A learning curve for laparoscopic fundoplication. Definable, avoidable, or a waste of time?

OBJECTIVE

The objective of this study was to determine whether a learning curve for laparoscopic fundoplication can be defined, and whether steps can be taken to avoid any difficulties associated with it.

SUMMARY BACKGROUND DATA

Although early outcomes after laparoscopic fundoplication have been promising, complications unique to the procedure have been described. Learning curve problems may contribute to these difficulties. Although training recommendations have been published by some professional bodies, there is disagreement about what constitutes adequate supervised experience before the solo performance of laparoscopic antireflux surgery, and the true length of the learning curve.

METHODS

The outcome of 280 laparoscopic fundoplications undertaken by 11 surgeons during a 46-month period was assessed prospectively. The experience was analyzed in three different ways: 1) by an assessment of the overall learning experience within chronologically arranged groups, 2) by an assessment of all individual experiences grouped according to the experience of individual surgeons, and 3) by a comparison of early outcomes of operations performed by the surgeons who initiated laparoscopic fundoplication with the early experience of surgeons beginning laparoscopic fundoplication later in the overall institutional experience.

RESULTS

The complication, reoperation, and laparoscopic to open conversion rates all were higher in the first 50 cases performed by the overall group, and in the first 20 cases performed by each individual surgeon. These rates were even higher in the initial first 20 cases, and the first 5 individual cases. However, adverse outcomes were less likely when surgeons began fundoplication later in the overall experience, when experienced supervision could be provided.

CONCLUSIONS

A learning curve for laparoscopic fundoplication can be defined. Experienced supervision should be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures. This should minimize adverse outcomes associated with an individual's learning curve.

Prospective double-blind randomized trial of laparoscopic Nissen fundoplication with division and without division of short gastric vessels

OBJECTIVE

To determine whether division of the short gastric vessels (SGVs) and full mobilization of the gastric fundus is necessary to reduce the incidence of postoperative dysphagia and other adverse sequelae of laparoscopic Nissen fundoplication.

SUMMARY BACKGROUND DATA

Based on historical and uncontrolled studies, division of the SGVs has been advocated during laparoscopic Nissen fundoplication to improve postoperative clinical outcomes. However, this modification has not been evaluated in a large prospective randomized trial.

METHODS

One hundred two patients with proven gastroesophageal reflux disease presenting for laparoscopic Nissen fundoplication were prospectively randomized to undergo fundoplication with (52 patients) or without (50 patients) division of the SGVs. Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded. Patients were blinded to the postoperative status of their SGVs. Clinical assessment was performed by a blinded independent investigator who used multiple standardized clinical grading systems to assess dysphagia, heartburn, and patient satisfaction 1, 3, and 6 months after surgery. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, and distal esophageal acid exposure and radiologic assessment of postoperative anatomy were also performed.

RESULTS

Operating time was increased by 40 minutes (median 65 vs. 105) by vessel division. Perioperative outcomes and complications, postoperative dysphagia, relief of heartburn, and overall satisfaction were not improved by dividing the SGVs. Lower esophageal sphincter pressure, acid exposure, and esophageal emptying times were similar for the two groups.

CONCLUSION

Division of the SGVs during laparoscopic Nissen fundoplication did not improve any clinical or objective postoperative outcome.

Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication

BACKGROUND

In the operative management of gastro-oesophageal reflux, a balance must be achieved between adequate control of reflux and excessive dysphagia. The ideal technique is not known. A randomized study was performed to determine whether laparoscopic anterior fundoplication is associated with a lower incidence of postoperative dysphagia than laparoscopic Nissen fundoplication, while achieving equivalent control of reflux.

METHODS

Patients presenting for laparoscopic antireflux surgery were randomized to undergo either a Nissen fundoplication (n = 53) or an anterior 180 degrees hemifundoplication (n = 54). Patients were blinded to which procedure had been performed, and follow-up was obtained by a blinded independent investigator. Standardized clinical grading systems were used to assess dysphagia, heartburn and patient satisfaction 1, 3 and 6 months after operation. Objective measurement of lower oesophageal sphincter pressure, oesophageal emptying time, distal oesophageal acid exposure and endoscopic healing of oesophagitis was also performed.

