Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision

Laparoscopic Collis Gastroplasty and Nissen Fundoplication for Reflux Esophagitis With Shortened Esophagus in Japanese Patients

BACKGROUND

There is an extremely small number of surgical cases of laparoscopic Collis gastroplasty and Nissen fundoplication (LCN procedure) in Japan, and it is a fact that the surgical results are not thoroughly examined.

PURPOSE

To investigate the results of LCN procedure for shortened esophagus.

PATIENTS AND METHODS

The subjects consisted of 11 patients who underwent LCN procedure for shortened esophagus and followed for at least 2 years after surgery. The group of subjects consisted of 3 men and 8 women with an average age of 65.0+/-11.6 years, and an average follow-up period of 40.7+/-14.4 months. Esophagography, pH monitoring, and endoscopy were performed to assess preoperative conditions. Symptoms were clarified into 5 grades between 0 and 4 points, whereas patient satisfaction was assessed in 4 grades. The use of postoperative acid-reducing medication and the recurrence of esophagitis were also investigated.

RESULTS

None of the patients experienced intraoperative complications, received transfusions, required conversion to open surgery, or died postoperatively. The average preoperative heartburn, regurgitation, and dysphagia scores were 2.36+/-1.29, 2.27+/-1.19, and 1.82+/-1.78 points, respectively. These scores improved after surgery to 0.55+/-1.21 (P=0.0063), 0.55+/-1.21 (P=0.0094), and 1.0+/-1.18 (P=0.1236) points, respectively. All patients had esophagitis preoperatively, which recurred in 3 patients (27%). In these 3 patients, acid-secreting mucosa was confirmed on the oral side of the wrap, by positive Congo-red staining. Hiatal hernia recurred in one patient, who also experienced recurrent esophagitis. Five patients received acid-reducing medication postoperatively. The degree of satisfaction was excellent in 2, good in 6 patients, fair in 2, and poor in 1 patient(s).

CONCLUSIONS

Although the LCN procedure can be performed safely, the outcome was not necessarily satisfactory. The LCN procedure requires avoidance of residual acid-secreting mucosa on the oral side of the wrapped neoesophagus. If acid-secreting mucosa remains, continuous acid suppression therapy should be employed postoperatively.

Open vs laparoscopic partial posterior fundoplication. A prospective randomized trial

OBJECTIVE

This study compares outcomes following open and laparoscopic partial posterior fundoplication for gastroesophageal reflux disease concerning perioperative course, postoperative complications, symptomatic relief, recurrent disease, and the need for reinterventional surgery.

METHODS

A prospective randomized trial was performed. Pre- and postoperative testing included endoscopy, esophageal function testing, patient questionnaire, and clinical assessment. Patients were followed for three years.

MATERIALS

Ninety-three patients were randomized to open and 99 to laparoscopic surgery.

RESULTS

Complication rates were higher, and length of stay (LOS) [5 (3-36) vs 3 (1-12) days] and time off work [42 (12-76) vs 28 (0-108) days] was longer in the open group (p < 0.01). Early side effects and recurrences were more common (p < 0.05) in the laparoscopic group. One patient in the open group and 8 patients in the laparoscopic group required surgery for recurrent disease and 7 patients required surgery for incisional hernias after open surgery. Overall, at one and three years, there were no differences in patient-assessed satisfactory outcome (93.5/93.5 vs 88.8/90.8%) or reflux control (p = 0.53) between the open and laparoscopic groups.

CONCLUSIONS

The finding of fewer general complications, shorter length of stay and recovery, similar need for reoperations, and comparable 3-year outcomes, makes the laparoscopic approach the primary choice when considering surgical options for the treatment of gastroesophageal reflux disease (GERD).

Anatomic findings and outcomes after antireflux procedures in morbidly obese patients undergoing laparoscopic conversion to Roux-en-Y gastric bypass

BACKGROUND

To report the anatomic findings and outcomes in patients undergoing laparoscopic takedown of Nissen fundoplication with conversion to Roux-en-Y gastric bypass.

METHODS

We reviewed the records of patients who underwent laparoscopic Nissen takedown with conversion to Roux-en-Y gastric bypass from January 2001 to April 2006 at the University of Minnesota Medical Center.

RESULTS

Eleven patients were identified. Nine patients had gastroesophageal reflux disease preoperatively, of whom six underwent 24-hour pH monitoring. In 2 patients, the pH study findings were negative. Eight prior procedures had been performed laparoscopically. Eight patients were women. The mean age was 44 years. The average body mass index preoperatively was 44 kg/m(2) (range 35-61). The mean follow-up was 13.8 months (range 4-39). The body mass index at follow-up was 30.2 kg/m(2). The operative time was 349 minutes (range 222-624). The hospital length of stay was 3.4 days (range 2-6). No conversions to open surgery were required. No major short-term complications developed. Minor complications included wound or drain site infection in 3 patients, with abscess in 2, pressure sore of the lateral aspect of the foot in 1, pneumonia in 2, and marginal ulcer in 2 patients. No strictures were observed. One internal hernia occurred. Of the 9 patients with gastroesophageal reflux disease preoperatively, all had 100% improvement in symptoms, with complete resolution in 7 (78%). Wrap disruption was present in 5 (45%) of 11 patients. Herniation of an intact wrap had occurred in 1 patient. One patient had both herniation and wrap disruption.

CONCLUSION

Laparoscopic conversion of Nissen fundoplication to Roux-en-Y gastric bypass is a feasible salvage operation for recurrent gastroesophageal reflux disease in the morbidly obese. The incidence of wrap disruption appears to be relatively high and the incidence of intact wrap herniation low in obese patients after failed Nissen fundoplication, suggesting that the mechanism of failure after primary antireflux surgery in obese patients may be different than that in normal-weight patients.

Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area

BACKGROUND

The closure of the hiatal crura has proven to be a fundamental issue in laparoscopic antireflux surgery. In particular, the use of prosthetic meshes for crural closure results in a significantly lower rate of postoperative hiatal hernia recurrence with or without intrathoracic migration of the fundic wrap. The aim of the present study was to evaluate different methods of crural closure depending on the size of the hiatal defect by measuring the hiatal surface area.

METHODS

Fifty-five consecutive patients (mean age = 53 years) with symptomatic gastroesophageal reflux disease (GERD) were scheduled for laparoscopic antireflux surgery (LARS) in our surgical unit. Intraoperatively, the length, breadth, and diameter of the hiatal defect was measured using an endoscopic ruler. In every patient, the hiatal surface area (HSA) was calculated using an arithmetic formula. Depending on the calculated HSA, hiatal closure was performed by (1) simple sutures, (2) simple sutures with a 1 x 3-cm polypropylene mesh, (3) simple sutures with dual Parietex dual mesh, or (4) "tension-free" polytetrafluoroethylene BARD Crurasoft mesh.

RESULTS

Twenty-six patients (47.2%) underwent laparoscopic 360 degree "floppy" Nissen fundoplication. The remaining 29 patients (52.8%) with esophageal body motility disorder underwent laparoscopic 270 degree Toupet fundoplication. Mean calculated HSA in all patients was 5.092 cm2. Thirty-two patients (58.2%) with a smaller hiatal defect (mean HSA = 3.859 cm2) underwent hiatal closure with simple sutures (mean number of sutures: = 2.0). In 12 patients (21.8%) with a mean HSA of 7.148 cm2, hiatal closure was performed with a 1 x 3-cm polypropylene mesh in addition to simple sutures. Five patients with a mean HSA of 6.703 cm2 underwent hiatal closure with Parietex mesh, and in the remaining six patients, who had a mean HSA of 8.483 cm2, the hiatus was closed using BARD Crurasoft mesh. For a mean followup period of 6.3 months, only one patient (1.8%) developed a postoperative partial intrathoracic wrap migration.

