.7% in TFG and 83.1% in BMIV group, P=0.1). In patients without oesophagitis (n=72), the success rate was 93.1%, while for patients with grade IV oesophagitis (n=89) this was 87.6% (P=0.2). Kaplan–Meier freedom from recurrent or new, operation-induced, symptoms at 10 years was 88.1% (89.5% in Nissen, 87.4% in TFG and 73.8% in BMIV groups, P=0.08). Conclusions: These data suggest that where the appropriate anti-reflux procedure is selected, surgery can achieve satisfactory mid- and long-term success rates across the spectrum of GORD. When oesophageal shortening is evident, or merely suspected, we favour a TFG. In the presence of impaired motility and no evidence of oesophageal shortening, a BMIV is the preferred approach. The Nissen procedure is used for uncomplicated cases.

Key Words: Tailored anti-reflux surgery • Gastro-oesophageal reflux disease • Nissen fundoplication • Total fundoplication gastroplasty • Belsey Mark IV

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 
Gastro-oesophageal reflux disease (GORD) is characterized by an abnormal exposure of the oesophageal lumen to acid and/or alkaline gastric contents, resulting in various degrees of oesophageal mucosal damage. Although the causes may be multifactorial, the presence of an incompetent lower oesophageal sphincter (LOS) and/or the inability of the oesophageal body to clear the detrimental gastric and/or duodenal juices are the most common underlying pathophysiological mechanisms [1].

Thus, the main objective of anti-reflux surgery is the restoration of a competent anti-reflux mechanism and the reversal of the pathological changes induced by the disease process, with the least possible side effects, such as dysphagia, gas bloating etc., caused by the operation itself [2].

The wide variability of the reported outcomes following the application of the many anti-reflux procedures would, nevertheless, suggest that none of them are likely to successfully deal with the entire spectrum of the GORD. In the Nottingham Thoracic Surgery Unit, Belsey Mark IV (BMIV) and total fundoplication gastroplasty (TFG) have been used as single anti-reflux procedures in two consecutive periods in the past [3,4].

From 1986, we adopted a tailored approach and selected what we felt was the appropriate anti-reflux operation based on the findings of each patient's preoperative anatomical and functional assessment.

The aim of this paper is the description and analysis of the intermediate and long-term clinical results achieved through this tailored surgical approach.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 
Between January 1986 and December 1996, 289 patients underwent a primary tailored anti-reflux operation in Nottingham City Hospital Thoracic Surgery Unit.

Thirteen patients were lost to follow-up. The remaining 276 patients (156 males and 120 females with a mean age of 51.1 years, range 18–80 years) are the subject of this report.

Patients having previous oesophageal or gastric operations, concomitant procedures, scleroderma or achalasia, and those undergoing repair of para-oesophageal hernias without having evidence of gastro-oesophageal reflux were excluded from the study.

2.1. Pre-operative assessment
Preoperative assessment was routinely carried out by means of clinical history, barium swallow, endoscopy, oesophageal manometry and prolonged pH monitoring studies.

At endoscopy, oesophagitis was assessed as grade I (mild, erythematous changes), grades II and III (superficial or deeper ulcerations with or without deeper necrosis) and grade IV (stricture with/or Barrett's metaplasia). The presence of oesophagitis was confirmed by the histological examination of oesophageal mucosal biopsy specimens in most instances.

2.2. Indication for surgery
All patients had a trial of full medical treatment with H2-receptor antagonists, alginic acid preparations and/or proton-pump inhibitors, as well as dilatations as required, which had failed to control the symptoms and/or the evolution of the pathological changes induced by GORD, before they were submitted to surgery.

2.3. Selection of anti-reflux procedure
The clinical history and the findings of the preoperative investigations were discussed by two thoracic surgeons, a gastro-intestinal physiology scientist and a specialized radiologist. Patients with severe (grade II, III or IV) oesophagitis or stricture, with or without obvious oesophageal shortening, were offered a TFG procedure [5–7]. In the presence of impaired motility (contraction amplitude of less than 30 mmHg and/or abnormal wave progression) and no evidence of severe oesophageal inflammation or shortening, a BMIV [2] was the preferred approach. Nissen total fundoplication [8], by thoracic or abdominal approach, was reserved for those having minimal or no mucosal inflammation and normal motility on oesophageal manometry.