RESULTS

Operating time was similar for the two procedures (58 min for the Nissen procedure versus 60 min for anterior fundoplication). Resting and residual lower oesophageal sphincter pressures were lower following anterior fundoplication (29 versus 18 mmHg, and 13 versus 6 mmHg), and oesophageal emptying times were faster (92 versus 116 s). Acid exposure times and ability to heal oesophagitis were similar. At 3 months' follow-up clinical outcomes were similar for the two procedures. At 6 months, however, patients who had undergone anterior fundoplication experienced significantly less dysphagia for solid food and were more likely to be satisfied with the clinical outcome.

CONCLUSION

Laparoscopic anterior fundoplication achieved equivalent control of reflux, more physiological postoperative manometry parameters, and an improved clinical outcome at 6 months. Continued follow-up remains necessary to confirm the long-term efficacy of the partial fundoplication procedure.

Gasless laparoscopy may reduce the risk of port-site metastases following laparascopic tumor surgery

OBJECTIVE

To compare the incidence of port-site metastases in an experimental tumor model following tumor manipulation during laparoscopy aided by conventional insufflation with laparoscopy using a gasless technique.

SETTING

An experimental model applied in a research laboratory.

PARTICIPANTS AND INTERVENTIONS

Malignant tumors were implanted in the abdominal wall of 24 rats. Twelve rats underwent tumor laceration at laparoscopy with carbon dioxide insufflation, and 12 rats underwent the same procedure during gasless laparoscopy achieved by abdominal wall suspension. Rats were killed 1 week later and were examined for evidence of tumor metastases. The surgical wounds were examined microscopically by a histopathologist who was unaware of the operative technique used and the site of origin of the specimens.

MAIN OUTCOME MEASURE

Histologically confirmed tumor metastasis to laparoscopic port wounds.

RESULTS

Growth of the primary tumor was equal in both groups. Wound metastases were less likely in the gasless laparoscopy group (3 of 12 vs 10 of 12; P = .01, Fisher exact test).

CONCLUSION

The use of laparoscopy without gas insufflation may reduce the risk of wound metastasis following laparoscopic surgery for cancer.

Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial

OBJECTIVE

Determine whether absorbable or nonabsorbable mesh in repair of large hiatus hernias reduces the risk of recurrence, compared with suture repair.

BACKGROUND

Repair of large hiatus hernia is associated with radiological recurrence rates of up to 30%, and to improve outcomes mesh repair has been recommended. Previous trials have shown less short-term recurrence with mesh, but adverse outcomes limit mesh use.

METHODS

Multicentre prospective double blind randomized controlled trial of 3 methods of repair: sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome-hernia recurrence assessed by barium meal radiology and endoscopy at 6 months. Secondary outcomes-clinical symptom scores at 1, 3, 6, and 12 months.

RESULTS

A total of 126 patients enrolled: 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Among them, 96.0% were followed up to 12 months, with objective follow-up data in 92.9%. A recurrent hernia (any size) was identified in 23.1% after suture repair, 30.8% after absorbable mesh, and 12.8% after nonabsorbable mesh (P = 0.161). Clinical outcomes were similar, except less heartburn at 3 and 6 months and less bloating at 12 months with nonabsorbable mesh; more heartburn at 3 months, odynophagia at 1 month, nausea at 3 and 12 months, wheezing at 6 months; and inability to belch at 12 months after absorbable mesh. The magnitudes of the clinical differences were small.

CONCLUSIONS

No significant differences were seen for recurrent hiatus hernia, and the clinical differences were unlikely to be clinically significant. Overall outcomes after sutured repair were similar to mesh repair.

Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication

Postoperative paraoesophageal hiatus hernia occurred in 17 of 253 patients who underwent laparoscopic fundoplication at five different hospitals. Ten patients have undergone subsequent surgical revision, eight by an open technique and two by laparoscopy. This complication may have important implications for the technique of laparoscopic fundoplication, as it is possible that routine posterior repair of the diaphragmatic hiatus may greatly reduce the risk. Early postoperative contrast radiology may also achieve earlier diagnosis, enabling correction to be undertaken by laparoscopy.