CONCLUSION

Measurement of HSA with subsequent tailoring of the hiatal closure to the hiatal defect is an effective procedure to prevent hiatal hernia recurrence and/or intrathoracic wrap migration in laparoscopic antireflux surgery.

Long-term evaluation of patient satisfaction and reflux symptoms after laparoscopic fundoplication with Collis gastroplasty

BACKGROUND

Esophageal shortening is a complication of advanced gastroesophageal reflux disease (GERD). For patients with short esophagus, Collis gastroplasty combined with fundoplication provides excellent symptomatic relief from GERD disease. The literature lacks studies comparing satisfaction and reflux symptoms between patients who underwent Nissen fundoplication with Collis gastroplasty and those who had primary fundoplication alone. This study aimed to assess long-term satisfaction and GERD-related quality of life after laparoscopic Collis-Nissen fundoplication, and to compare them with those for Nissen fundoplication alone.

METHODS

A nested case-control study was conducted. In this study, 14 cases of laparoscopic Collis-Nissen fundoplications were matched for age, gender, and length of the follow-up period to a cohort of 120 control subjects who underwent laparoscopic Nissen fundoplication. All the patients were mailed a follow-up survey which included a Short Form-12 (SF-12) health status (quality-of-life) questionnaire (a validated quality-of-life instrument), a Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire (a GERD-specific quality-of-life instrument), and queries regarding long-term satisfaction and medication use.

RESULTS

Both groups showed a significant postoperative increase in QOLRAD mean scores (p = 0.01). However, the difference in the delta (postoperative-preoperative) score between the two groups was not significant (Fig. 1). There were no differences in mental (MCS) or physical (PCS) SF-12 scores between the two groups. The rate of satisfaction with the surgery was similar in the Nissen-Collis fundoplication (87.5%) and Nissen fundoplication (87%) groups.

CONCLUSIONS

Collis gastroplasty combined with Nissen fundoplication is an effective procedure for patients with a shortened esophagus diagnosed intraoperatively during antireflux surgery. Patient satisfaction, postoperative quality of life, and QOLRAD score improvement after this procedure are comparable with those observed in patients treated with Nissen fundoplication alone.

Five-year subjective and objective results of laparoscopic and conventional Nissen fundoplication: a randomized trial

OBJECTIVE

The purpose of this prospective study was to compare the subjective and objective outcome of laparoscopic (LNF) and conventional Nissen fundoplication (CNF) up to 5 years after surgery as obtained in a multicenter randomized controlled trial.

SUMMARY OF BACKGROUND DATA

LNF is regarded as surgical treatment of first choice for refractory gastroesophageal reflux disease by many surgeons based on several short- and mid-term studies. The long-term efficacy of Nissen fundoplication, however, is still questioned as objective data gathered from prospective studies are lacking.

METHODS

From 1997 to 1999, 177 patients were randomized to undergo LNF or CNF. Five years after surgery, all patients were requested to fill in questionnaires and to undergo esophageal manometry and 24-hour pH-metry.

RESULTS

A total of 148 patients agreed to participate in the follow-up study: 79 patients after LNF and 69 after CNF. Of these, 97 patients (48 LNF, 49 CNF) consented to undergo esophageal manometry and 24-hour pH-metry. At 5 years follow-up, 20 patients had undergone reoperation: 12 after LNF (15%) and 8 after CNF (12%). There was no difference in subjective outcome, with overall satisfaction rates of 88% and 90%, respectively. Total esophageal acid exposure times (pH < 4) were 2.1% +/- 0.5% and 2.0% +/- 0.6%, respectively (P = 0.21). Antisecretory medication was taken daily in 14% and 16%, respectively (P = 0.29). There was no correlation between medication use and acid exposure and indices of symptom-reflux association (symptom index and symptom association probability). No significant differences between subjective and objective results at 3 to 6 months and results obtained at 5 years after surgery were found.

CONCLUSIONS

The effects of LNF and CNF on general state of health and objective reflux control are sustained up to 5 years after surgery and the long-term results of LNF and CNF are comparable. A substantial minority of patients in both groups had a second antireflux operation or took antisecretory drugs, although the use of those medications did not appear to be related to abnormal esophageal acid exposure.

Repair of 104 failed anti-reflux operations

OBJECTIVE

To assess whether reoperative surgery for failed Nissen fundoplication is beneficial and to classify all mechanisms of failure recognized.

SUMMARY BACKGROUND DATA

Antireflux surgery is often necessary, but a 10% failure rate is commonplace. We report results for patients undergoing reoperative surgery and present a nomenclature of mechanisms of failure.

METHODS

A total of 104 patients, who had a previous fundoplication for gastroesophageal reflux disease (GERD), underwent reoperative surgery. Manometry (n = 86), endoscopy (n = 101), pH monitoring (n = 27), upright esophagram (n = 90), gastric emptying (n = 26), and symptom assessment (n = 104) were performed prior to reoperative surgery. Patients were also assessed before and during reoperation for mechanism of failure using a newly proposed classification. The operative approach was laparoscopic in 58 patients, via open laparotomy in 12, and a thoracotomy in 34 patients. Follow-up was conducted by phone interview and was completed in 97 patients (97%; 3 were deceased) with a mean follow-up of 32 months (range, 1-146 months).

RESULTS

The conversion rate to laparotomy for laparoscopic patients was 8%. The perioperative complication rate was 32%. One patient died of respiratory insufficiency after a laparotomy. Seven patients required additional surgery for correction of persistent or recurrent symptoms. The short and long-term complication rate was similar for the different operative approachs. Symptom resolution (rare or absent) occurred in 74% of patients with dysphagia, 75% with heartburn, 85% with regurgitation, and 94% with chest pain. The overall post-reoperative patient satisfaction was 7 on a scale of 1 to 10 and 3 on a scale of 1 to 4 when patients were asked to grade the operative result. There was no difference in the symptom resolution for patients operated upon by the laparoscopic approach as compared with laparotomy, but those patients undergoing a Collis gastroplasty had poorer results. The preoperative accuracy of assessment for mechanism of failure was 78%. A nomenclature of mechanisms of failure is included to aide reoperative assessment and new mechanisms of failure are described.

CONCLUSION

Reoperative surgery results for GERD are satisfactory. A variety of operative approaches proved equally effective. Poorer results were observed in patients with more advanced disease.

Complications After Surgery for Gastroesophageal Reflux Disease

Most complications after surgery for GERD can be avoided by experience and proper surgical technique. Often, what is termed a "slipped" or "twisted" wrap is one that was not properly constructed during the initial surgery. These technical errors can be avoided by complete mobilization of the stomach and esophagus, removal of the epigastric fat pad to identify esophageal shortening, and preservation of both vagus nerves. It is critical to avoid these errors, because an improperly constructed wrap will probably condemn the patient to significant dysphagia, recurrent reflux, and the need for reoperation. Should reoperation be required, the wrap should be completely dismantled so the technical error can be identified and a proper antireflux mechanism created.

Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery

BACKGROUND

Laparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus.

