Laparoscopic surgery for gastroesophageal reflux disease patients with impaired esophageal peristalsis: total or partial fundoplication?

Fundoplication for gastroesophageal reflux and factors associated with the outcome 6 to 10 years after the operation: multivariate analysis of prognostic factors using the propensity score

BACKGROUND

The impact from the mode of operation (partial vs total fundoplication) on long-term outcome after fundoplication still is unknown, although short-term randomized studies have not shown significant differences in the efficacy of reflux control. To obtain some insight concerning the long-term results, the data of a nonrandomized cohort were analyzed using propensity score statistics.

METHODS

For 134 patients who underwent laparoscopic fundoplication for gastroesophageal reflux disease (GERD), the time until recurrence of reflux symptoms was assessed. The impact of putative prognostic factors and the mode of operation (partial vs total fundoplication) on outcome were tested for significance using univariate and multivariate statistics, including the propensity score, correcting for nonrandomized treatment groups. The follow-up period was 60 to 123 months (median, 93 months). In this study, 45 patients had a partial (Toupet) fundoplication, and 89 patients underwent a total (Nissen) fundoplication.

RESULTS

The rate of recurrence after 93 months (the median follow-up interval) was 14% after Nissen and 9% after Toupet fundoplication (nonsignificant difference) as estimated according to Kaplan and Meier. Massive acid exposure to the esophagus was associated with an increased risk of recurrence for 23% of the patients with a DeMeester score of 50 or higher, but only for 9% of the patients with less severe reflux (DeMeester score <50; p < 0.05). Multiple proportional hazard regression using the propensity score did not show additional significance for the variables of age, gender, presence of a Barrett esophagus, and mode of operation.

CONCLUSION

The operation method did not have a significant impact on the efficacy of laparoscopic fundoplication in a cohort during a follow-up period of 60 to 123 months (median, 93 months).

Influence of wrap length on the effectiveness of Nissen and Toupet fundoplication: a prospective randomized study

BACKGROUND

Incontinence or hypercontinence of the fundic wrap depends primarily on the length of the valve or the type of procedure. Much less attention has been paid to the fundic wrap length. This study aimed to compare the effectiveness of two different wrap lengths among the patients undergoing partial or total fundoplication.

METHODS

For this study, 153 patients were randomized to either Nissen (1.5- or 3-cm wrap) or Toupet (1.5- or 3-cm wrap) laparoscopic fundoplication. The groups were compared according to intensity of dysphagia, esophageal manometry data, ambulatory 24-h pH monitoring data, postoperative esophagitis rate, and overall treatment failure rate.

RESULTS

In all the groups, the tone of the lower esophageal sphincter was significantly increased and the DeMeester score significantly decreased, reaching normal levels. At 6 months after surgery, the Toupet 1.5-cm group had significantly more cases of esophagitis than the 3-cm wrap group (24.2% vs 3.3%; p<0.05). At 12 months after surgery, only one patient in the Nissen 3-cm group had moderate to severe dysphagia. In all cases, failures were associated with persistent erosive esophagitis. At the 12-month follow-up assessment, treatment failures were significantly more common in Toupet 1.5-cm group than in the Toupet 3-cm group (17.5% vs 2.7%; p<0.05). However, such differences were not observed in the Nissen groups (7.8% for 1.5 cm and 15.6% for 3 cm; p>0.05).

CONCLUSIONS

Evaluation of the treatment results suggests that the wrap length is important in partial Toupet fundoplication to avoid treatment failures. The 3-cm wrap is superior to the 1.5-cm wrap in cases of partial posterior Toupet fundoplication. The influence of wrap length on treatment failure remains unconfirmed for the Nissen procedure.