Antireflux surgery in the laparoscopic era

BACKGROUND

The recent development of laparoscopic techniques for fundoplication has created renewed interest in surgery for gastro-oesophageal reflux disease, leading to reports of large clinical series from many centres. However, controversy remains about technical aspects of laparoscopic antireflux surgery, with no consensus yet reached about a standard operative technique. It is important, therefore, to reassess critically the results of laparoscopic surgery for reflux disease, so that its current status can be determined.

METHODS

Published outcome studies for laparoscopic antireflux surgery, as well as selected studies from the era of open antireflux surgery, were reviewed to assess outcomes.

RESULTS

The results of case series for laparoscopic antireflux surgery with short- and medium-term follow-up, as well as the early results of randomized trials, confirm that this approach reduces the early overall morbidity of surgery for reflux disease. However, certain complications may be more common, for instance paraoesophageal hiatus herniation, pneumothorax and oesophageal perforation, requiring surgeons to use specific strategies which can help to avoid these problems. Published studies and trials do not support the routine or selective application of a posterior partial fundoplication technique or routine division of the short gastric vessels during Nissen fundoplication.

CONCLUSION

At present, a short loose Nissen fundoplication performed laparoscopically, with or without division of the short gastric vessels, is an appropriate surgical approach for gastro-oesophageal reflux disease. However, long-term outcomes following laparoscopic antireflux surgery will not be available for some years, and must be awaited before the final status of the various laparoscopic techniques can be confirmed.

Laparoscopic versus open splenectomy for immune thrombocytopenic purpura

BACKGROUND

We sought to determine whether laparoscopic techniques can reduce the operative morbidity of surgery in patients undergoing splenectomy for immune thrombocytopenic purpura (ITP).

METHODS

All patients (60) undergoing splenectomy for ITP at the Royal Adelaide Hospital from January 1985 to November 1995 were reviewed. Results of patients undergoing open operation were obtained by means of retrospective case note review, whereas details of all patients undergoing laparoscopic splenectomy were collected prospectively and maintained on a computerized database.

RESULTS

Forty-seven patients underwent splenectomy with an open technique and 13 with a laparoscopic technique. Patient groups were demographically similar. All laparoscopic procedures were completed with the laparoscopic technique. An accessory spleen was also removed at laparoscopic operation from two (15%) patients and at open operation from three patients (6%). Two more accessory spleens were missed at the original procedure, one at open operation and one at laparoscopic operation. These required later removal by using open and laparoscopic techniques, respectively. Blood and platelet transfusion requirements were reduced by the laparoscopic approach. Although mean operating times were similar (87 versus 88 minutes), laparoscopic splenectomy was associated with a greatly reduced postoperative hospital stay (10 versus 2 days, median; p < 0.0001) and no major morbidity. Long-term normalization of platelet counts was similar for the two techniques. The laparoscopic approach resulted in a reduction in hospital treatment costs from $4224 to $2238 per case (cost savings of $1986 per case).

CONCLUSIONS

Laparoscopic splenectomy results in improved clinical outcomes and reduced costs for patients undergoing elective splenectomy for ITP.

Totally endoscopic Ivor Lewis esophagectomy

Esophagectomy is associated with significant risks of perioperative morbidity and mortality, as well as prolonged convalescence due to effects of the incisions used for conventional surgical access. Because the outcome of this procedure is palliative in the majority of patients, it is possible that laparoscopic techniques could improve initial postoperative outcomes and therefore make surgery more acceptable for patients with esophageal cancer. A new technique is described for Ivor Lewis esophagectomy, which incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis. Initial experience in two patients has been encouraging, with postoperative hospital stay and convalescence shortened.

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication

HYPOTHESIS

Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication.

DESIGN

A multicenter, prospective, double-blind, randomized controlled trial.

SETTING

Nine university teaching hospitals in 6 major cities in Australia and New Zealand.

PARTICIPANTS

One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study.

INTERVENTIONS

Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication.

MAIN OUTCOME MEASURES

Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment.

RESULTS

Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures.

