Clinical results of laparoscopic fundoplication at ten years after surgery

Management of complications after laparoscopic Nissen's fundoplication: a surgeon's perspective

Introduction

Gastro-oesophageal reflux disease (GORD) is a common problem in the Western countries, and the interest in the minimal access surgical approaches to treat GORD is increasing. In this study, we would like to discuss the presentations and management of complications we encountered after Laparoscopic Nissen's fundoplication in our District General NHS Hospital. The aim is to recognise these complications at the earliest stage for effective management to minimise the morbidity and mortality.

Methods

301 patients underwent laparoscopic treatment for GORD by a single consultant surgeon in our NHS Trust from September 1999. The data was prospectively collected and entered into a database. The data was retrospectively analysed for presentations for complications and their management.

Results

Surgery was completed laparoscopically in all patients, except in five, where the operation was technically difficult due to pre-existing conditions. The complications we encountered during surgery and follow-up period were major intra-operative bleeding (n = 1, 0.33%), severe post-operative nausea and vomiting (n = 1, 0.33%), wound infection (n = 3, 1%), port-site herniation (n = 1, 0.33%), wrap-migration (n = 2, 0.66%), wrap-ischaemia (n = 1, 0.33%), recurrent regurgitation (n = 4, 1.32%), recurrent heartburn (n = 29, 9.63%), tension pneumothorax (n = 2, 0.66%), surgical emphysema (n = 8, 2.66%), and port-site pain (n = 4, 1.33%).

Conclusion

Minimal access approach to treat GORD has presented with some specific and unique complications. It is important to recognise these complications at the earliest possible stage as some of these patients may present in an acute setting requiring emergency surgery. All members of the department, and not just the members of the specialised team, should be aware about these complications to minimise the morbidity and mortality.

The use of medication after laparoscopic antireflux surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) significantly improves symptoms of gastro-esophageal reflux disease (GERD) and quality of life. Nevertheless, 14-62% of patients report using antisecretory medication after surgery, although only a tiny percentage has proven recurrence of GERD. We sought to determine symptoms of GERD, quality of life, and use of medication before and after LARS, and to compare our findings with those from previous studies.

METHODS

Five hundred fifty-three patients with GERD who underwent LARS were evaluated before and at 1 year after surgery. After surgery, multidisciplinary follow-up care was provided for all patients by surgeons, psychologists, dieticians, and speech therapists.

RESULTS

Symptoms of GERD and quality of life improved significantly and only 4.2% of patients still required medication after surgery [proton pump inhibitors (PPI) (98.4 vs. 2.2%; p < 0.01), prokinetics (9.6 vs. 1.1%; p < 0.01), and psychiatric medication (8 vs. 1.6%; p < 0.01)].

CONCLUSION

LARS significantly reduced medication use at 1-year follow-up. However, these effects might be attributed, in part, to the multidisciplinary follow-up care. Further studies are therefore required to investigate which patients may benefit from multidisciplinary follow-up care and whether its selective application may reduce the need for medication after LARS.

Ten-year results of a randomized clinical trial of laparoscopic total fundoplication with or without division of the short gastric vessels

BACKGROUND

Total fundoplication is the most common antireflux operation and can be performed with or without division of the short gastric vessels. There seems to be no difference in short-term outcomes with either approach. The aim of the study was to determine whether there were the long-term differences (after 10 years).

METHODS

Ninety-nine patients were enrolled in the study. Short gastric vessels were divided in 52 patients (group 1) and left intact in 47 (group 2). Ten patients were lost to follow-up and seven patients died, leaving 42 patients for analysis in group 1 and 40 in group 2. All patients were evaluated by standardized quality of life questionnaires.

RESULTS

Three patients underwent reoperation within 5 years. Thirty-eight of 42 patients with a completely mobilized fundus reported no reflux symptoms, compared with 31 of 40 patients with intact vessels. There were no differences between the groups in other symptoms reflecting post-fundoplication complaints and quality of life outcomes.

CONCLUSION

When total fundoplication is performed it makes no difference whether the fundus is mobilized or not. Both types of repair provide lasting control of reflux.

Antireflux transoral incisionless fundoplication using EsophyX: 12-month results of a prospective multicenter study

Background

A novel transoral incisionless fundoplication (TIF) procedure using the EsophyX system with SerosaFuse fasteners was designed to reconstruct a full-thickness valve at the gastroesophageal junction through tailored delivery of multiple fasteners during a single-device insertion. The safety and efficacy of TIF for treating gastroesophageal reflux disease (GERD) were evaluated in a prospective multicenter trial.