METHODS

A search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected.

RESULTS

The results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure.

CONCLUSIONS

Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.

Assessment of diaphragmatic stressors as risk factors for symptomatic failure of laparoscopic nissen fundoplication

An important limitation of antireflux surgery is a 5%-10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery. Forty-one study cases who underwent a reoperative antireflux operation from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, body mass index (BMI), postoperative gagging, vomiting, weight lifting (greater than 100 pounds), coughing, hiccuping, motion sickness, retching, belching, antidepressant use, smoking, preoperative grade of esophagitis, size of hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures, and preoperative response to proton pump inhibitors. Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis: gagging (P = 0.005), belching (P = 0.02), and hernia size greater than 3 cm (P = 0.04; Table 1). Other potential risk factors show trends as obvious in Fig. 2. Vomiting was significant (P = 0.01) in the earlier models but lost significance when logistic regression was applied. Patients with postoperative gagging and an intraoperative hiatal hernia (greater than 3 cm) have a poorer outcome, whereas patients with postoperative belching have a better long-term outcome.

EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure

BACKGROUND

In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication.

METHODS

EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined.

RESULTS

EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern.

CONCLUSIONS

EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Clinical results of laparoscopic fundoplication at ten years after surgery

BACKGROUND

Several studies have demonstrated laparoscopic antireflux surgery (LAS) for the treatment of gastroesophageal reflux disease (GERD) to be efficient at short- and midterm follow-up evaluations. The aim of this study was to evaluate the results for LAS 10 years after surgery.

METHODS

The 100 consecutive patients who underwent LAS by a single surgeon in 1993 were entered into a prospective database. Nissen fundoplication was performed for 68 patients, and partial posterior fundoplication (modified Toupet procedure) was performed for 32 patients. Evaluations of the outcome were made 5 and 10 years after surgery. A structured symptom questionnaire and upper gastrointestinal barium series were used at 5 years. The same questionnaire and an added quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI]) were used at 10 years.

RESULTS

Seven patients died of unrelated causes during the 10-year period. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms. Three patients were lost to any follow-up study. At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major side effects (flatulence and abdominal distension) were related to "wind" problems. The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors.

CONCLUSIONS

Elimination of GERD symptoms improved quality of life and eliminated the need for daily acid suppression in most patients. These results, apparent 5 years after the operation, still were valid at 10 years.

Beyond heartburn: a systematic review of the extra-oesophageal spectrum of reflux-induced disease

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a chronic condition affecting up to one-quarter of the Western population. GORD is characterized by heartburn and acid regurgitation, but is reported to be associated with a spectrum of extra-oesophageal symptoms.

OBJECTIVE

The aim of this systematic review was to critically evaluate postulated extra-oesophageal symptoms of GORD.

METHODS

Extra-oesophageal symptoms were identified from population-based studies evaluating their association with GORD (either defined as heartburn and/or acid regurgitation, or diagnosed in general practice). The response of these symptoms to acid-suppressive therapy was investigated using randomized, double-blind, placebo-controlled studies. Pathogenic mechanisms were evaluated using clinical and preclinical studies.

RESULTS

An association between GORD and symptoms or a diagnosis of chest pain/angina, cough, sinusitis and gall-bladder disease was evident from three eligible population-based studies of GORD. Randomized placebo-controlled studies (n=20) showed that acid-suppressive therapy provides symptomatic relief of chest pain, asthma and, potentially, chronic cough and laryngitis. Mechanistic models, based on direct physical damage by refluxate or vagally mediated reflexes, support a causal role for GORD in chest pain and respiratory symptoms, but not in gall-bladder disease.

CONCLUSION

GORD is likely to play a causal role in chest pain and possibly asthma, chronic cough and laryngitis. Further investigation is desirable, particularly for other potential extra-oesophageal manifestations of GORD such as chronic obstructive pulmonary disease, sinusitis, bronchitis and otitis. Acid-suppressive therapy is likely to benefit patients with non-cardiac chest pain, but further placebo-controlled studies are needed for other symptoms comprising the extra-oesophageal spectrum of GORD.

[Conventional and minimally invasive surgical methods for gastroesophageal reflux]

The introduction of minimally invasive techniques has had great influence on the indication and surgical therapy for gastroesophageal reflux disease. This analysis is an overview of the current evidence-based status and a critical reprisal of open and laparoscopic antireflux surgery.

RESULTS

The analysis of randomized trials showed an advantage for patients after laparoscopy for total and partial fundoplication because of reduced morbidity, shorter postoperative hospitalization due to faster recovery, and significantly fewer scar and wound problems. The functional results of open and laparoscopic techniques were similar. Five-year follow-up results for the latter showed effective reflux control in at least 85% of patients. Randomized trials regarding technical variations did not show an advantage for division of the short gastric vessel. A bougie for the cardia calibration can prevent postoperative dysphagia after fundoplication.

Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap

BACKGROUND

Postoperative dysphagia after laparoscopic antireflux surgery usually is transient and resolves within weeks after surgery. Persistent dysphagia develops in a small percentage of patients after surgery. There still is debate about whether postoperative dysphagia is caused by the type or placement of the fundic wrap or by mechanical obstruction of the hiatal crura. This study aimed to investigate patients who experienced recurrent or persistent dysphagia after laparoscopic antireflux surgery, and to identify the morphologic reason for this complication.

METHODS

A sample of 50 patients consecutively referred to the authors' unit with recurrent, persistent, or new-onset of dysphagia after laparoscopic antireflux surgery were prospectively reviewed to identify the morphologic cause of postoperative dysphagia. According to their radiologic findings, these patients were divided into three groups: patients with signs of obstruction at or above the gastroesophageal junction suspicious of crural stenosis (group A; n = 18), patients with signs of total or partial migration of the wrap intrathoracically (group B; n = 27), and patients in whom the hiatal closure was radiologically assessed to be correct with a supposed stenosis of the wrap (group C; n = 5). The exact diagnosis of a too tight (group A) or too loose (group B) hiatus in contrast to a too tight wrap (group C) was established during laparoscopic redo surgery (groups B and C) or by x-ray during pneumatic dilation (group A).

RESULTS

For all 18 group A patients, intraoperative x-ray during pneumatic dilation showed the typical signs of hiatal tightness. Of these, 15 were free of symptoms after dilation, and 3 had to undergo laparoscopic redo surgery because of persistent dysphagia. In all these patients, the hiatal closure was narrowing the esophagus. All the group B patients underwent laparoscopic redo surgery because of intrathoracic wrap migration. Intraoperatively, all the patients had an intact fundoplication, which slipped above the diaphragm. Definitely, only in 10% of all 50 patients (group C) presenting with the symptom of dysphagia, was the morphologic reason for the obstruction a problem of the fundic wrap.

CONCLUSIONS

In most patients, postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap.

Laparoscopic mesh repair antireflux surgery for treatment of large hiatal hernia

One of the most frequently occurring anatomic failures after laparoscopic fundoplication is migration of the wrap into the chest, with or without disruption. This so-called 'slipped' Nissen fundoplication may be the result of inadequate closure of the diaphragmatic crura or rupture of the sutures or disruption of the muscle fibers approached. From January 2000 to December 2002, a total of seven patients (four male) with a mean age of 56 years (range 22-72 years), were considered for laparoscopic antireflux procedure using DACRON mash to reinforce the crural hiatal closure. The patients were operated under general anesthesia; laparoscopy was performed by classical approach with five trocars. The mean operative time was 120 minutes (range 40-240 min). There were no deaths. The average of postoperative hospital stay was 3.5 days (range, 3-5). Patients returned to normal activities usually on postoperative day 10 (range, 7-15). The follow-up time was at least 2 years. There was only one late complication related to the use of DACRON mesh at the hiatus, due to migration of the mesh into the esophageal lumen causing disphagia. In conclusion the mesh repair antireflux surgery is a good alternative for closing the diaphragmatic defect in large hiatal hernias or to correct this problem in case of recurrence or Barrett's esophagus.