CONCLUSIONS

At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.

Five Year Follow-up of a Randomized Controlled Trial of Laparoscopic Repair of Very Large Hiatus Hernia With Sutures Versus Absorbable Versus Nonabsorbable Mesh

OBJECTIVE

To determine whether absorbable or nonabsorbable mesh repair of large hiatus hernias is followed by less recurrences at late follow-up compared to sutured repair.

SUMMARY OF BACKGROUND DATA

Radiological recurrences have been reported in up to 30% of patients after repair of large hiatus hernias, and mesh repair has been proposed as a solution. Earlier trials have revealed mixed outcomes and early outcomes from a trial reported previously revealed no short-term advantages for mesh repair.

METHODS

Multicentre prospective double-blind randomized controlled trial of 3 methods of hiatus hernia repair; sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 3-4 years. Secondary outcomes - clinical symptom scores at 2, 3, and 5 years.

RESULTS

126 patients were enrolled - 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Clinical outcomes were obtained at 5 years in 89.9%, and objective follow-up was obtained in 72.3%. A recurrent hernia (any size) was identified in 39.3% after suture repair, 56.7% - absorbable mesh, and 42.9% - nonabsorbable mesh (P = 0.371). Clinical outcomes were similar at 5 years, except chest pain, diarrhea, and bloat symptoms which were more common after repair with absorbable mesh.

CONCLUSIONS

No advantages were demonstrated for mesh repair at up to 5 years follow-up, and symptom outcomes were worse after repair with absorbable mesh. The longer-term results from this trial do not support mesh repair for large hiatus hernias.

Complications of laparoscopic antireflux surgery

Over the last decade, the laparoscopic approach to antireflux surgery has been widely applied, resulting in improved early outcomes and greater patient acceptance of surgery for gastroesophageal reflux disease. However, although short-term outcomes are probably better overall than those following open surgery, it has become apparent that the laparoscopic approach is associated with an increased risk of some complications, and as well as the occurrence of new complications specific to the laparoscopic approach. Significant complications include acute paraesophageal hiatus herniation, severe dysphagia, pneumothorax, vascular injury, and perforation of the gastrointestinal tract. The incidence of some of these complications decreases as surgeons gain experience; others can be minimized by using an appropriate operative technique. In addition, laparoscopic reintervention is usually straightforward in the 1st postoperative week. For this reason, the surgeon should have a low threshold for early laparoscopic reexploration, facilitated by early radiological contrast studies, in order to reduce the likelihood that problems will arise later.

Importance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias

HYPOTHESIS

Laparoscopic repair of large hiatal hernia is an appropriate management strategy.

DESIGN

A prospective patient series.

SETTING

A university teaching hospital.

PATIENTS

All patients with hiatal hernias 10 cm or greater in diameter repaired laparoscopically between February 1, 1992, and September 30, 1998.

INTERVENTIONS

Two operative strategies were used for laparoscopic repair: the first, which was used until early 1996, entailed initial esophageal dissection while leaving the sac in the mediastinum. The second involved preliminary dissection of the hernial sac from the mediastinum before dissecting the esophagus.

MAIN OUTCOME MEASURES

Successful completion of the procedure using a laparoscopic technique, postoperative complication rate, reoperation rate, and clinical outcome.

RESULTS

Eighty-six patients with a large hiatal hernia underwent attempted repair using laparoscopic methods. The median age was 63 years (range, 30-91 years), and 45 patients (52%) were women. There were 30 sliding, 10 rolling, and 46 mixed hiatal hernias. Operating times ranged from 48 to 240 minutes (median, 90 minutes), and 20 procedures (23%) were converted to an open operation. Conversion was significantly more common in the first half of our experience (16 [40%] of 40 patients vs 4 [9%] of 46 patients) before the operative strategy was changed. Esophageal-lengthening procedures were not carried out for any patient. At follow-up of a median of 2 years, 1 patient has moderate dysphagia, 4 patients have reflux symptoms, and 1 patient has undergone further surgery for a recurrent paraesophageal hernia. An overall satisfactory outcome was achieved in 81 patients (94%).