2.4. The operations and postoperative management
One hundred and forty patients had a TFG, 77 had a Nissen fundoplication and 59 had a BMIV procedure. Patients were given fluids orally after 48 h, and semisolids and solids on the ensuing days. A barium meal was performed before the discharge of patients from the hospital to ensure a satisfactory radiographic appearance of the repair.

2.5. Postoperative evaluation
The unit policy is for life-long follow-up. Patients were interviewed at the clinic 6 weeks after the operation, at 3-monthly intervals for the first year, at 6-monthly intervals for the second year, every year until the tenth year and every 2 years thereafter.

Interviews were conducted by the consultant thoracic surgeons or by the resident medical staff. Patients were specifically asked for the presence of recurrent symptoms of GORD and/or for new symptoms such as dysphagia, difficulties in belching, symptoms of gas bloat syndrome and post-thoracotomy incisional pain.

Symptoms were graded according to the previously published criteria [2] as A (asymptomatic), B (completely relieved of all reflux symptoms but with mild, non-specific complaints), C (symptomatic of reflux or appearance of new persistent procedure-related symptoms, but without objective evidence of recurrence on re-investigation) and D (documented recurrent hiatus hernia and/or reflux). A and B were considered as excellent and good results, and C and D as failures.

Patients with recurrent or persistent new symptoms were re-investigated by means of barium meal, endoscopy, manometry and pH studies. Patients without symptoms had no further investigation.

The information obtained from the patient's most recent out-patient visit was used for the evaluation of the outcome, unless recurrent symptoms or side effects became apparent earlier.

2.6. Statistics
The means were compared with the unpaired t-test and proportions with the Chi-square test. The probability of success (freedom from recurrent symptoms or side effects of the operation) for each procedure, was calculated using the Kaplan–Meier product limit method and compared with the log-rank test. A P-value of less than 0.05 was considered significant. All statistical analyses were done using the statistical package SPSS PC (version 7.5) (SPSS Inc., Chicago, IL).

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 
3.1. Preoperative clinical and pathological features
The most commonly presenting symptoms in the three groups are shown in Table 1. Patients having a Nissen fundoplication were least likely to present with regurgitation, whereas dysphagia was by far more prevalent amongst those treated with a TFG (Table 1).

Similarly, reflecting the selection process, patients having a Nissen total fundoplication or a BMIV procedure were more likely to have no oesophageal mucosal damage, and less likely to have grade IV oesophagitis than their counterparts having a TFG (Table 2).

3.2. Operative mortality and morbidity
There has been one operative death (0.3%) in a 67-year-old female (TFG group) who suffered acute myocardial infarction on the first postoperative day.

The usual early postoperative complications were minor respiratory problems in 25 patients (9%) and supraventricular arrythmias in 33 patients (12%), and were similarly distributed amongst the three operative groups. Gastric perforation was recorded in three patients (two patients in the TFG and one in the BMIV group) and bleeding requiring re-exploration in two patients (both in the TFG group).

3.3. Late complications
Undesired effects following patient discharge from the hospital included transient dysphagia in 66 (22.1%) patients, moderate dysphagia in 51 (18.7%) (eight patients in Nissen (10.3%), 29 in TFG (20.7%) and 14 (23.7%) in BMIV groups), severe persistent dysphagia in 11 (4.0%) (one patient in Nissen (1.3%), eight patients in TFG (5.7%) and two (3.4%) in the BMIV groups), gas bloating in 16 (5.8%), difficulty in belching in 11 (4.0%), flatulence in nine (3.2%) and post-thoracotomy incisional pain in 13 (4.7%) patients.

3.4. Follow-up
The mean follow-up was 6.7 years (range 2.2–13.1 years). One hundred and eight patients (39.1%) were followed-up for less than 5 years, 109 (39.5%) patients between 5 and 10 years, and 61 (22.1%) for more than 10 years. The length of exposure to follow-up was similar in the three groups.

3.5. Successful outcome
Two hundreds and forty-seven patients (89.5%) had excellent or good (A or B) clinical results, remaining free of recurrent or new, anti-reflux procedure-induced, symptoms by the end of this study. Notably, the success rate remained similarly high regardless of the degree of oesophagitis at preoperative endoscopy (Table 3).