Management of esophageal symptoms following fundoplication

Laparoscopic antireflux surgery has emerged as a widely used and effective management option for the properly selected patient with gastroesophageal reflux disease. Poor symptomatic outcomes occur even in the best of hands, the most common being recurrent or persistent heartburn (or atypical symptoms) and dysphagia. When heartburn predominates, the initial management step is an anatomical and physiologic evaluation to determine whether acid reflux is controlled and if the postoperative neoanatomy is appropriate. If anatomical evaluation indicates surgical failure (eg, slipped or loose fundoplication, recurrent hiatal hernia), earlier re- operation may be warranted. Objective evidence of ongoing acid reflux or a reflux-symptom association despite anatomical integrity indicates reintroduction of antireflux medical therapy. Evidence favoring physiologic and anatomical success should direct treatment toward functional heartburn, including the use of tricyclic antidepressants. Dysphagia in the immediate postoperative setting mandates reassurance, as conservative measures alone often suffice while postoperative changes resolve. With persistent dysphagia, anatomical and physiologic evaluation is again indicated in the search for a mechanical-, motility-, or reflux-related symptom basis. Dilation techniques can prevent the need for re-operation, but persistent dysphagia associated with distorted postoperative anatomy will likely require surgical intervention. Regardless of the indication, re-operation carries substantial morbidity and reduced success rates compared with the initial procedure. These procedures mandate careful patient selection and referral to a center with thorough surgical experience.

Austrian experiences with redo antireflux surgery

BACKGROUND

From 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results.

METHODS

A questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms).

RESULTS

Out of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach.

CONCLUSION

Laparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience.

Short-term cost effectiveness and long-term cost analysis comparing laparoscopic Nissen fundoplication with proton-pump inhibitor maintenance for gastro-oesophageal reflux disease

BACKGROUND

This study examined the short-term cost-effectiveness and long-term cost of laparoscopic Nissen fundoplication (LNF) versus maintenance proton-pump inhibitor (PPI) medication for severe gastro-oesophageal reflux disease (GORD) based on a randomized clinical trial.

METHODS

Costs and outcomes for 12 months were obtained from the first 100 patients in the trial. Detailed costing was performed using resource use data from hospital records and general practitioners' notes. Short-term incremental cost-effectiveness ratios, calculated as the cost difference divided by the effectiveness difference between LNF and PPI therapy, were analysed using net benefit and bootstrap approaches. Long-term cost was examined using sensitivity analyses incorporating published data from other large series.

RESULTS

The incremental cost of LNF compared with PPI therapy per additional patient returned to a physiologically normal acid score (less than 13.9) at 3 months was pound5515 (95 per cent confidence interval (c.i.) pound3655 to pound13 400) and the incremental cost per point improvement in combined Gastro-Intestinal and Psychological Well-being score at 12 months was pound293 (90 per cent c.i. pound149 to pound5250). On average, LNF cost pound2247 (95 per cent c.i. pound2020 to pound2473) more than PPI therapy in year 1 and broke even in year 8. Break-even was highly sensitive to hospital unit costs but less sensitive to PPI ingestion rate after LNF, LNF reoperation rate, PPI relapse rate, future PPI price, PPI dose escalation and discount rate.

CONCLUSION

From a National Health Service perspective, LNF may be cost-saving after 8 years compared with maintenance PPI therapy for the treatment of GORD.

When fundoplication fails: redo?

OBJECTIVE

The largest series in the literature dealing with redo fundoplication was presented and published in 1999 and included 100 patients. Herein we update this initial series of 100, with 207 additional patients who have undergone redo fundoplication (n = 307).

SUMMARY BACKGROUND DATA

Increasing numbers of patients are failing esophagogastric fundoplication and requiring redo procedures. Data regarding the nature of these failures have been scant.

METHODS

Data on all patients undergoing foregut surgery are collected prospectively. Between 1991 and 2004, 307 patients underwent redo fundoplication for the management of anatomic complications or recurrent GERD. Statistical analysis was performed with multiple chi2 and Mann-Whitney U analyses, as well as ANOVA.

RESULTS

Between 1991 and 2004, 1892 patients underwent primary fundoplication for GERD (1734) or paraesophageal hernia (158). Of these, 54 required redo fundoplication (2.8%). The majority of failures (73%) were managed within 2 years of the initial operation (P = 0.0001). The mechanism of failure was transdiaphragmatic wrap herniation in 33 of 54 (61%). In the 231 patients who underwent fundoplication elsewhere, 109 had transdiaphragmatic herniation (47%, P = NS). In this group of 285 patients, 22 (8%) required another redo (P = NS). The majority of the procedures were initiated laparoscopically (240/307, 78%), with 20 converted (8%). Overall mortality was 0.3%.

CONCLUSIONS

Failure of fundoplication is unusual in experienced hands. Most are managed within 2 years of the initial operation. Wrap herniation has now become the most common mechanism of failure requiring redo. Redo fundoplication was successful in 93% of patients, and most could be safely handled laparoscopically.

Functional Problems Following Esophageal Surgery

Functional problems following esophageal surgery for GERD are not infrequent. The majority of patients improve with time. Careful patient selection and attention to surgical technique are key factors in preventing such functional disorders. When anatomic abnormalities related to the fundoplication are identified, reoperation may offer symptom relief. Before embarking on re-fundoplication, a thorough preoperative evaluation of the esophageal physiology is recommended.

Laparoscopic reoperative surgery after laparoscopic fundoplication: an initial experience

BACKGROUND

Primary fundoplication results are good to excellent. We explored failure patterns and results of redo fundoplication surgery.

STUDY DESIGN

Between January 1999 and July 2002, 10 redo laparoscopic fundoplications were attempted, 1 for the third time. Indications were large symptomatic hiatal hernia-2, hiatal hernia with reflux-2, hiatal hernia with reflux and dysphagia-1, hiatal hernia with dysphagia-2, bloating with dysphagia-1, dysphagia-1, and dysphagia for the third attempt.

RESULTS

Two conversions (20%) were caused by dense adhesions at the crura and mediastinum. There were 8 recurrent hiatal hernia repairs. Fundoplication was left in place in 2 patients. Fundoplication was redone in 4 (2 were slipped), converted to Toupet in 2, or taken down in 1 (with esophageal myotomy). Pyloroplasty was performed in 2 patients and cruroplasty in 1. Laparoscopy operating room time was 140 (64 to 210) minutes and converted 210 and 295 minutes. Intraoperative complications occurred in 30% of patients (gastric perforation 1, bilateral chest tubes 2). Length of hospital stay was 3 (1 to 8) days for laparoscopic, 3 and 5 for converted. One patient was reoperated on acutely for a hiatal reherniation. Follow-up was 16 (1 to 40) months: 3 were symptom free, 2 had mild reflux symptoms, and were on prn H2 blockers, 1 mild bloating, 2 mild dysphasia, 2 moderate dysphagia, 1 had been dilated, and the other failed dilation and was redone.