Levels of evidence available for techniques in antireflux surgery

The objective of this study was to determine the levels of evidence and grades of recommendations available for techniques in antireflux surgery. Areas of technical controversy in antireflux surgery were identified and developed into eight answerable questions. The external evidence was surveyed using the databases Medline and EMBASE. Abstracts and appropriate articles were identified from January 1966 to December 2005. A set of search strategies was systematically employed to determine the levels of evidence available for each clinical question. Primary outcome measures included the determination of levels of evidence and grade of recommendation based on The Oxford Center for Evidence-Based Medicine. Secondary outcome measures included for randomized controlled trials were Jadad scores, noting the presence of a sample size calculation, and the determination of an effect estimate and the reporting of a confidence interval. Higher quality randomized controlled trials (mostly level 2b, occasional level 1b) existed to answer three questions: whether to complete a 360 degrees or partial wrap; whether or not to divide the short gastric vessels; and whether to perform laparoscopic or open surgery. Lower quality randomized controlled trials were available to determine whether the use of mesh was helpful, whether or not to use a bougie catheter for calibration of the wrap, and whether an anterior or posterior wrap results in a superior outcome. This was deemed to be of inferior grade of recommendation due to the lack (< 2) of trials available and the sole presence of level 2b evidence. The final two questions: whether to complete fundoplication using a thoracic or abdominal approach and whether to use intraoperative manometry relied exclusively upon level 4 evidence and thus received a lower grade of recommendation. A higher Jadad score seemed to be associated with studies having a higher level of evidence available to answer the question. Sample size calculations were given to answer three questions. Effect estimate was difficult to interpret given inconsistent findings, composite outcomes and lack of reported confidence intervals. In conclusion, antireflux surgery has many randomized controlled trials available upon which to base clinical practice. Unfortunately, these are generally of poor quality. We recommend that esophageal surgeons determine consistent outcome measures and endeavor to improve the quality of randomized controlled trials they perform.

Optimization of outcome after laparoscopic antireflux surgery

Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery.

Long-term control of gastroesophageal reflux disease symptoms after laparoscopic Nissen-Rosetti fundoplication

Laparoscopic fundoplication is the gold standard surgical treatment for gastroesophageal reflux disease, although some patients develop recurrence or collateral symptoms related to surgery. The aims of this study were to describe the long-term symptoms control in patients undergoing laparoscopic fundoplication, to analyze the patterns of failure and to correlate postoperative symptoms with anatomic and physiologic findings. Extensive preoperative and postoperative work-up including symptom questionnaire, barium meal, endoscopy, manometry, and 24-hour pH-metry were performed in 130 consecutive patients undergoing laparoscopic fundoplication. Mean follow-up was 52 months. After laparoscopic fundoplication, 117 patients (90%) were asymptomatic with Visick grade I and II symptoms reported by 124 patients (95%). On evaluation, 119 (92%) patients were satisfied and willing to repeat surgery. Two failure patterns, anatomic abnormalities (wrap migration into the chest or down onto the stomach with or without repair disruption) and functional (incompetence of antireflux mechanism), were reported in 17 patients. Reflux can be controlled in up to 90% of patients with gastroesophageal reflux disease with relatively few complications and a high degree of patient satisfaction. The most common cause of recurrent symptoms is an anatomic failure of the fundoplication.

The impact of reflux composition on mucosal injury and esophageal function

The components of refluxed gastric juice are known to cause mucosal injury, but their effect on esophageal function is less appreciated. Our aim was to determine the effect of acid and/or bile on mucosal injury and esophageal function. From 1993-2004, 402 patients with reflux symptoms had 24-hour pH and Bilitec monitoring, manometry, and endoscopy with biopsies. Mucosal injury (esophagitis or Barrett's esophagus) and esophageal function (lower esophageal sphincter [LES] characteristics and body contractility) in patients with acid reflux, bile reflux, or both were compared with patients without reflux. Reflux was present in 273/402 patients; of these, 37 (13.5%) had increased exposure to bile, 82 (30.0%) had increased exposure to acid, and 154 (56.4%) had increased exposure to both. Mucosal injury was most common with increased mixed acid and bile exposure, followed by acid alone, and was uncommon with bile alone (P < 0.0001). Functional deterioration paralleled mucosal injury (P < 0.0001). Mixed acid and bile exposure was present in more than half of patients with reflux and was associated with the most severe mucosal injury and the greatest deterioration of esophageal function. This suggests that composition of gastric juice is the primary determinant of inflammatory mucosal injury and subsequent loss of esophageal function.