The overall 10-year Kaplan–Meier freedom from recurrent or new anti-reflux procedure-induced symptoms) for all patients was 88.1% (Fig. 1), whereas for the Nissen, BMIV and TFG groups, this was 89.5, 73.8 and 87.4%, respectively; P=0.08 (Fig. 2).

View larger version (17K): [in this window] [in a new window]   Fig. 1. Kaplan–Meier success rates (freedom form recurrent symptoms or side effects of the operation) for all (n=276) patients at 5, 10 and 13 years were 91.9, 88.1 and 82.7%. SE, standard error; CI, confidence intervals. The time and y-axes were cut for graphical reasons.

View larger version (19K): [in this window] [in a new window]   Fig. 2. Kaplan–Meier success rates (freedom from recurrent or new symptoms) at 5 and 10 and 13 years: Nissen fundoplication, 91.5, 89.5 and 89.5% (mean freedom, 147 months; SE, 4.26; 95% CI, 136–153); TFG, 94.8, 87.4 and 82% (mean freedom, 132 months; SE, 7; 95% CI, 119–155); BMIV, 84.5, 73.8 and 73.8% (mean freedom, 143 months; SE, 3.3; 95% CI, 137–150) (log-rank test, P=0.08). The time and y-axes were cut for graphical reasons. SE, standard error; CI, confidence intervals.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 
Despite the availability of powerful medications, about one fourth of patients with GORD are likely to have recurrent, progressive disease and may eventually require an operation [9]. The objective of the surgical treatment is for the long-term relief of reflux symptoms and the reversal of the anatomical changes induced by the disease process, with the least possible side effects [2]. This objective is more likely to be achieved if an anti-reflux procedure is selected based on a sound knowledge of the underlying pathophysiological mechanisms of the disease.

It has been clearly shown in the past that failure to adjust the operation to each patient's anatomical and functional situation may lead to an unfavourable outcome. We have previously reported a success rate of 50% in patients with grade IV oesophagitis [3], reduced to 42% [4] in the most recent review, as opposed to 90% in those with no oesophagitis undergoing a BMIV as a single procedure between 1976 and 1983.

Before us, Orringer, Skinner and Belsey reported a similar experience, a failure rate of 40% amongst patients having oesophageal shortening treated with a BMIV [2]. Analysis of those results suggested that tension on the repair was the main reason for the recorded failures and this led to the development of procedures combining a Collis [10] gastroplasty with a partial Belsey-type fundoplication, as described by Pearson [11] and modified by Jeyasingham [12]. Henderson [5,6] and Orringer [13] have subsequently advocated two versions of Collis gastroplasty with a total Nissen-type fundoplication, the TFG and the Collis–Nissen procedures, respectively.

TFG was used as a single anti-reflux procedure in our unit from 1983 to 1986. Despite the good results obtained by using the TFG as single procedure [4], it was felt that the performance of a gastroplasty in the absence of severe oesophageal inflammation is not essential, since similar results in such patients could be obtained through a simple Nissen [14]. In fact, Moghissi [15] was able to observe a success rate of 91.2% in a particularly difficult group of 45 patients with stricture and acquired short oesophagus treated with a supradiaphragmatically-positioned Nissen-type repair. It was also anticipated that lower rates of transient, moderate, or severe dysphagia amongst patients with impaired motor function could be achieved through a partial, BMIV, fundoplication.

The presence or otherwise of impaired oesophageal motility and/or severe oesophagitis or stricture are the main points on which the tailored approach currently favoured in this unit is based.

In patients with normal oesophageal motility and minimal or no oesophagitis, a transabdominal Nissen total fundoplication is the procedure of choice.