CONCLUSIONS

Hiatal hernia was the most common cause of symptoms leading to redo surgery. Laparoscopic redo surgery is effective for dysphagia and recurrent heartburn. Results are not as good as for first-time fundoplication and morbidity is higher.

Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication

BACKGROUND

Total fundoplication for gastro-oesophageal reflux disease may be followed by unwanted side-effects. A randomized trial demonstrated that an anterior 180 degrees partial fundoplication achieved effective reflux control and was associated with fewer side-effects in the short term than total fundoplication. This paper reports longer-term (5 year) outcomes from that trial.

METHODS

Between December 1995 and June 1997, 107 patients were randomized to undergo either laparoscopic total fundoplication or a laparoscopic anterior 180 degrees fundoplication. After 5 years, 101 of 103 eligible patients (51 total, 50 anterior) were available for follow-up. Each patient was interviewed by a single blinded investigator and a standardized questionnaire was completed. The questionnaire focused on symptoms and overall satisfaction with the results of fundoplication.

RESULTS

There were no significant differences between the two groups with regard to control of heartburn or patient satisfaction with the overall outcome. Dysphagia, measured by a visual analogue score for solid food and a composite dysphagia score, was worse at 5 years after total fundoplication. Symptoms of bloating, inability to belch and flatulence were also more common after total fundoplication. Reoperation was required for dysphagia in three patients after total fundoplication and for recurrent reflux in three patients after anterior fundoplication.

CONCLUSION

Anterior 180 degrees partial fundoplication was as effective as total fundoplication for managing the symptoms of gastro-oesophageal reflux in the longer term. It was associated with a lower incidence of side-effects, although this was offset by a slightly higher risk of recurrent reflux symptoms.

Tension-free repair of hiatal hernia during laparoscopic fundoplication: a ten-year experience

BACKGROUND

The breakdown of a hiatal hernia repair can lead to clinical failure. The use of prosthetic material at the esophageal hiatus to strengthen the crural repair is relatively new and questions remain. This report examines the safety and efficacy of a tension-free crural repair with mesh.

PATIENTS AND METHODS

Since 1993, 135 consecutive patients (19-86) [9 re-do] completed laparoscopic tension-free hiatal hernia repair prior to Nissen wrap. Esophageal hiatus was patched with a PTFE mesh (first 112 patients) or a PTFE/ePTFE composite (23 patients) secured across the defect with staples to each crura. 130 patients completed a phone questionnaire during 2003/2004 (mean f/u 64 months).

RESULTS

There have been no short-term nor long-term infections related to the PTFE mesh. Symptoms were resolved or improved and resolved with meds in 122/130 (94%). Early re-herniation occurred in one patient after vigorous exercise.

CONCLUSIONS

Mesh repair/patch of the esophageal hiatus can be done without infection, with results similar to standard crural repair and consistent with surgical principles of non-tension.

Failed fundoplications

BACKGROUND

Five percent of patients who undergo fundoplication will require reoperation. The cause of this high failure rate and the best management for these patients remains poorly understood. The aim of this study was to identify patterns and causes of failure of primary antireflux procedures.

METHODS

Retrospective review of the medical records of patients who underwent revisional antireflux surgery at 2 tertiary referral centers.

RESULTS

Between 1998 and 2003, 39 patients underwent laparoscopic revisional antireflux surgery. The time between primary and revisional surgery was 5.9 +/- 0.4 years. Primary operations included 26 laparoscopic and 13 open fundoplications. All of the 39 revisional operations were attempted laparoscopically, and there was 1 open conversion. Revisional procedures included 31 Nissen and 8 partial fundoplications. The duration of surgery was 138 +/- 10 minutes. Length of hospital stay was 2.1 +/- 0.3 days. At a mean follow-up of 6 months, reflux resolved in 94% of patients. Morbidity occurred in 23% of patients. Four types of failure were identified: type 1 = herniation of the gastroesophageal junction through the hiatus with or without the wrap (n = 21); type 2 = paraesophageal hernia (n = 9); type 3 = malformation of the wrap (n = 2). Six patients had primary wrap failure, and 1 had esophageal dysmotility.

CONCLUSIONS

Laparoscopic revisional antireflux surgery is effective treatment for patients with failed primary fundoplications. Successful revisional surgery depends on identification and correction of the reason for primary fundoplication failure.

Robotic Laparoscopic Fundoplication

Gastroesophageal reflux disease is a very common disorder, and both medical and surgical treatments have shown outstanding results. Whereas proton pump inhibitors are the mainstay of treatment, laparoscopic fundoplication has become a very attractive alternative due to its efficacy and low morbidity. There are defined patient categories that may benefit more from laparoscopy than medical therapy, but a conclusive comparison between the two is lacking. Robotic laparoscopic fundoplication can be performed safely without increased morbidity. Potential advantages include enhanced precision, improved dexterity, and remote telesurgical applications. Disadvantages include increased cost and prolonged operative times. Further studies and more long-term outcome data are needed to fully evaluate the procedure. Robotic surgery is currently in its infancy and not cost effective but has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.

Reoperative Fundoplications are Effective Treatment for Dysphagia and Recurrent Gastroesophageal Reflux

With wide application of antireflux surgery, reoperations for failed fundoplications are increasingly seen. This study was undertaken to document outcomes after reoperative fundoplications. Sixty-four patients, 26 men and 38 women, of average age 55 years ± 15.6 (SD), underwent reoperative antireflux surgery between 1992 and 2003. Fundoplication prior to reoperation had been undertaken via celiotomy in 27 and laparoscopically in 37. Both before and after reoperative antireflux surgery, patients scored their reflux and dysphagia on a Likert Scale (0 = none, 10 = continuous). Reoperation was undertaken because of dysphagia in 16 per cent, recurrent reflux in 52 per cent (median DeMeester Score 52), or both in 27 per cent. Failure leading to reoperation was due to hiatal failure in 28 per cent, wrap failure in 19 per cent, both in 33 per cent, and slipped Nissen fundoplication in 20 per cent. Laparoscopic reoperations were completed in 49 of 54 patients (91%); 15 had reoperations undertaken via celiotomy. Eighty-eight per cent of reoperations were Nissen fundoplications. With reoperation, Dysphagia Scores improved from 9.5 ± 0.7 to 2.6 ± 2.8, and Reflux Scores improved from 9.1 ± 1.4 to 1.8 ± 2.7. Seventy-nine per cent of patients with reflux prior to reoperation, 100 per cent with dysphagia, and 74 per cent with both noted excellent or good outcomes after reoperation. We conclude that failure after fundoplication occurs. Reoperations reduce the severity of dysphagia and reflux, thus salvaging excellent and good outcomes in most. Laparoscopic reoperations are generally possible. Reoperative fundoplications are effective treatment for dysphagia and recurrent gastroesophageal reflux, and their application is encouraged.

Reoperative laparoscopic fundoplication for the treatment of failed fundoplication

OBJECTIVE

This study was undertaken to determine the safety and efficacy of reoperative laparoscopic fundoplication for patients with failed fundoplication.