Methods

Patients (n = 86) with chronic GERD treated with proton pump inhibitors (PPIs) were enrolled. Exclusion criteria included an irreducible hiatal hernia > 2 cm.

Results

The TIF procedure (n = 84) reduced all hiatal hernias (n = 49) and constructed valves measuring 4 cm (2–6 cm) and 230° (160°–300°). Serious adverse events consisted of two esophageal perforations upon device insertion and one case of postoperative intraluminal bleeding. Other adverse events were mild and transient. At 12 months, aggregate (n = 79) and stratified Hill grade I tight (n = 21) results showed 73% and 86% of patients with ≥50% improvement in GERD health-related quality of life (HRQL) scores, 85% discontinuation of daily PPI use, and 81% complete cessation of PPIs; 37% and 48% normalization of esophageal acid exposure; 60% and 89% hiatal hernia reduction; and 62% and 80% esophagitis reduction, respectively. More than 50% of patients with Hill grade I tight valves had a normalized cardia circumference. Resting pressure of the lower esophageal sphincter (LES) was improved significantly (p < 0.001), by 53%. EsophyX-TIF cured GERD in 56% of patients based on their symptom reduction and PPI discontinuation.

Conclusion

The 12-month results showed that EsophyX-TIF was safe and effective in improving quality of life and for reducing symptoms, PPI use, hiatal hernia, and esophagitis, as well as increasing the LES resting pressure and normalizing esophageal pH and cardia circumference in chronic GERD patients.

Long-term results of laparoscopic Nissen fundoplication due to gastroesophageal reflux disease. A ten year follow-up in a low volume center

BACKGROUND AND AIMS

Laparoscopic 360 degrees nissen fundoplication has been our routine surgical procedure since 1995, in the treatment of gastroesophageal reflux disease (GERD). We have reviewed our results of patients treated with laparoscopic Nissen fundoplication (LNF) during 1995-1998.

MATERIAL AND METHODS

170 patients have undergone LNF in our hospital since 1995. during the period of 1995-1998, 33 patients were treated. all patients were asked to return a structured follow-up questionnaire, using a Visick grading scale, after an average of 69 months (2003) and 117 months (2007). 29 questionnaires (90%) were answered in 2003, and 31 questionnaires (97%) were answered in 2007. one patient died at home before the first questionnaire in 2003, and is therefore not included. We present our results on LNF after an observation time of 117 months (range 99-144 months).

RESULTS

patient satisfaction after LNF is rated as very good or good (Visick 1-2) in 93% in 2003 and 97% in 2007. 97% of the patients would recommend the same treatment to other patients with similar symptoms at ten year follow up. One patient has undergone resurgery during follow up. Daily gas bloat and flatulence is reported in 52% in 2003 and 39% in 2007, and is the most common reason for reduced satisfaction. Five patients report of reflux symptoms, one patient daily and four patients sometimes, where the first patient still uses proton pump inhibitor (PPI) daily and three patients use PPI occasionally.

CONCLUSIONS

patient satisfaction after LNF treatment for gerd is high at long-term (10 years) follow-up. Bloating and flatulence persistently occurred to a great extent and the need for preoperative information regarding these symptoms is important.

Ten-year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180( degrees ) partial fundoplication

BACKGROUND

A randomized trial of laparoscopic Nissen fundoplication and anterior 180 degrees partial fundoplication was undertaken to determine whether the anterior procedure might reduce the incidence of dysphagia and other adverse outcomes following surgery for gastro-oesophageal reflux disease. This study evaluated clinical outcomes after 10 years.

METHODS

Some 107 patients were randomized to undergo laparoscopic Nissen or anterior 180 degrees partial fundoplication. Ten-year data were not available for 18 patients. Information was obtained from 89 patients (48 Nissen, 41 anterior fundoplication) using a standard clinical questionnaire that focused on symptoms of reflux, potential postoperative side-effects and overall satisfaction with the outcome of surgery.

RESULTS

There were no significant differences between the two groups with regard to reflux symptoms, dysphagia, abdominal bloating, ability to belch and overall satisfaction. Between 5 and 10 years after surgery, revisional surgery was required for reflux in two patients after anterior fundoplication. Two patients had revision after Nissen fundoplication, for reflux and recurrent hiatus hernia.