CONCLUSIONS

Large hiatal hernias can be treated effectively laparoscopically. Dissecting the sac fully from the mediastinum before dissecting the esophagus helps to safely mobilize the esophagus, and we think changing to this strategy is the main reason for the improved laparoscopic success rate reported in the latter half of this series.

Laparoscopic reoperation following failed antireflux surgery

BACKGROUND

The aim was to determine the feasibility of laparoscopic revision surgery following previous open and laparoscopic antireflux operations.

METHODS

The outcome was determined for 27 patients (14 men, 13 women) who had undergone attempted laparoscopic revision between 3 months and 25 years after a previous antireflux operation. Median follow-up was 12 (range 3-48) months.

RESULTS

Thirteen patients had previously had an open antireflux procedure (Nissen fundoplication, seven; transthoracic anatomical repair, five; Belsey procedure, one) and 14 a laparoscopic procedure (Nissen, 12; anterior partial fundoplication, two). The indications for revision were: recurrent reflux, 15; paraoesophageal hiatus hernia, six; troublesome dysphagia, six. Fifteen procedures comprised construction of a new Nissen fundoplication, six conversion from a Nissen to a partial wrap, three repair of a paraoesophageal hernia and three widening of the oesophageal hiatus. Revision was successfully completed laparoscopically in 12 patients following a previous laparoscopic procedure and in nine following a previous open operation. Median operating time was 105 min after previous open surgery and 80 min after laparoscopic surgery. No perioperative complications occurred in either group and a good outcome was achieved in 25 of the 27 patients.

CONCLUSION

Laparoscopic reoperative antireflux surgery is feasible. Reoperation is likely to be more difficult following failure of an open procedure than a laparoscopic one.

Laparoscopic surgery for gastro-oesophageal reflux: beyond the learning curve

From September 1991 to October 1995, 320 Nissen fundoplications were undertaken laparoscopically by 12 surgeons at a single institution. To assess the performance of the procedure in the hands of five 'experienced' surgeons, the first 20 procedures performed by each surgeon or surgical trainee were excluded, providing a group of 174 patients for review. A short loose 360 degrees fundoplication was performed in all instances, with short gastric vessel division performed in 35.0 per cent of patients and hiatal repair in 66.7 per cent. Median operating time was 80 (range 30-210) min and median postoperative stay was 3 (range 1-19) days. Sixteen procedures (9.2 per cent) could not be completed laparoscopically and required conversion to open surgery. Some 144 patients were reviewed by a scientific officer 3 months after surgery, 85 at 12 months, and 32 at 2 years, using a standard clinical questionnaire. All but one were free from reflux symptoms, although 20.1 per cent reported some dysphagia at 3 months' follow-up; this figure declined to 11 per cent at 12 months and 6 per cent (two of 34 patients) at 2 years. At each follow-up interval, 91 per cent of patients were satisfied with the outcome of the surgery. Objective testing with oesophageal motility (75 patients) and barium swallow (113) studies 3-6 months after surgery confirmed the clinical outcome. Complications occurred in nine patients (5.2 per cent); four (2.3 per cent) of these required a subsequent operation within 30 days of surgery for bleeding (one patient), paraoesophageal herniation (one) and dysphagia (two). A further procedure was necessary in six other patients (3.4 per cent) for late problems, including paraoesophageal herniation (two), hiatal stenosis (three) and gastric obstruction (one). Revision was performed laparoscopically in two patients. The clinical results of laparoscopic Nissen fundoplication by 'experienced' laparoscopic surgeons were comparable with those of open surgery.

Stenosis of the esophageal hiatus following laparoscopic fundoplication

Three patients from an overall experience of more than 250 laparoscopic Nissen fundoplications have undergone further surgery for stenosis of the esophageal hiatus. This complication may be associated with diathermy dissection of the esophagus during laparoscopic mobilization.

A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair

HYPOTHESIS

The technique used for repair of the esophageal hiatus during laparoscopic Nissen fundoplication can influence the likelihood of postoperative dysphagia.

DESIGN

A prospective double-blind randomized control trial.

SETTING

A university teaching hospital.