METHODS

Thirty-nine of 612 consecutive patients who had undergone fundoplication underwent laparoscopic reoperative fundoplication for recurrent symptoms, persistent dysphagia, or gas bloat. An additional 15 patients were referred from outside facilities for reoperation. Preoperative evaluation included barium swallow (n = 54), esophagogastroduodenoscopy (n = 54), esophageal manometry (n = 34), and 24-hour ambulatory pH measurement (n = 32). Symptom severity before and after surgery was evaluated with a visual analog scoring scale. The mean follow-up was 22.5 months.

RESULTS

The primary symptoms that led to reoperation in the 54 patients were heartburn (n = 26), dysphagia (n = 23), and gas bloat (n = 5). Average time from initial operation to reoperation was 22.7 months. There were 3 conversions to open technique. An anatomic reason for the failure of the initial fundoplication was found in 69% of cases: slipped or misplaced fundoplication (n = 14), disrupted fundoplication (n = 8), transdiaphragmatic herniation (n = 7), achalasia (n = 1), and tight fundoplication (n = 7). Fourteen patients had 15 perioperative complications. Mean hospital stay was 2.3 days. Symptoms such as heartburn, dysphagia, and gas bloat improved significantly after reoperation; 40% to 50% of patients had scores 0 to 2, 21% to 45% had scores 3 to 7, and 9% to 29% had scores 8 to 10. Proton-pump inhibitor use after operation decreased from 88% to 36%. Fifty-two percent of patients completely discontinued any antireflux medications. Three patients had failure of the reoperation and required additional procedures.

CONCLUSION

Laparoscopic reoperation for failed fundoplication is feasible and can achieve resolution of symptoms for a significant percentage of patients.

Review article: anti-reflux surgery and endoluminal therapies

In the short term, fundoplication and antisecretory medication are equally effective in the management of gastro-oesophageal reflux disease. However, over the long term, the fundoplication wrap tends to become loose, and many surgical patients continue to take antisecretory medication after surgery. The operation is technically complex and takes a long time to learn. Inexperience of the individual surgeon is a major factor contributing to the occurrence of postsurgical complications. Fundoplication does not prevent the occurrence of Barrett's oesophagus nor its progression to oesophageal adenocarcinoma. There is no evidence to suggest that the procedure is less costly or more cost-effective than long-term maintenance therapy with antisecretory medications, especially if surgical failures and postsurgical complications are taken into account. Fundoplication represents an alternative to medical therapy in patients with gastro-oesophageal reflux disease who cannot or do not want to be on long-term maintenance therapy with antisecretory medication. Endoluminal procedures, such as radiofrequency ablation, endoscopic suturing and injection at the gastro-oesophageal junction, work only in mild forms of reflux disease. They fail to provide complete relief of reflux symptoms and do not heal erosive oesophagitis. All endoluminal procedures would have to undergo major technological improvements before they could become comparable with fundoplication or antisecretory therapy.

The role of the hiatus hernia in gastro-oesophageal reflux disease

A sliding hiatus hernia disrupts both the anatomy and physiology of the normal antireflux mechanism. It reduces lower oesophageal sphincter length and pressure, and impairs the augmenting effects of the diaphragmatic crus. It is associated with decreased oesophageal peristalsis, increases the cross-sectional area of the oesophago-gastric junction, and acts as a reservoir allowing reflux from the hernia sac into the oesophagus during swallowing. The overall effect is that of increased oesophageal acid exposure. The presence of a hiatus hernia is associated with symptoms of gastro-oesophageal reflux, increased prevalence and severity of reflux oesophagitis, as well as Barrett's oesophagus and oesophageal adenocarcinoma. The efficacy of treatment with proton pump inhibitors is reduced. Our view on the significance of the sliding hiatus hernia in gastro-oesophageal reflux disease has changed enormously in recent decades. It was initially thought that a hiatus hernia had to be present for reflux oesophagitis to occur. Subsequently, the hiatus hernia was considered an incidental finding of little consequence. We now appreciate that the hiatus hernia has major patho-physiological effects favouring gastro-oesophageal reflux and hence contributing to oesophageal mucosal injury, particularly in patients with severe gastro-oesophageal reflux disease.

Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery

BACKGROUND

Prospective studies comparing laparoscopic to open Heller myotomy for esophageal achalasia are lacking. The aim of this study was to compare functional outcome after laparoscopic and open Heller myotomy for esophageal achalasia.

METHODS

Eighty-two patients who underwent Heller-Dor myotomy for achalasia, via laparoscopy (n=52) or open surgery (n=30) were recorded prospectively (1993-2002). Median follow-up was 51 (12-111) months. Perioperative functional data were assessed via dysphagia and overall clinical (dysphagia, chest pain, regurgitation, gastroesophageal reflux) scores.

RESULTS

In laparoscopy patients, the operative time was longer (145 [95-290] vs 120 [70-230] minutes, P <.0001); the postoperative hospital stay and feeding resumption time was shorter (4 [2-25] vs 7.5 [5-18] days, P <.0001 and 2 [1-15] vs 4 [1-14] days, P <.0001). Three mucosal tears necessitated conversion to open surgery (6%). The rates of " excellent" or " satisfactory" results after laparoscopic and open surgery were 92% (n=48/52) versus 93% (n=28/30), and 83% (n=43/52) versus 83% (n=25/30) on overall clinical score. In both groups, the overall clinical score indicated significant improvement during 12-month follow-up. The laparoscopy and open surgery symptomatic gastroesophageal reflux rates were 10% and 7%, respectively.

CONCLUSIONS

Laparoscopic Heller myotomy favorably compares with open surgery regarding dysphagia relief and gastroesophageal reflux rate. Overall clinical score indicates gradual improvement in patient functional status during 12-month follow-up.

Laparoscopic Fundoplication: 5-Year Follow-up

There are few published reports on outcomes of 5 or more years following laparoscopic fundoplication. Gastroesophageal reflux disease (GERD) specific quality of life questionnaires (QOLRAD), short form health surveys (SF12), and queries regarding current medication use and long-term satisfaction were mailed to all patients who underwent laparoscopic fundoplication at our institution. Results are reported as mean ± SEM. Seventy-six patients underwent laparoscopic fundoplication (63 Nissen, 13 Toupet) between November 1992 and December 1997. Fifty-two patients completed questionnaires (68%). Mean follow-up was 5.1 ± 0.2 years (range, 4–9 years). Mean QOLRAD scores were 5.8 ± 0.2, (scale 0–7, a higher score reflecting improved QOL), which is comparable to the general population (6.0 mean). SF-12 mental and physical scores were 46.6 ± 1.7 and 34.2 ± 1.6, respectively, versus 50.7 and 51.2 for the general population. Forty-seven patients (92%) would have the procedure again. Eleven (21%) remained on antisecretory medications (15% proton pump inhibitor and 6% H2 receptor antagonists). None of the 11 patients underwent 24-hour pH testing to document persistent acid exposure. Furthermore, postoperative symptoms of heartburn, dysphagia, and abdominal bloating were rated as none to mild in the majority of patients. Laparoscopic fundoplication is an effective long-term treatment for GERD, resulting in high patient satisfaction, improved quality of life, and elimination of antisecretory medicines in the majority of patients.

Stapled-wedge Collis gastroplasty for the shortened esophagus

BACKGROUND

Minimally invasive Collis gastroplasty is an established technique for managing the shortened esophagus. The purpose of this report is to describe our new technique, the wedge gastroplasty, and report the short-term outcomes.