CONCLUSION

Both laparoscopic anterior 180 degrees partial and Nissen fundoplication are safe, effective and durable at 10 years' follow-up. Most patients are satisfied with the clinical outcome.

Surgical management of gastroesophageal reflux disease

Managing gastroesophageal reflux disease (GERD) is difficult because it is a chronic relapsing disease. Surgical management of GERD is indicated only after medical management has failed. In patients who have the most advanced forms of GERD, surgical therapy is good for treating symptoms and healing esophagitis, but far from a gold standard. Freedom from symptoms, side effects, medical therapy, or reoperation cannot be guaranteed. Care must be taken when prescribing surgery for GERD, and it is best that an experienced surgeon at a specialty center participate in the patient's lifelong care.

Magnetic augmentation of the lower esophageal sphincter: results of a feasibility clinical trial

BACKGROUND

The high prevalence of gastroesophageal reflux disease continues to encourage the development of treatment modalities to fill the gap between acid-suppression therapy and the laparoscopic Nissen fundoplication. The Magnetic Sphincter Augmentation device has been designed to augment the lower esophageal sphincter barrier using magnetic force. A multi-center feasibility trial was done to evaluate safety and efficacy.

METHODS

Patients with typical heartburn (at least partially responding to proton-pump inhibitors), abnormal esophageal acid exposure, and normal esophageal peristalsis were enrolled. Patients with hiatal hernia >3 cm were excluded from the study. The device was implanted laparoscopically around the distal esophagus.

RESULTS

Over a 1-year period, 38 out of 41 enrolled patients underwent this procedure in 3 hospitals. No operative complications were recorded. A free diet was allowed since post-operative day one, and 97% of patients were discharged within 48 h. The mean follow-up was 209 days (range 12-434 days). The GERD-HRQL score decreased from 26.0 to 1.0 (p < 0.005). At 3 months post-operatively, 89% of patients were off anti-reflux medications, and 79% of patients had a normal 24-h pH test. All patients preserved the ability to belch. Mild dysphagia occurred in 45% of patients. No migrations or erosions of the device occurred.

CONCLUSIONS

Laparoscopic implant of the MSA device is safe and well tolerated. It requires minimal surgical dissection and a short learning curve compared to the conventional Nissen fundoplication.

[Less reflux recurrence following Nissen fundoplication : results of laparoscopic antireflux surgery after 10 years]

BACKGROUND

Reflux recurrence is the most common long-term complication following fundoplication. Results for different techniques of laparoscopic antireflux surgery were retrospectively compared after 10 years.

METHODS

From 1992 to 1997, the 120 patients studied had laparoscopic fundoplication with 'tailored' approaches: 88 Nissen, 22 anterior, and ten Toupet fundoplications. Follow-up of 87% of these patients included disease-related questions and the gastrointestinal quality of life index (GIQLI).

RESULTS

Of the patients, 89% would select surgery again. Regurgitations after fundoplication were noted from 15% of patients after Nissen, 44% after anterior, and 10% after Toupet types (P=0.04). Twenty-eight percent were on acid suppression therapy. Proton pump inhibitors were used less frequently following Nissen fundoplication (P=0.01). The GIQLI score was 110+/-24 without significant differences for type of fundoplication.

DISCUSSION

Overall results are satisfactory after 10 years of experience with fundoplication. Total fundoplication appears to control reflux better than partial fundoplication.

Ten-year outcome of laparoscopic antireflux surgery

BACKGROUND

Reflux recurrence is the most common long-term complication of fundoplication. Its frequency was independent from the type of fundoplication in randomized studies. Results for different techniques of laparoscopic antireflux surgery were retrospectively evaluated after 10 years.

METHODS

From 1992 to 1997, 120 patients had primary laparoscopic fundoplication with a "tailored approach" (type of wrap chosen according to esophageal peristalsis): 88 received a Nissen, 22 an anterior, and 10 a Toupet fundoplication. Follow-up of 87% of the patients included disease-related questions and the gastrointestinal quality-of-life index (GIQLI).

RESULTS

Of the patients, 89% would select surgery again. Heartburn was reported by 30% of the patients. Regurgitations were noted from 15% of patients after a Nissen, 44% after anterior fundoplication, and 10% after a Toupet (p = 0.04). Twenty-eight percent were on acid-suppressive drugs again. Following Nissen fundoplication, proton pump inhibitors were less frequently used (p = 0.01) and on postoperative pH-metry reflux recurrence rate was lower (p = 0.04). The GIQLI was 110 +/- 24 without significant differences for the type of fundoplication.