In the presence of impaired oesophageal contractility (contraction amplitude of less than 30 mmHg) or abnormal wave progression, in order to avoid increased outflow resistance, a BMIV partial fundoplication is employed. The choice of the most suitable anti-reflux procedure for patients having mild impairment of oesophageal motor function may be difficult. In a prospective randomized study [16] comparing the objective and subjective outcome in 45 patients undergoing a Nissen total fundoplication, Hill repair or BMIV anti-reflux procedure, it has been shown that the Nissen procedure produced the greatest increase in the distal oesophageal pressure and was more effective in preventing recurrent reflux, but resulted in a higher incidence of postoperative dysphagia than the other two procedures. In our view, it may be preferable to accept a somewhat higher risk for recurrent reflux symptoms by performing a partial fundoplication rather having to deal with a patient suffering from persistent dysphagia as a consequence of total fundoplication.

If there is oesophageal shortening, stricture, Barrett's oesophagus and/or severe persistent oesophagitis, even without obvious shortening, a TFG is the favoured operative approach. Although the rationale of using a TFG in patients with obvious oesophageal shortening appears obvious, we believe that some patients with severe persistent oesophageal mucosal inflammation and peri-oesophagitis may, in fact, have subtle shortening and they may, therefore, also benefit by the performance of a gastroplasty procedure [3,4]. If impaired motility and severe oesophagitis or stricture co-exist we still perform a TFG, reducing the length of the wrap, as previously suggested by Henderson, to 1 mm, constructing a single-stitch wrap [5–7].

The surgical access for all patients undergoing a TFG or a BMIV operation is thoracic. The Nissen total fundoplication is normally performed through an abdominal approach. However, in the presence of marked obesity or where there is a history of previous major intra-abdominal operation, a thoracic approach is utilized.

Other centres advocated the use of a tailored approach in the surgical treatment of GORD and reported similar success rates.

Coosemans et al. [17] use a partial laparoscopic fundoplication or a transthoracic BMIV for patients with impaired motility, a Belsey or Collis–Nissen procedure when oesophageal shortening precludes the construction of a tension-free repair, and preferably, a laparoscopic Nissen–Rossetti operation for those having normal oesophageal motility and length. In this report from Leuven, there were 115 patients, many of whom had complicated disease and underwent a repeat surgery, and the combined objective and subjective success rate was 90.2%.

Kauer et al. [18] reported on 104 patients who underwent a primary tailored antireflux operation. They used an open (transabdominal or transthoracic) or laparoscopic Nissen fundoplication for the uncomplicated cases, a BMIV for cases with motility problems and Collis–Besley for cases with shortened oesophagus. The subjective success rate in this series, with a median follow-up of 4 years, was 88.7%.

Fuchs et al. [19] described 35 patients. They employed a laparoscopic Nissen–DeMeester operation for the uncomplicated cases, a 180-degree anterior hemifundoplication for cases of impaired motor function, and a highly selective vagotomy for patients having increased gastric acidity. Thirty-two patients (91%) were satisfied with the outcome of their operations.

The overall 89.5% clinical success rate in our 276 patients, with a mean follow-up of 6.7 years and the Kaplan–Meier prediction of 10-year freedom from recurrent or anti-reflux procedure induced symptoms of 88.1% (Fig. 1), seems to be rewarding. Notably, the success rates in the Nissen fundoplication (patients with uncomplicated disease) and the TFG groups (patients with severe oesophagitis, Barrett's metaplasia and/or strictute) were similar (Table 3). The 83% success rate in the BMIV group, on the other hand, was somewhat lower, but quite acceptable if one considers that all these patients had various degrees of disordered oesophageal peristalsis and/or abnormal wave progression at preoperative manometry.

	5. Conclusion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 
The selection of an anti-reflux procedure with regard to each patient's anatomical and functional situation can result in satisfactory mid- and long-term clinical success rates even in the most complicated forms of GORD.

	Footnotes

 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 
Dr K. Moghissi (East Yorkshire, UK): Can I ask you a question which is really related to the title of the paper, ‘tailored operation’. In what way did you tailor the operation for the patient. You performed three types of operation, what were the criteria for allocating patients to the three types of operation?

Dr Alexiou: The criteria for selecting the BMIV was the presence of impaired motility, that is, contraction amplitude of less than 30 mmHg, or abnormal wave progression on preoperative manometry, and the absence of severe oesophagitis.

The TFG was performed in patients having a short oesophagus or severe oesophagitis. This is based on our belief that severe mucosal inflammation may cause subtle shortening.

Patients, finally, with no severe oesophagitis, and normal oesophageal length and motility would qualify for a Nissen total fundoplication.