Effects of partial (Belsey Mark IV) and complete (Nissen) fundoplication on proximal gastric function and esophagogastric junction dynamics

OBJECTIVES

This study aimed to assess the effects of Belsey Mark IV 270 degrees (partial) and Nissen 360 degrees (complete) fundoplication on proximal stomach function, transient lower esophageal sphincter relaxation (TLESR) elicitation and the esophagogastric junction (EGJ) pressure profile during TLESR to further elucidate the mechanism of action of fundoplication.

METHODS

Ten patients after partial and 10 patients after complete fundoplication were studied. High-resolution EGJ manometry and pH recording were performed for 1 h at baseline and 2 h following meal ingestion (500 mL/300 kcal). Three dimensional (3D) ultrasonographic images of the stomach were acquired every 15 min after meal ingestion. From the 3D ultrasonographic images, proximal gastric volumes were computed.

RESULTS

Postprandial proximal to complete gastric volume distribution ratios were larger among patients after partial (0.42 +/- 0.028) compared with patients after complete fundoplication (0.37 +/- 0.035; p < 0.05). Partial fundoplication patients had a markedly greater postprandial rate of TLESR (1.7 +/- 0.3/h) than patients after complete fundoplication (0.8 +/- 0.2/h; p < 0.05). The axial EGJ pressure profile was minimally affected by partial fundoplication but instead markedly changed after complete fundoplication.

CONCLUSIONS

Patients after partial fundoplication exhibit a larger meal-induced increase in proximal stomach volume, a higher TLESR rate, and a minimally affected axial EGJ pressure profile compared to patients after complete fundoplication.

Effects of laparoscopic Nissen fundoplication on esophageal motility

BACKGROUND

This study aimed to evaluate the long-term impact of laparoscopic Nissen fundoplication on esophageal motility in patients with preoperative esophageal dysmotility.

METHODS

This study prospectively followed 580 patients who underwent laparoscopic Nissen fundoplication between 1992 and 1999. Esophageal manometry, 24-h pH monitoring, and symptom score assessment were performed before surgery, then 6 months, 2 years, and 5 years after surgery. Preoperatively, 533 of the patients (93.5%) had normal esophageal contractile pressure (group 1), whereas 38 of the patients (6.5%) had reduced contractile pressure (<30 mmHg) (group 2).

RESULTS

Esophageal contractile pressures increased significantly in the patients with low preoperative values, whereas it remained unchanged in the patients with normal preoperative contractile pressures. Both groups reported a significant reduction in the dysphagia symptom score after surgery.

CONCLUSION

Nissen fundoplication produces a significant long-lasting increase in esophageal contractile pressures in patients with preoperative esophageal dysmotility (i.e., contractile pressure lower than 30 mmHg). Preoperative esophageal dysmotility is therefore not a contraindication to laparoscopic Nissen fundoplication.

Five-year results of laparoscopic Toupet fundoplication as the primary surgical repair in GERD patients: is it durable?

INTRODUCTION

Most surgeons operate on gastroesophageal reflux disease (GERD) patients using the concept of "tailored approach," which depends on esophageal motility. We have abandoned this concept and performed laparoscopic Toupet fundoplication in all patients suffering from GERD, independent of their esophageal motility.

METHODS

In a prospective trial we have assessed and evaluated our 5-year results of the first 100 consecutive patients treated with laparoscopic Toupet fundoplication. All patients were evaluated preoperatively by endoscopy and 24-h pH manometry. The patients were followed up clinically 1, 2, 6, 12 and 60 months postoperatively. The course of clinical DeMeester score, appearance and treatment of wrap-related side-effects as well as long-term outcome and patient satisfaction were evaluated.