METHODS

All patients (n = 143) undergoing laparoscopic fundoplication from May 2000 to March 2001 were assessed intraoperatively for shortened esophagus. After mediastinal dissection, 15 patients with inadequate intraabdominal esophageal length underwent wedge gastroplasty. Preoperative symptoms, operative times, and short-term outcomes were evaluated.

RESULTS

Mean operative time was 184 +/- 36 minutes (range 138 to 258). There was 1 cervical esophageal tear from bougie passage and no other minor or major complications. At 6 weeks, there was more improvement in esophageal symptoms compared with extraesophageal symptoms.

CONCLUSIONS

Wedge gastroplasty is effective in decreasing symptoms in patients with shortened esophagus and takes less time to perform than other gastroplasty techniques. Further study is needed to assess long-term outcomes.

Pregnancy and delivery after antireflux surgery

BACKGROUND

Concerns have been raised that subsequent pregnancy after antireflux surgery (ARS) may predispose to wrap disruption or herniation and adversely affect outcomes. Some surgeons withhold ARS in women of childbearing age for fear of this, but outcomes in this population have not been reported.

METHODS

All childbearing-age women who underwent ARS for gastroesophageal reflux disease (GERD) between January 1991 and July 2000 were asked to complete a detailed questionnaire. Patients with subsequent pregnancies (SP) after ARS were compared with patients without subsequent pregnancies (NP).

RESULTS

Ninety-five of the 118 patients (81%) completed the questionnaire at a mean follow-up of 4.9 years. Fifteen patients had 19 subsequent pregnancies after undergoing ARS, and retching and/or vomiting were reported during 13 of the pregnancies (69%). Preoperative incidence of complicated-GERD including strictures (11% vs. 20%), Barrett's esophagus (19% vs. 13%), esophagitis (36% vs. 33%), and ulceration (4% vs. 0%)-were similar between the nonpregnant and pregnant groups. Incidence of postoperative moderate to severe esophageal (7% vs. 8%) and extraesophageal symptoms (0% vs. 6%) were similar between the SP and NP groups. Postoperative prevalence of antisecretory medications was similar in SP and NP groups (13% and 23%, respectively). The incidence of fundoplications redone did not reach statistical difference between the NP (11%) and SP (0%) groups. Long-term outcomes and failure rates were similar in both groups, except the SP group reported greater overall satisfaction with ARS.

CONCLUSIONS

Women of childbearing age have a high incidence of complicated GERD, which may contribute to higher-than-expected rates of symptomatic and anatomic fundoplication failures than first-time ARS. Subsequent pregnancies do not adversely affect outcomes after ARS.

Laparoscopic Nissen repair: indications, techniques and long-term benefits

BACKGROUND

The Nissen fundoplication or total 360 degrees fundoplication is probably the most frequently used anti-reflux procedure throughout the world. With the advent of laparoscopic surgery the popularity among surgeons to perform a laparoscopic Nissen fundoplication has even increased.

AIM

The purpose of this paper is to provide an overview of the experience of laparoscopic Nissen fundoplication over the past 15 years.

METHOD

We performed an extensive review of the literature in order to ascertain the representative papers. In addition, available consensus papers, especially with regard to indication and technique, were assessed. Indication for a laparoscopic Nissen fundoplication should depend on documentation of the presence of disease as well as objective testing of the functional disorders and the complications. The technique of Nissen fundoplication is discussed controversially. Consensus exists with regard to floppiness of the wrap, necessary closure of the crurae and the use of a calibration method during the performance of the wrap.

RESULTS

The laparoscopic technique creates a learning curve, which needs to be respected. Large prospective series in recent years have shown a complication rate between 5% and 10%, depending on the definition of the complication. In these last prospective series good and excellent results have been reported, of between 85% and 95%. Reflux recurrence is reported as between 1% and 8.5%, with a concomitant dysphagia rate of 0%-10%.

CONCLUSIONS

The Nissen fundoplication is currently performed throughout the world, most frequently in a minimally invasive technique. Several randomized trials that have been performed in the past years document that the Nissen fundoplication is an effective procedure for the treatment of pathological gastro-oesophageal reflux disease when a critical indication is used for well-defined patients.

Prevention of recurrence by reinforcement of hiatal closure using ligamentum teres in laparoscopic repair of large hiatal hernias

BACKGROUND. Several attempts were made to develop an effective technique to reduce the high recurrence rate associated with the repair of large hiatal hernias.

METHODS

A new laparoscopic technique was introduced to reinforce hiatal closure with the ligamentum teres. Its feasibility, safety, and efficacy were evaluated. Four patients with gastroesophageal reflux disease and large hiatal hernia (>6 cm) entered the study. After closure of the diaphragmatic crura the teres ligament was dissected, brought behind the esophagus, and sutured to the crura. A fundoplication was also added. Patients were followed with barium swallow at 3 months postoperatively.

RESULTS

The mean operation time was 109.5 min. No intraoperative complications, perioperative morbidity, or mortality were registered. At the follow-up, barium swallows revealed no recurrence.

CONCLUSION

On the basis of these preliminary results laparoscopic reinforcement of the hiatal closure with the ligamentum teres seems feasible and safe; therefore this promising technique should be considered as an option for the treatment of large hiatal hernias.

Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive value of preoperative assessment

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has established itself as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). There are, however, few available data on the assessment of long-term failures after LNF.

METHODS

We sought to clarify the mechanisms of failure among a group of patients who reported suboptimal results after LNF. In addition, we attempted to identify specific elements in the preoperative evaluation of GERD patients that might herald a predisposition to anatomical or physiological failure.

RESULTS

One hundred and thirty-one consecutive patients who underwent LNF by a single surgeon were analyzed to identify reasons for surgical failure. Fourteen patients (10.6%) comprised the failure group. Detailed independent statistical analysis identified a hiatus hernia greater than 3 cm at operation (P = 0.003), abnormal preoperative pH analysis in the upright position (P = 0.039), failure to respond to proton pump inhibition preoperatively (P = 0.015), and a preoperative psychiatric history (P = 0.0012) as predictors of subsequent failure.

CONCLUSIONS

In patients who do not respond to proton pump inhibition preoperatively, the evaluating surgeon should be circumspect in advocating antireflux surgery. A detailed assessment of underlying psychiatric or psychological symptoms must also be made. If a large (>3 cm approximately) hiatus hernia is identified or there is abnormal pH analysis in the upright position preoperatively, the surgeon should be guarded about the long-term outcome, and patients should be advised accordingly.

Endoluminal therapies for gastroesophageal reflux disease

While medical therapy, particularly with proton pump inhibitors, is effective for the large majority of patients with reflux disease, there remains a subset of patients who are dissatisfied, due to cost, side effects of medications, or persistent symptoms such as regurgitation. For this population, surgical fundoplication has been, and remains, an appropriate option. A new class of endoluminal interventions, attempting to create a mechanical antireflux barrier, has emerged recently. Three such devices are currently approved and available, and a number of others are in various stages of evaluation. This article will review the approved technologies, as well as selected promising emerging ones. with particular emphasis on the scientific evidence available to date supporting their efficacy.

The management of patients who have "failed" antireflux surgery

Gastroenterologists may be called upon to manage patients who have had antireflux surgery that failed. The available literature on this topic comprises predominantly reports on retrospective, observational studies written by surgeons who often have focused on how technical deficiencies in performing the operation led to the failure. Such reports are of limited value to the gastroenterologist seeking guidance on patient management. Furthermore, comparisons among the reports are confounded by the lack of a standardized definition for failed antireflux surgery. This report critically reviews the available literature, and suggests a practical approach to the management of patients who have symptoms that were not completely relieved, that reappeared later, or that were caused by antireflux surgery.

