Endoscopic and laparoscopic treatment of gastroesophageal reflux

Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.

Disposable and reusable trocars

A wide variety of disposable and reusable trocars have been designed and marketed for use in laparoscopic surgery. The performance of these instruments varies considerably. Disposable trocars usually contain valve designs which allow the easy passage of instrumentation and safety mechanisms which reduce the likelihood of visceral injury from the trocar point. Whilst most reusable trocars have not provided safety mechanisms, and have been less user-friendly, newer designs are beginning to bridge the gap. The choice of a trocar for laparoscopic surgery will depend on each surgeon's perception of the advantages and disadvantages of competing instrumentation, which may need to be balanced against the budgetary requirements of their practice location.

Preoperative endoscopic grading of esophagitis versus outcome after laparoscopic Nissen fundoplication

OBJECTIVES

Preoperative grading of esophagitis has recently been advocated as a means of selecting patients suitable either for laparoscopic Nissen fundoplication for patients with uncomplicated esophagitis, or for open operations in patients with complicated esophagitis (stricture or Barrett's esophagus). This study was performed to determine whether the degree of esophagitis preoperatively influences the clinical outcome after laparoscopic Nissen fundoplication.

METHODS

Two hundred thirty-one patients who underwent a laparoscopic Nissen fundoplication were classified into three groups according esophagitis grade. Of these patients, 59 had no evidence of endoscopic esophagitis (group 1), 148 had uncomplicated esophagitis (group 2), and 24 had Barrett's esophagus or an esophageal stricture (group 3). Postoperative clinical assessment of heartburn, dysphagia, and patient satisfaction using visual analogue scales was performed by an independent investigator.

RESULTS

No significant differences were found between the groups in regard to their clinical outcome.

CONCLUSIONS

We conclude that laparoscopic Nissen fundoplication is a suitable approach for all patients with objectively proven gastroesophageal reflux disease selected for surgery, irrespective of their preoperative esophagitis grade.

Laparoscopic fundoplication for gastro-oesophageal reflux

The initial teaching and learning experience of four surgeons performing a laparoscopic Nissen fundoplication is reported. A total of 33 patients underwent the laparoscopic approach for Nissen fundoplication. Two patients also underwent concomitant cholecystectomy. A loose 360 degrees fundoplication secured by three or four sutures was performed, with 29 patients also undergoing posterior crural repair. Three operations were converted to open procedures. Two patients required subsequent surgery, one when the fundoplication and proximal stomach slipped into the chest and one for oesophageal obstruction. No other complications occurred. All patients are well and free of reflux symptoms at follow-up ranging up to 10 months (median 5 months). Operating time ranged from 47 min to 154 min (median 81 min) for fundoplication alone. The laparoscopic fundoplications with cholecystectomy required 145 and 170 min. Postoperative stay ranged from 3 to 12 days (median 3 days). Laparoscopic Nissen fundoplication is feasible in the management of gastro-oesophageal reflux disease. These early results demonstrate that this new technique may reduce some of the morbidity associated with open antireflux surgery. A prospective randomised study has been started to assess efficacy and benefits more thoroughly.

Illness behavior influences the outcome of laparoscopic antireflux surgery

BACKGROUND

While gastroesophageal reflux is amenable to medical and surgical treatment, the severity of pathophysiologic changes of the disease correlates poorly with the symptomatology. Similarly, the overall successful outcome of surgical therapy can be lessened by the poor outcome in a small number of patients despite the technical success of the operation. We conducted a study to determine the influence of illness behavior on the outcome and efficacy of laparoscopic Nissen fundoplication.

STUDY DESIGN

From a larger group of patients undergoing a laparoscopic Nissen fundoplication, 77 patients (57 male, 20 female) completed an illness behavior questionnaire before and after surgery. This previously validated questionnaire assessed 10 scales of illness behavior. The results were compared with visual analog scales of outcome for overall satisfaction, heartburn, and solid food dysphagia, which were elicited independently from a standardized clinical follow-up questionnaire.

RESULTS

Patients completed the questionnaire on average 2 months before and 25 months after surgery. High preoperative and postoperative scores for the "affective" and "hypochondriacal" scales were associated with poorer satisfaction with the surgical outcome. Although successful relief of reflux symptoms was unrelated to any preoperative illness behavior scale, postoperative scores for "disease conviction" and "disease affirmation" were predictors of further symptomatic heartburn in a small group of patients. Dysphagia did not correlate with illness behavior. When preoperative and postoperative scores were compared, no change in illness behavior was demonstrated, with the exception of lower scores for disease conviction and disease affirmation.

CONCLUSIONS

These results suggest that while patient perception of disease is improved by laparoscopic fundoplication, patient satisfaction with the surgical outcome is in part determined by preoperative illness behavior.

Surgical bypass for palliation of malignant oesophageal obstruction

It is possible to achieve satisfactory palliation for most patients with malignant oesophageal obstruction by endoscopic means, surgical resection or radiotherapy. Despite these options, a small group of patients remains for whom another alternative should be considered. Fifteen patients presenting with extensive tumour, a non-dilatable stricture, or a tracheo-oesophageal fistula, not suitable for any of the standard methods of palliation, underwent palliative surgical bypass using stomach or colon. The hospital mortality was 33% and the median survival 6 months. Anastomotic leakage occurred in six patients and the median postoperative stay was 28 days (range 20-42 days). All patients who survived surgery, except one, achieved satisfactory palliation. The nature of these patients is such that whatever is done, mortality will almost inevitably be high. The authors believe that all patients in this series were better off than they would have been if left untreated, and oesophageal bypass should be considered for patients with distressing dysphagia due to disease not amenable to standard palliative methods.