RESULTS

The 5-year follow-up rate was 87%. Laparoscopic Toupet fundoplication achieved a 5-year healing rate of GERD in 85%. Of all operated patients, 3.5% had to be reinstalled on a regular PPI treatment because of postoperative GERD reappearance. The median clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to 0.47 +/- 0.9 points 5 years postoperatively (p < 0.0005). Because of persistent postoperative dysphagia, 5% of the patients required endoscopic dilatation therapy. Persistent postoperative gas-bloat syndrome occurred in 1.1%. Wrap dislocation was identified in 3.4% of patients. Reoperation rate was 5%. Total morbidity rate was 19.5% and operative related mortality rate was 0%. Overall, 96.6% of patients were pleased with their outcome at late follow-up, and 95.4% of patients stated they would consider undergoing laparoscopic fundoplication again if necessary.

CONCLUSION

Our long-term results showing a low recurrence and morbidity rate of laparoscopic Toupet fundoplication encourage us to continue to perform this procedure as the primary surgical repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet fundoplication has proven to be a safe and successful therapeutic option in GERD patients.

Primary esophageal motility disorders: Concise review for clinicians

Primary esophageal motility disorders comprise various abnormal manometric patterns which usually present with dysphagia or chest pain. Some, such as achalasia, are diseases with a well defined pathology, characteristic manometric features, and good response to treatments directed towards the palliation of symptoms. Other disorders, such as diffuse esophageal spasm and nutcracker esophagus, have no well defined pathology and could represent a range of motility abnormalities associated with subtle neuropathic changes, gastresophageal reflux and anxiety states. On the other hand, hypocontracting esophagus is generally caused by weak musculature commonly associated with gastresophageal reflux disease. Although manometric patterns have been defined for these disorders, the relation with symptoms is poorly defined and in some cases the response to medical or surgical therapy unpredictable. The aim of this paper is to present a wide spectrum of the primary esophageal motility disorders, as well as to give a concise review for the clinicians encountering these specific diseases. .

[Laparoscopic fundoplication: current data]

Laparoscopic fundoplication is as effective as its open counterpart, allowing reduced morbidity, shorter hospital stay and recovery, lower consumption of analgesics, and very low mortality, with no significant differences in early functional outcome. Rate of early recurrence is similar after partial and total fundoplication, but but the partial approach has a significantly reduced rate of reoperation for failure, mainly due to postoperative dysphagia. Long-term follow-up is required to evaluate dysphagia and quality-of-life.

Illness behavior and laparoscopic antireflux surgery: tailoring the wrap to suit the patient

Psychological factors are believed to play a role in gastroesophageal reflux disease. It has previously been shown that preoperative illness behavior influences the outcome after laparoscopic Nissen fundoplication. Between August 2001 and June 2004 we considered a partly subjective assessment of illness behavior when selecting patients with gastroesophageal reflux disease for laparoscopic anterior partial (n = 77) or total fundoplication (n = 90). A prospective questionnaire study of illness behavior was also undertaken and the results were correlated with clinical follow up after 12 months. There was a statistically significant difference in age (P < 0.001), primary esophageal peristalsis on manometry (P = 0.037) and two illness behavior category scores related to hypochondriasis (P = 0.041 and P = 0.025) between laparoscopic anterior partial fundoplication and Nissen total fundoplication groups. Despite these differences, there was no significant correlation between preoperative illness behavior score and patient satisfaction in either group. There was a statistically significant negative correlation between the ability to express personal feelings and postoperative heartburn score in those who had a laparoscopic anterior partial fundoplication (P = 0.048). The clinical outcome in both groups was good to excellent in terms of postoperative heartburn and satisfaction scores. A tailored approach in the choice of wrap, taking into account psychological factors preoperatively, is an appropriate strategy for laparoscopic fundoplication.