Dr S. Mattioli (Bologna, Italy): I totally agree with the concept that antireflux surgery has to be tailored. However, I would like to remark that you have a very high percentage of Collis gastroplasties in your series; it is 50%. You also have a very high percentage of very good results, mainly with respect to severe oesophagitis, which is quite remarkable. So, I have two questions.

I think that you did the Collis–Nissen through a thoracotomy, so you had the opportunity to fully mobilize the thoracic oesophagus; if this is correct, which criteria did you follow when you decided to elongate the oesophagus?

Dr Alexiou: Yes, TFG was always performed through a thoracotomy.

The high proportion of gastroplasty procedures reflects partly the evolution of the antireflux surgery in our institution. TFG was initially used as a single procedure for all patients requiring an antireflux surgery. Subsequently, in the context of the tailored approach, has been, and is currently being, employed in the cases of short oesophagus or severe oesophagitis. The rationale of elongating a shortened oesophagus is obvious. Our preference for doing a gastroplasty in patients with severe oesophagitis, stems, as already discussed with Professor Moghissi, from our contention that these patients may have, in fact, a subtle shortening.

The decision regarding the degree of the oesophageal elongation required was based on the interpretation of the radiological and endoscopical findings, and on the subjective assessment of the operating surgeon, the principle being that this should be done to such an extent as to provide a tension-free repair.

Dr A. Lerut (Leuven, Belgium): When you say that there is a need for preoperative assessment in deciding whether you are going to do a gastroplasty, I think you have to put that against what is accepted as the gold standard for antireflux surgery in the non-complicated reflux disease. Today, this is the laparoscopic approach, typically a laparoscopic Nissen. In other words, how would you assess, radiologically, whether to go for a thoracic approach or for an abdominal, i.e. laparoscopic approach?

Dr Alexiou: Besley Mark IV and TFG were always performed through a thoracotomy. Nissen total fundoplication was normally done through a laparotomy, but in the presence of marked obesity or where there was a history of major intra-abdominal operation, a thoracotomy was utilized. Laparoscopic techniques were not employed in this series.

Dr K. Jeyasingham (Bristol, UK): I'm glad that you have given us a tailored approach. In allocating patients to the various groups, if I interpret it right, the least symptomatic group went into the Nissen. Those who had dysphagia had to go into the gastroplasty and fundoplication, and the ones with dysmotility went on to the BMIV.

Now, we know that the ageing process affects dysmotility greatly. They do suffer from dysmotility as they get older. In your assessment of the outcome for success, did you take into consideration just reflux or reflux controlled by swallow or clearance, or oesophagitis or dysphagia? Did you take all these factors into consideration in your outcome?

Dr Alexiou: The particular factors you mentioned, Mr Jeyasingham, have not been taken into consideration in the analysis of the outcome. In this respect, of course, one should take into account that the patients who had a BMIV had various degrees of impaired mobility.

Mr Jeyasingham: So, if I interpret that right again, if a chap started off with dysmotility symptoms prior to surgery, he would have continued to have dysmotility symptoms afterwards; am I right?

Mr Alexiou: Yes.

Mr Jeyasingham: That would affect the outcome results and percentages?

Mr Alexiou: Correct.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusion Appendix A. Conference... References

 