A 25-year experience with open primary transthoracic repair of paraesophageal hiatal hernia

OBJECTIVE

The optimal surgical treatment of paraesophageal hiatal hernia is in debate. Our experience with a traditional transthoracic approach was reviewed to provide "benchmark" data against which newer surgical techniques can be measured.

METHODS

Between 1977 and 2001, 240 patients had primary transthoracic repair of paraesophageal hiatal hernia. Presenting complaints included reflux (69%), pain (67%), dysphagia (36%), and bleeding or anemia (33%). Preoperative esophageal function testing showed abnormal reflux in 86%. Hernia types were combined (type III) in 92% and type IV in 8%. All patients had reduction of the hernia and a concomitant antireflux procedure. An esophageal lengthening Collis gastroplasty was performed in 96%.

RESULTS

There were 3 perioperative deaths (1.7%). The median length of hospital stay was 7 days. Early complications requiring reoperation occurred in 12 patients (5%) and included recurrent hernia in 4, leak in 3, and a tight hiatal closure in 3. Mean follow-up in 226 patients was 42 months (median 27.8 months). Satisfactory results were obtained in 86% of patients. Follow-up complaints (moderate or persistent symptoms) included dysphagia (4), reflux (1), dumping (3), and post-thoracotomy pain (1). Routine postoperative barium radiographs showed intact repair in 71% (108/153). Of 19 patients with an anatomic recurrence, 4 (2%) had more than a partial asymptomatic migration of the fundoplication and required reoperation. Postoperative esophageal function testing, obtained in 28% of the patients, showed abnormal gastroesophageal reflux in 2.

CONCLUSION

Open transthoracic repair of paraesophageal hiatal hernia provides good to excellent long-term control of both the hernia and gastroesophageal reflux with relatively low early morbidity.

Efficacy of laparoscopic antireflux surgery in patients with Barrett's esophagus

BACKGROUND

Laparoscopic antireflux surgery (LARS) corrects significant physiologic and anatomic abnormalities in patients with gastroesophageal reflux disease (GERD); however, debate exists whether LARS prevents recurrent symptoms and malignant transformation in patients with Barrett's esophagus (BE). This study compared clinical outcomes after LARS in patients with and without BE.

METHODS

From 1994 to 2001, 448 patients who underwent LARS were studied. Of these, 68 (15%) had preoperative evidence of BE with low-grade dysplasia in 3 (4%), and 380 (85%) were without BE. Mean postoperative follow-up was more than 30 months in each group.

RESULTS

After LARS, there was equivalent reduction in acid reduction medication use and typical GERD symptoms in both groups. Anatomic failures developed in 12% of patients with BE and in 5% of those without BE (P = 0.05). Upper endoscopy with biopsies was obtained in 50 of 68 patients (74%) with BE at 37 +/- 22 months postoperatively. Intestinal metaplasia was no longer present in 7 of 50 (14%) BE patients, and low-grade dysplasia regressed to nondysplastic Barrett's in 2 of 3 patients. New low-grade dysplasia developed in 1 BE patient (2%) at postoperative endoscopic surveillance. No BE patients developed high-grade dysplasia or adenocarcinoma.

CONCLUSIONS

After LARS, patients with BE have symptomatic relief and reduction in medication use equivalent to non-BE patients. Regression of intestinal metaplasia and the absence of progression to high-grade dysplasia or adenocarcinoma suggest that LARS is an effective approach for the management of patients with Barrett's esophagus. The higher failure rate of LARS in BE is of concern and mandates ongoing follow-up of these patients.

Disparity between symptomatic and physiologic outcomes following esophageal lengthening procedures for antireflux surgery

Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia were identified from a prospectively maintained database. Symptom questionnaires were used during follow-up to assess symptomatic outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients. Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed changes associated with Barrett's esophagus that were not present preoperatively. Distal esophageal injury can persist after EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique during EGF.

Laparoscopic Nissen fundoplication in children: 2-5-year follow-up

PURPOSE

This study aims to document the current status of a cohort of children who underwent laparoscopic fundoplication at a single centre between 1996 and 1998.

METHODS

Parents were contacted and a questionnaire regarding preoperative and current symptoms completed. Case notes were reviewed for results of postoperative investigations.

RESULTS

Forty-five laparoscopic Nissen fundoplications were performed. The median age was 5 years. Twenty-eight children were neurologically impaired. Five died of underlying medical problems during follow-up. Two were lost to follow-up, leaving 38 parents interviewed. Median follow-up was 36 months. Twenty-five children were asymptomatic, and 13 reported upper gastrointestinal symptoms. In ten, symptoms were less severe than preoperatively. Nine of the 13 children were taking acid suppressing drugs. No children reported problems with dysphagia. Twelve of the 13 symptomatic children had investigations for recurrent reflux. In no case was there evidence of reflux or wrap disruption. One of the children who died had been demonstrated to have recurrent reflux on barium swallow.

CONCLUSIONS

Sixty-six percent of patients reported complete relief, and a further 26% reported considerable improvement of their symptoms. There was a high degree of parental satisfaction with the outcome of the operation. The results suggest that laparoscopic fundoplication is a durable procedure with documented recurrent reflux in only 2% of children at a median follow-up of 3 years.

Comparison of patient satisfaction after redo and primary fundoplications

BACKGROUND

Although much has been written about the results and patient satisfaction with fundoplication for the treatment of gastroesophageal reflux disease, the reports have focused primarily on surgical successes. With the growing number of fundoplications being performed, more patients are requiring reoperation because of recurrent symptoms or side effects. Reports of success rates for reoperation are available, but information regarding patient satisfaction is limited.

METHODS

All the patients undergoing fundoplication at our institution were sent short-form health surveys (SF-12), Gastroesophageal reflux disease-specific quality-of-life questionnaires (QOLRAD), and queries regarding long-term satisfaction.

RESULTS

Between November 1992 and July 2000, 221 patients (198 primary and 23 redo) underwent fundoplication. There were 19 open cases (3 primary and 16 redo). In the primary group, 173 patients underwent Nissen, 23 underwent Toupet, and 2 underwent Collis fundoplications. In the redo group, 12 patients underwent Nissen, 9 underwent Toupet, 1 underwent Collis, and l underwent Belsey fundoplications. Follow-up surveys were completed for 130 patients (112 primary and 18 redo) at a mean of 32.6 months (range, 0.8-98 months). In the primary group, 87% of the patients were satisfied with their operation, as compared with 75% in the redo group. There was a trend toward higher SF-12 mental scores (46 +/- 12 vs 40 +/- 14; p = 0.07) and QOLRAD scores (6.2 +/- 1.3 vs 5.2 +/- 2.0; p = 0.07) in the primary fundoplication group. There was a significant difference in the SF-12 physical scores between the groups (32 +/- 13 for the primary group vs 18.5 +/- 11 for the redo group; p = 0.0002). Additionally, 61% of the patients in the redo group were again using antireflux medications, whereas only 24% of the patients in the primary group were using medications again.

CONCLUSION

Gastroesophageal reflux disease symptom scores and quality-of-life scores for patients undergoing redo fundoplication are lower than the scores of patients having primary fundoplication. Quality of life is similar between primary and redo fundoplication patients in the mental component. However, redo patients do not do as well physically more than 2 years after surgery.