Esophagography predicts favorable outcomes after laparoscopic Nissen fundoplication for patients with esophageal dysmotility

BACKGROUND

We undertook this study to determine if clearance of a food bolus at preoperative esophagography predicts acceptable outcomes after laparoscopic Nissen fundoplication for patients with manometrically abnormal esophageal motility.

STUDY DESIGN

Patients with gastroesophageal reflux disease (GERD) or symptomatic hiatal hernia with evidence of esophageal dysmotility by stationary manometry underwent videoesophagography to document the ability of their esophagus to clear food boluses of varying consistencies. Sixty-six patients were identified who had manometric dysmotility yet were able to clear a food bolus at esophagography, and subsequently underwent laparoscopic Nissen fundoplication. These patients were compared with 100 randomly selected patients with normal motility who underwent laparoscopic Nissen fundoplication. Symptom reduction and satisfaction were assessed through followup. Patients with normal motility were compared with those with manometrically moderate and severe dysmotility.

RESULTS

Preoperative patient demographic data, symptoms, and symptom scores were similar among patients with normal motility and moderate or severe dysmotility. After fundoplication, symptom reduction was notable for all patients regardless of preoperative motility (p < 0.01, paired Student's t-test). There was no notable difference in postoperative symptom scores (p = NS, Kruskal-Wallis ANOVA) or in patient satisfaction (p = NS, chi-square analysis) among patients stratified by esophageal motility.

CONCLUSIONS

Patients with esophageal dysmotility documented by manometry who are able to clear a food bolus at contrast esophagography, have functional results after laparoscopic Nissen fundoplication similar to patients with normal motility. Preoperative esophagography predicts successful outcomes after laparoscopic Nissen fundoplication for patients with manometric esophageal dysmotility.

Changes in functional gastrointestinal symptoms as a result of antireflux surgery

BACKGROUND

This study identifies how functional symptoms are altered after antireflux surgery and whether there are any predictors of such change.

METHODS

A total of 206 patients underwent successful laparoscopic Nissen fundoplication. A questionnaire was sent at a median of 4.3 years (range = 0.3-8.4) after fundoplication. Patients were asked to provide scores for reflux and functional symptoms that were experienced prior to surgery and at the time of the questionnaire.

RESULTS

Eighty-one percent of patients responded. Scores for heartburn, regurgitation, and difficulty swallowing were felt to have significantly improved (p < 0.01). Flatulence was the only functional symptom to have significantly worsened (p < 0.01). A regression analysis incorporating prospectively collected data identified variables that were predictive of changes in functional symptoms following surgery.

CONCLUSIONS

Flatulence was the only functional symptom to have worsened overall after surgery. Predictors of changes in functional symptoms may help clinicians when informing patients about gastrointestinal side effects following antireflux surgery.

Technical Controversies in Fundoplication Surgery

Gastroesophageal reflux disease (GERD) is a common health problem affecting more than 50% of the population. For those who experience more than occasional symptoms, GERD has a profound effect on their quality of life. With the advent of laparoscopic surgery, fundoplication has been used to treat GERD. Fundoplication also is used in the surgical management of paraesophageal hernias. Technical controversies are addressed in this article, including open versus laparoscopic approaches, the choice of complete (360 degres) or partial fundoplication, whether or not a gastroplasty is required, and the use of prosthetic materials in crural repair.

Gastrointestinal complications of fundoplication

In children with medically refractory gastroesophageal reflux disease (GERD), fundoplication is effective and safe. However, in a subset of patients, gastrointestinal dysfunction occurs postoperatively. Symptoms include chest pain, persistent dysphagia in 5%, gas bloat in 2% to 4%, diarrhea in up to 20%, and dumping syndrome in up to 30%. Symptoms are often nonspecific, arising from recurrent or persistent GERD, anatomic complications such as disrupted or herniated wrap, functional disturbances such as rapid gastric emptying or altered gastric accommodation, or alternative diagnoses such as cyclic vomiting syndrome or food allergy. Detailed investigation, including various combinations of pHmetry, videofluoroscopy, endoscopy, motility studies, and dumping provocation testing, may be required to clarify pathophysiology and guide management.