DISCUSSION

Ten years after laparoscopic fundoplication, overall outcome is good. A quarter of the patients are on acid-suppressive drugs. Nissen fundoplication appears to control reflux better than a partial fundoplication.

Endolumenal fundoplication with EsophyX: the initial North American experience

EsophyX is a novel endolumenal therapeutic option for the treatment of gastroesophageal reflux disease (GERD). The device is passed into the stomach, where it deploys a series of full-thickness fasteners to create a neogastroesophageal valve. The objective of this study was to demonstrate the safety and characterize the effectiveness of this approach in the initial North American experience. This is a retrospective study of consecutive patients with GERD who had undergone endolumenal fundoplication with the EsophyX device. At follow-up, proton pump inhibitor usage was elicited and 2 validated questionnaires were administered measuring GERD health-related quality of life (range 0-50) and symptom severity (range 0-72). In limited preliminary evaluation, the initial North American experience with endolumenal fundoplication using the EsophyX device is that it appears to be safe and provides moderate effectiveness in treating the symptoms of GERD. Further studies comparing this technique with conventional medical and surgical therapies are necessary.

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).

Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux disease

Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.

Laparoscopic mesh-augmented hiatoplasty as a treatment of gastroesophageal reflux disease and hiatal hernias-preliminary clinical and functional results of a prospective case series

BACKGROUND

Because fundoplication-related side effects are frequent, we evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as a potential treatment option for gastroesophageal reflux disease and/or symptomatic hiatal herania. LMAH aims to prevent reflux solely by mesh-reinforced narrowing of the hiatus and lengthening of the intra-abdominal esophagus.

METHODS

Twenty-two consecutive patients with LMAH were evaluated prospectively using a modified Gastrointestinal Symptom Rating Scale questionnaire, pH measurement, manometry, and endoscopy. Follow-up was scheduled at 3 and 12 months after surgery.

RESULTS

Total reflux decreased from 16.3% before surgery to 3.5% 3 months after surgery (P = .001). The reflux score decreased from 3.8 before surgery to 2.1 1 year after surgery (P = .001). The respective values of the indigestion score were 3.4 and 2.0 (P < .001). After surgery, all patients were able to belch. Vomiting was impossible only for 2 patients, and 90% of patients assessed their results as good to excellent.

CONCLUSIONS

LMAH seems to be feasible, safe, and has no significant side effects.

Nissen versus Toupet fundoplication: results of a randomized and multicenter trial

BACKGROUND

Laparoscopic Toupet fundoplication (TF) is reported to be as effective as Nissen (NF), but to be associated with fewer unfavorable postoperative side-effects. This study evaluates the one- and three-year clinical outcome of 140 randomized patients after a laparoscopic NF or TF.

PATIENTS AND METHODS

Inclusion criteria included patients over 16 years old with complications of gastro-oesophageal reflux disease (GORD) and persistence or recurrence of symptoms after three months of treatment. Subjects with a previous history of gastric surgery or repeated fundoplication, brachy-oesophagus or severe abnormal manometry results were excluded. Seventy-seven NF and 63 TF were performed. The severity of symptoms was assessed before and after the procedure.

RESULTS

One hundred and twenty-one of the 140 patients after one year, and 118 after three years, were evaluated and no statistically significant clinical difference was observed. The level of satisfaction concerning the outcome of the operation remained high after one or three years regardless of the type of fundoplication performed.

CONCLUSIONS

Functional complications after NF are not avoided with TF.

Systematic review: endoluminal therapy for gastro-oesophageal reflux disease: evidence from clinical trials

