This report evaluates the efficacy of the combined Collis-Nissen operation in achieving long-term reflux control in patients with reflux strictures. A Collis-Nissen procedure with dilation of a reflux stricture was performed in 64 adults. The strictures were mild (easily dilated) in 37, moderate (requiring some force to dilate) in 17, and severe (requiring very forceful dilation) in 10. Two strictures were perforated intraoperatively. There was 1 postoperative death, and 4 patients have been lost to follow-up. The remaining 59 patients have been followed from 2 to 120 months (average, 43 months) after operation. Subjectively, reflux is absent in 48 (81%), mild in 4 (7%), moderate in 5 (9%), and severe in 2 (3%). Objectively, intraesophageal pH studies show good or excellent reflux control in 94% at 1 year and 66% at 2 to 5 years. Dysphagia has been eliminated in 71%, is mild in 10%, moderate (requiring occasional dilation) in 12%, and severe (requiring regular dilations) in 7%. The combined Collis-Nissen operation provides good long-term reflux control and relief of dysphagia in most patients with reflux strictures. However, patients with reflux strictures after previous repairs are likely to have unsatisfactory results and may best be managed with resectional therapy. Resection may also ultimately prove to be a better option for patients with more severe strictures.

The bulk of available evidence supports the view that Barrett's oesophagus is an acquired condition due to chronic gastro-oesophageal reflux. It is possible that a few cases are congenital. Barrett's oesophagus gives rise to severe stricture and ulceration and has a significant malignant potential. Treatment is designed to prevent reflux and, if possible, to reverse the metaplastic change. Dysplasia is of ominous significance and requires frequent careful surveillance.

Barrett's esophagus is now thought to be an acquired condition rather than a congenital condition. It has a dangerous potential for malignancy; yet, aggressive medical management, antireflux procedures, and diligent follow-up may reduce the incidence of malignancy in this condition.

Columnar epithelium-lined lower esophagus (CLLE) or Barrett's esophagus was found in 34 patients diagnosed by endoscopic biopsy. In one-half of them, the CLLE extended up to 30 cm from the incisors (limited group) and in the other half, it reached above this level (extended group). Eight patients with stricture and limited CLLE had the lesion in the lower third of the esophagus, whereas 6 of 8 with strictures in the extended group had narrowing in the upper third of the esophagus. Two other patients with extended CLLE were seen with bleeding from Barrett's ulcer, 3 had adenocarcinoma, and the remaining 4 had CLLE without these complications. The three classic histologic types were encountered in both groups. However, in the extended group there was more of the intestinal type and less of the junctional type of epithelium, the latter being seen mostly in the limited group. The extended group had very low lower esophageal sphincter (LES) pressures (mean, 7.3 mm Hg) with severe reflux. The limited group had a higher mean LES pressure (11.2 mm Hg) with less severe reflux. In both groups, LES pressure and reflux improved following effective antireflux operation; some patients who continued to have demonstrable reflux and a lack of improvement in LES pressure despite antireflux operation, the disease progressed, as evidenced by extension of CLLE.

During a 7-year period, 130 patients with oesophageal stricture resulting from long-standing reflux oesophagitis and hiatal hernia were referred for surgery. Eighty-seven of these patients underwent conservative surgery consisting of intraoperative transgastric retrograde dilatation combined with one of two types of anti-reflux operation: in 34 patients (group 1) an Allison-type operation for hiatal hernia was undertaken, and in the remaining 53 patients (group 2), a Nissen-type fundoplication was carried out. In 22 patients in this latter group the oesophagogastric junction could not be brought down into the abdomen in spite of extensive oesophageal mobilization and the fundoplication was finally placed above the diaphragm. From the successful results in both groups (particularly in group 2), it is concluded that conservative surgery should be considered in cases of hiatal hernia with a reflux stricture that yields to intraoperative dilatation.