Abstract
Objective: The selection of a suitable procedure for surgical solution of gastroesophageal reflux (GER) complications. Most severe complications of GER include reflux esophageal strictures.
There are various therapeutic procedures: medication, dilation, dilation before or after surgery, antireflux plasty, or resection of stricture and anastomosis of esophagus or substitution of esophagus by stomach or intestine. The authors refer to advantages of preoperative medication in combination with dilation of esophageal stricture.
In the algorithm there are immediate steps - surgery - antireflux plasty according to Nissen and again dilation of esophageal stricture. Long termresults of this intervention proved to be very good.
Method: At authors workplace, 390 patients have been operated on for GER during 23 years. In 23 patients the operation was indicated for established reflux esophageal stricture (mean age at the time of operation was 7.5 years, range 10 months to 14 years).
The study included 17 patients. After establishment of diagnosis, pharmacotherapy was initiated (antacids, cisaprid, H2 antagonists, omeprazol).
The preoperative dilation of the stricture was performed in 7 patients (bougie dilation twice, balloon dilation five times). The preoperative dilation was indicated by a stricture causing difficulties in swallowing of liquids.
The antireflux plasty according to Nissen followed. In two patients with very narrow stricture nutritional gastrostomy was applied at the same time.
The dilation after thee surgery was performed in 10 patients (once to 9 times), dilation before and after the operation was made in 4 patients. Results: The results were evaluated as very good in 15 patients since they did not suffer from clinical difficulties for more than a year and their conditions has not required further dilations.
Two patients underwent repeated dilations of the cuff after fundoplication. Pharmacological treatment ended immediately after the operation.
The patients have been further observed in out-patient department. Conclusion: The therapy of reflux stricture would be complex - a combination of pharmacological, dilation and surgical treatment.
As soon as the diagnosis is established, pharmacological therapy should ensue immediately. The dilation before the surgery should be made only in cases, when the patients experiences difficulties with swallowing of liquid food.
Among available surgical procedures the authors prefer 360 degree fundoplication according to Nissen.