During the last few decades many endoscopic interventions have been developed as an alternative for the treatment of gastro-oesophageal reflux disease (GORD). In many countries, these interventions are thus being performed in the general clinical setting. The aim of this study is to systematically review the evidence on the effect of endoscopic therapies for GORD. A systematic search of the literature on this subject in English, indexed in MEDLINE (1966 to May 2007) and in the Cochrane Library, was carried out. For the study selection, retrospective and prospective open-label and randomized, sham-controlled trials were taken into account. The exclusion criteria included the following: case series that included fewer than 10 patients, abstracts, studies involving children or those with a follow-up shorter than 3 months. For data extraction, two reviewers, using standardized forms, independently abstracted data on study design and methods, population, sample size, function studies (e.g. pH-metry), type of endoscopic treatment, follow-up, health-related and quality of life scores, outcomes and complications. Data synthesis involved the following: 43 studies, including four randomized, sham-controlled trials that met the inclusion criteria, out of 4182 citations. The primary end point in most studies was the reduction of the use of proton pump inhibitors (PPIs) by more than 50%. In view of these findings, the majority of studies suggested the efficacy of endoluminal therapies for the control of symptoms in GORD. In the sham-controlled studies, the effect of placebo was, nevertheless, as high as 50%. Most studies were small feasibility studies, with follow-ups of less than 1 year. No study comparing endoscopic techniques with other established treatment options such as PPIs existed. All endoscopic therapies were associated with a small but important percentage of mild to severe complications, which included perforation, abscess and death. In conclusion, the data from most of the short-term follow-up and the few sham-controlled studies demonstrate that subgroups of patients experienced improvement or resolution of typical GORD symptoms and decreased PPI usage. Currently, however, there are not enough scientific and clinical data on safety, efficacy and durability to support the use of endoluminal therapies for GORD in routine clinical practice.

Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up: a new surgical procedure

BACKGROUND

Although laparoscopic repair of large, mostly paraesophageal hiatal hernias is widely applied, there is a great concern regarding the higher recurrence rate associated with this procedure. In order to reduce this high recurrence rate, several techniques have been developed, mostly applying a mesh prosthesis for hiatal reinforcement.

METHODS

We have recently introduced a new laparoscopic technique in which the hiatal closure is reinforced with the teres ligament. To date 26 patients have been entered into this ongoing prospective study. After the operation patients were called back on a regular basis for symptom evaluation and barium swallow. All 26 patients agreed to undergo barium swallow, with a mean follow-up of 35 months.

RESULTS

The mean operative time was 115 min. Perioperative morbidity was 11.5%, and conversion to an open procedure was performed in six cases. No mortality was registered. Anatomic recurrence, investigated by barium swallows was observed in four patients (15.3%). Of those four, only one (3.85%) had a symptomatic recurrent paraesophageal hernia; the other three had asymptomtic sliding hernias. In three of the four patients with anatomic recurrence, the diameter of the hiatal hernia was greater than 9 cm at the original operation, and the fourth patient underwent reoperation for recurrent hiatal hernia. No symptomatic recurrence was found in patients with diameter of hiatal hernia between 6 and 9 cm.

CONCLUSIONS

Laparoscopic reinforcement of the hiatal closure with the ligamentum teres is safe and effective treatment for large hiatal hernias. However, it appears that patients with extremely large hiatal hernias are at greater risk of recurrence, and therefore large hernias are not suitable for this new technique.

Is there a changing trend in surgical management of gastroesophageal reflux disease in children?

Gastroesophageal reflux disease (GORD) is a pathological process in infants manifesting as poor weight gain, signs of esophagitis, persistent respiratory symptoms and changes in neurobehaviour. It is currently estimated that approximately one in every 350 children will experience severe symptomatic gastroesophageal reflux necessitating surgical treatment. Surgery for GORD is currently one of the common major operations performed in infants and children. Most of the studies found favour laparoscopic approach which has surpassed open antireflux surgery as the gold standard of surgical management for GORD. However, it must be interpreted with caution due to the limitation of the studies, especially the small number of subject included in these studies. This review reports the changing trends in the surgical treatment of GORD in children.

Laparoscopic Nissen fundoplication: clinical outcomes at 10 years

BACKGROUND

Laparoscopic Nissen fundoplication is now the most common operative procedure for treatment of gastroesophageal reflux disease, although longterm clinical outcomes after this procedure remain uncertain.

STUDY DESIGN

Outcomes for 250 patients who underwent Nissen (total) fundoplication at least 10 years ago (September 1991 to August 1995) were determined prospectively using a structured questionnaire that evaluated clinical symptom scores for heartburn, dysphagia, and satisfaction with clinical outcomes.

RESULTS

Clinical followup data for at least 10 years (120 to 167 months) after operation were available for 226 patients, an additional 21 patients had died, making outcomes for 247 patients (99%). Of the three (1%) remaining patients, one was lost to followup and dementia developed in two. One hundred eighty-seven (83%) patients were highly satisfied with the clinical outcomes. One hundred eighty-nine (84%) had good or excellent control of heartburn. Symptom scores for heartburn, dysphagia, and overall satisfaction were unchanged from 5-year followup data. Forty-two (17%) patients underwent revision operations, 28 (22%) were in the first 125 patients and 14 (11%) in the subsequent 125 patients. Antireflux medication use increased gradually, resulting in 47 (21%) patients using medication at 10 years. Of 21 deaths, 1 was postoperative and the remaining 20 were similar to that predicted for a matched population. A high preoperative heartburn score correlated with high patient satisfaction and lower dysphagia score at 10 or more years (p = 0.038 and p = 0.041, respectively).