1. DeMeester T.R. Definition, detection and pathophysiology of gastroesophageal reflux disease. In: DeMeester T.R., Matthews H.R., eds. International trends in general thoracic surgery. Benign esophageal disease. St. Louis, MO: C.V. Mosby, 1987:99-127.
2. Orringer M.B., Skinner D.B., Belsey R.H.R. Long-term results of the mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972;63:25-33.[Medline]
3. Salama F.D., Lamont G. Long-term results of the Belsey Mark IV antireflux procedure in relation to the severity of oesophagitis. J Thorac Cardiovasc Surg 1990;100:517-519.[Abstract]
4. Alexiou C., Salama F.D., Beggs D., Brackenbury T.E., Knowles K.R. Comparison of long-term results of total fundoplication gastroplasty and Belsey Mark IV anti-reflux operations in relation to the severity of oesophagitis. Eur J Cardio-thorac Surg 1999;15:620-626.
5. Henderson R.D. Reflux control following gastroplasty. Ann Thorac Surg 1977;24:206-214.[Abstract]
6. Henderson R.D., Marryatt G.V. Total fundoplication gastroplasty (Nissen gastroplasty): 5-year review. Ann Thorac Surg 1985;39:74-79.[Abstract]
7. Beggs F.D., Salama F.D., Knowles K.R. Management of benign oesophageal stricture by total fundoplication gastroplasty. J R Coll Edin 1995;40:305-307.
8. Nissen R. Eine einfache operation zum beeiflussung der refluxoesophagitis. Schweiz Med Wochenschr 1956;86:590-592.[Medline]
9. DeMeester T.R. Prolonged esophageal pH monitoring. In: Read N.W., ed. Gastro-intestinal motility: which test?. Petersfield: Wrightson Biomedical Publishing, 1989:41-51.
10. Collis L.J. Gastroplasty. Thorax 1961;16:197-206.
11. Pearson F.G., Langer B., Henderson R.D. Gastroplasty and Belsey hiatus hernia repair. An operation for the management of peptic stricture with acquired short oesophagus. J Thorac Cardiovasc Surg 1971;61:50-63.[Medline]
12. Reilly K.M., Jeyasingham K. A modified Pearson gastroplasty. Thorax 1984;39:67-69.[Free Full Text]
13. Orringer M.B., Sloan H. Combined Collis–Nissen reconstruction of the oesophagogastric junction. Ann Thorac Surg 1978;25:16-21.[Abstract]
14. Ellis H.F., Jr The Nissen fundoplication. Ann Thorac Surg 1992;54:1231-1235.[Abstract]
15. Moghissi K. Intrathoracic fundoplication for reflux stricture associated with short oesophagus. Thorax 1983;38:36-40.[Abstract/Free Full Text]
16. Demeester T.R., Johnson L.F., Kent A.H. Evaluation of current operations for the prevention of the gastro-oesophageal reflux. Ann Surg 1974;180:511-523.[Medline]
17. Coosemans W., DeLeyn P., Deneffe G., VanRaemdock D., Lerut T. Laparoscopic antireflux surgery and the thoracic surgeon: what now?. Eur J Cardio-thorac Surg 1997;12:683-688.[Abstract]
18. Kauer W.K.H., Peters J.H., DeMeester T.R., Heimbucher J., Ireland A.P., Bremner C.G. A tailored approach to antireflux surgery. J Thorac Cardiovasc Surg 1995;110:141-147.[Abstract/Free Full Text]
19. Fuchs J., Heimbucher J., Freys S.M., Thiede A. Management of gastro-oesophageal reflux disease 1995. Tailored concept of anti-reflux operations. Dis Esophagus 1994;7:250-254.

This article has been cited by other articles:

				C. N. Scipione, A. C. Chang, A. Pickens, C. L. Lau, and M. B. Orringer Transhiatal Esophagectomy in the Profoundly Obese: Implications and Experience Ann. Thorac. Surg., August 1, 2007; 84(2): 376 - 383. [Abstract] [Full Text] [PDF]

				O. A. Khan, G. Kanellopoulos, M. L. Field, K. R. Knowles, F. D. Beggs, W. E. Morgan, and J. P. Duffy Redo antireflux surgery--the importance of a tailored approach Eur. J. Cardiothorac. Surg., November 1, 2004; 26(5): 875 - 880. [Abstract] [Full Text] [PDF]

				M. Migliore, M. Arcerito, A. Vagliasindi, R. Puleo, F. Basile, and G. Deodato The place of Belsey Mark IV fundoplication in the era of laparoscopic surgery Eur. J. Cardiothorac. Surg., October 1, 2003; 24(4): 625 - 630. [Abstract] [Full Text] [PDF]

				R C Heading Should abnormal oesophageal motility in gastro-oesophageal reflux disease (GORD) influence decisions about fundoplication? Gut, May 1, 2002; 50(5): 592 - 593. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christos Alexiou David Beggs Fayek D. Salama Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Alexiou, C. Articles by Knowles, K. R. Search for Related Content PubMed PubMed Citation Articles by Alexiou, C. Articles by Knowles, K. R.