Management of Paraesophageal Hernias

A tailored approach to the management of patients who have para-esophageal herniation appears to be the best policy. No one approach can universally apply to this patient population if optimal therapy, quality of life, and overall survival are to be optimized.

Partial Versus Complete Fundoplication: Is There a Correct Answer?

Gastroesophageal reflux disease is a common disorder, and patients diagnosed with GERD face a lifelong treatment requirement. A surgical antireflux procedure may be offered as an alternative to lifelong treatment with proton-pump inhibitors. Many investigations have been performed to help discover the best surgical alternative to medical management. An ideal antireflux procedure should be safe, effective, durable, and result in minimal complications. Total fundoplication in the form of Nissen fundoplication is the most widely used antireflux operation worldwide. Although its efficacy is well documented, the clinical success rate in terms of reflux control is occasionally compromised by troublesome mechanical side effects. Because of these unsatisfactory symptoms and continued hindered quality of life, the Nissen fundoplication has undergone many modifications. The current standard appears to be the 2 cm floppy Nissen; however, the alternative approach has been the use of a partial fundoplication, most frequently the Toupet procedure. Both the Nissen and Toupet fundoplications have proven to provide relief in the majority of patients, but each has its own drawback. Patients undergoing Nissen fundoplication have a higher incidence of dysphagia early after operation, although this appears to resolve in most. The Toupet, on the other hand, may not be as durable, and may lead to the early re-emergence of symptoms. The problem of post-Nissen dysphagia led many surgeons to believe that the Nissen night be contraindicated in patients who have dysmotility,because it would cause even greater dysphagia; however, recent articles have not demonstrated this to be the case. It seems that the floppy Nissen performed over a large bougie (56-60 Fr) with division of short gastrics and crural closure is an acceptable operation for reflux in both those who have normal motility and those who have mild to moderate dysmotility. Thus, for most patients who have GERD and normal motility, either procedure appears effective in the majority of patients; however, those patients who have severe dysmotilty disorders and who require an antireflux procedure(ie, scleroderma, postmyotomy achalasia) are likely best served with a partial fundoplication.

Nissen or partial posterior fundoplication: which antireflux procedure has a lower rate of side effects?

INTRODUCTION

In patients with gastroesophageal reflux disease (GERD) it is still controversial as to which type of antireflux procedure-the Nissen or the partial posterior fundoplication-offers the lower rate of side effects in the long term.

PATIENTS AND METHODS

In this follow-up study the Nissen fundoplication was performed only in GERD patients with normal oesophageal peristalsis. The partial posterior fundoplication was preserved for patients with weak peristalsis. Only patients with effective postoperative control of GERD were included in the study. The study groups consisted of 77 patients who underwent the Nissen fundoplication and 132 patients who underwent partial posterior fundoplication. Clinical assessment of side effects was performed after a median of 52 months following surgery. Manometric assessment of the lower esophageal sphincter (LES) and of esophageal peristalsis was achieved 6 months after surgery.

RESULTS

Side effects such as dysphagia, bloating, inability to belch and vomit, epigastric pain and early satiety were significantly more common after the Nissen fundoplication than after partial posterior fundoplication. Improvement of the antireflux barrier was equal in both groups; however, LES relaxation was incomplete following the Nissen fundoplication but normal after partial posterior fundoplication. Partial posterior fundoplication resulted in improved oesophageal peristalsis, whereas the Nissen fundoplication caused slight impairment of peristalsis.

CONCLUSIONS

Partial posterior fundoplication is a more physiological antireflux procedure than the Nissen fundoplication, and, therefore, this operation has now become our preferred technique for all GERD patients.