PARTICIPANTS

A total of 102 patients with proven gastroesophageal reflux disease, undergoing a laparoscopic Nissen fundoplication were randomized to undergo fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Patients were excluded for the following reasons: they had esophageal motility disorders, required a concurrent abdominal procedure, had undergone previous antireflux surgery, or had very large hiatus hernias.

INTERVENTIONS

Laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair.

MAIN OUTCOME MEASURES

Independent assessment of dysphagia, heartburn, patient satisfaction, and other symptoms 1, 3, and 6 months following surgery, using multiple standardized clinical grading systems. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, distal esophageal acid exposure, and endoscopic assessment of postoperative anatomy and esophageal mucosa.

RESULTS

Symptoms of postoperative dysphagia, relief of heartburn, and overall satisfaction 6 months after surgery were not influenced by the hiatal repair technique. However, to achieve a similar incidence of dysphagia, more patients who initially underwent posterior hiatal repair required a second surgical procedure (6 vs 0 patients). The hiatal repair technique did not affect the likelihood of early postoperative paraesophageal herniation.

CONCLUSION

Anterior suturing of the hiatus appears to be at least as good in the short-term as posterior suturing as a method of narrowing the hiatus during laparoscopic Nissen fundoplication.

Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations

From September 1991 to January 1995 we performed 230 Nissen fundoplications by a laparoscopic technique. Whilst a loose 360 degree fundoplication secured by 3 or 4 sutures was performed in all instances, there was variation between surgeons regarding the performance of hiatal repair and division of short gastric vessels; 207 operations were completed laparoscopically and 23 were converted to an open operation when a satisfactory wrap could not be achieved. Operating time ranged from 30 to 260 min (median 95) and the median postoperative stay was 3 days (1-19). Twenty-three patients (10%) underwent a subsequent operation (14 within 3 months of the original surgery), 2 for recurrent reflux, 10 for para-esophageal herniation, 2 for a misplaced fundoplication resulting in gastric obstruction, 7 for persistent dysphagia (4 due to stenosis of the esophageal hiatus), 1 for bleeding, and 1 for mesenteric thrombosis. (This patient died.) Five other patients were readmitted to hospital subsequent to their discharge--four because of pulmonary emboli and one because of gastric obstruction. Some 226 patients (98%) are free of reflux symptoms with follow-up ranging up to 40 months (median 16). Absence of reflux and the integrity of the fundoplication has been confirmed by postoperative esophageal manometry and pH monitoring in 90 patients, and by barium meal in 126. Postoperative recovery has been quick and wound-related morbidity minimal. Although the rate of surgical revision was significant in this series, the likelihood of complications or further surgery, as well as incidence of conversion to open surgery, decreased in the second half of the experience.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic fenestration of giant posterolateral liver cyst

A patient with a giant liver cyst in the posterolateral aspect of the right lobe successfully underwent laparoscopic fenestration. The procedure was facilitated by placing the patient in the lateral position, which provided direct access to the cyst.

Laparoscopic fundoplication in patients with an aperistaltic esophagus and gastroesophageal reflux

A minority of patients with severe gastroesophageal reflux who present to surgeons for antireflux surgery have absent esophageal peristalsis when investigated before surgery with esophageal manometry. Some of these patients also have systemic sclerodema. While conventional wisdom suggests that these patients are at risk of a poor outcome if they proceed to fundoplication, some will have severe reflux symptoms, which are poorly controlled by medical therapy, and surgery will therefore offer the only chance of 'cure'. We performed this study to determine the outcome of laparoscopic fundoplication in the subset of patients with gastroesophageal reflux and an aperistaltic esophagus. From 1991 to 2003, the operative and follow-up details for all 1443 patients who underwent a laparoscopic fundoplication in our Departments have been prospectively collected on a database. These patients were then followed yearly using a standardized symptom assessment questionnaire. A subset of patients whose preoperative esophageal manometry demonstrated complete absence of esophageal body peristalsis and absent lower esophageal sphincter tone (aperistaltic esophagus) were identified from this database, and their outcome following laparoscopic fundoplication was determined. Twenty-six patients with an aperistaltic esophagus who underwent a laparoscopic fundoplication were identified. Six of these had a systemic connective tissue disease (scleroderma), and 20 had an aperistaltic esophagus without a systemic disorder. A Nissen fundoplication was performed in four patients, and an anterior partial fundoplication in 22. Follow-up extended up to 12 years (median, 6). A good overall symptomatic outcome was achieved in 88% at 1 year, 83% at 2 years and 93% at 5-12 years follow-up. Reflux symptoms were well controlled by surgery alone in 79% at 1 year, and 79% at 5-12 years. At 2 years, 87% were eating a normal diet. Two patients underwent further surgery - one at 1 week postoperatively for a tight esophageal hiatus, and one at 1 year for recurrent reflux. Patients with troublesome reflux and an aperistaltic esophagus can be effectively treated by laparoscopic fundoplication. An acceptable outcome will be achieved in the majority of patients.

Laparoscopic resection of benign tumors of the posterior gastric wall

Laparoscopic wedge excision of benign gastric tumors using stapling instruments alone is not feasible for distal lesions and some tumors arising from the posterior gastric wall. An alternative transgastric approach to distal posterior wall lesions utilizing an anterior gastrotomy for access has been successfully applied in two reported cases.

Outcome of laparoscopic anterior 180-degree partial fundoplication for gastroesophageal reflux disease

Although Nissen fundoplication controls gastroesophageal reflux disease effectively, it is associated with an incidence of side effects. For this reason we have investigated the use of a laparoscopic 180-degree anterior fundoplication as a technique that has the potential to control reflux, but with less associated postoperative dysphagia and fewer gas-related side effects. Good short-term (6-month) outcomes have been previously reported within the content of a randomized trial. This report details the technique we used and describes the outcome of this procedure with longer follow-up in a much larger group of patients. The outcome for patients with gastroesophageal reflux disease who underwent a laparoscopic anterior 180-hemifundoplication was determined. Clinical follow-up was carried out prospectively by an independent scientist who applied a standardized questionnaire yearly following surgery. This questionnaire evaluated symptoms of reflux, postoperative problems including dysphagia, gas bloat, ability to belch, and overall satisfaction with clinical outcome. From July 1995 to May 1999, a total ofc107 patients underwent a laparoscopic anterior hemifundoplication. Four patients underwent further surgery for recurrent heartburn, and persistent troublesome dysphagia occurred in one. At 1 year 89% of patients remained free of reflux symptoms, and at 3 years 84% remained symptom free. Of those with symptoms of reflux, approximately half of them had only mild symptoms. The overall incidence and severity of dysphagia for liquids and solids was not altered by partial fundoplication. Epigastric bloating that could not be relieved by belching was uncommon, and only 11% of the patients at 1 year and 10% at 3 years following surgery were unable to belch normally. Overall satisfaction with the outcome of surgery remained high at 3 years' follow-up. Laparoscopic anterior partial fundoplication is an effective operation for gastroesophageal reflux, with a low incidence of side effects and a good overall outcome.

Efficacy of anterior, posterior and total fundoplication in an experimental model

BACKGROUND

This study examined the effect of different types of laparoscopic fundoplication on an incompetent lower oesophageal sphincter to test their effectiveness at preventing gastro-oesophageal reflux in the early postoperative period.

METHODS

An experimental porcine model was used. Initial oesophageal myotomy ensured an incompetent lower oesophageal sphincter with free reflux of 'intragastric fluid'. Anterior, posterior or total fundoplication was then performed laparoscopically in 15 laboratory pigs (five in each group). Fundoplication competence and efficacy were determined 2 weeks after laparoscopic antireflux surgery by inflating the stomach with liquid through a gastrostomy cannula. Some animals were also studied at 4 and 6 weeks. Lower oesophageal sphincter pressure was determined using a water-perfused oesophageal manometry catheter incorporating a Dent sleeve.

RESULTS

All three types of fundoplication produced similar increases in postoperative resting lower oesophageal sphincter pressure and restored adequate competence to the gastro-oesophageal junction.

CONCLUSION

All three variants of laparoscopic fundoplication restore gastro-oesophageal competence in the early postoperative period.