CONCLUSIONS

Laparoscopic Nissen fundoplication is an effective longterm treatment for gastroesophageal reflux disease.

Ten-Year Follow up after Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease

Laparoscopic Nissen fundoplication was first undertaken in the early 1990s. Appreciable numbers of patients with 10-year follow up are only now available. This study assesses long-term outcome and durability of outcome after laparoscopic Nissen fundoplication for treatment of gastro-esophageal reflux disease. Since 1991, 829 patients have undergone laparoscopic fundoplications and are prospectively followed. Two hundred thirty-nine patients, 44 per cent male, with a median age of 53 years (± 15 standard deviation) underwent laparoscopic Nissen fundoplications at least 10 years ago; 28 (12%) patients were “redo” fundoplications. Before and after fundoplication, among many symptoms, patients scored the frequency and severity of dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before versus after fundoplication were compared using a Wilcoxon matched-pairs test. Data are reported as median, mean ± standard deviation, when appropriate. After fundoplication, length of stay was 2 days, 3 days ± 4.8. Intra-operative inadvertent events were uncommon and without sequela: 1 esophagotomy, 1 gastrotomy, 3 cardiac dysrhythmias, and 3 CO2 pneumothoraces. Complications after fundoplication included: 1 postpneumonic empyema, 3 urinary retentions, 2 superficial wound infections, 1 urinary tract infection, 1 ileus, and 1 intraabdominal abscess. There were two perioperative deaths; 88 per cent of the patients are still alive. After laparoscopic Nissen fundoplication, frequency and severity scores dramatically improved for all symptoms queried (P < 0.001), especially for heartburn frequency (8, 8 ± 3.2 versus 2, 3 ± 2.8, P < 0.001) and severity (10, 8 ± 2.9 versus 1, 2 ± 2.5, P < 0.001). Eighty per cent of patients rate their symptoms as almost completely resolved or greatly improved, and 85 per cent note they would again have the laparoscopic fundoplication as a result of analysis of our initial experience, thereby promoting superior outcomes in the future. Nonetheless, follow up at 10 years and beyond of our initial experience documents that laparoscopic fundoplication durably provides high patient satisfaction resulting from long-term amelioration of the frequency and severity of symptoms of gastroesophageal reflux disease. These results promote further application of laparoscopic Nissen fundoplication.

Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes

BACKGROUND

A small but significant percentage of patients are considered failures after laparoscopic Nissen fundoplication (LNF). We sought to identify preoperative predictors of failure in a cohort of patients who underwent LNF more than 10 years ago.

METHODS

Of 312 consecutive patients undergoing primary LNF between 1992 and 1995, recent follow-up was obtained from 166 patients at a mean of 11.0 +/- 1.2 years. Eight additional patients who underwent reoperation were lost to follow-up but are included. Failure is broadly defined as any reoperation, lack of satisfaction, or any severe symptoms at follow-up. Potential predictors evaluated included sex, age, body-mass index (BMI), response to acid reducing medications (ARM), psychiatric history, typical versus atypical symptoms, manometry, esophageal pH, and others. Logistic regression was used to assess significance of predictors in univariate analysis.

RESULTS

Of 174 known outcomes, 131 were classified as successful (75.3%), while 43 were failures (24.7%): 26 reoperations, 13 unsatisfied, and 13 with severe symptoms. Response and lack of response to ARM were associated with 77.1% and 56.0% success rates respectively (P = 0.035). Eighty five percent of patients with typical symptoms had a successful outcome, compared to only 41% with atypical symptoms (P < 0.001). Preoperative morbid obesity (BMI > 35 kg/m2) was associated with failure (P = 0.036), while obesity (BMI 30-34.9 kg/m2) was not. A history of psychiatric illness trended toward significance (P = 0.06).

CONCLUSIONS

In a cohort with 11 years follow-up after LNF, factors predictive of a successful outcome include preoperative response to ARM, typical symptoms, and BMI < 35 kg/m2. Patients with atypical symptoms, no response to ARM, or morbid obesity should be informed of their higher risk of failure. Some patients in these groups do have successful outcomes, and further research may clarify which of these patients can benefit from LNF.

The durability of laparoscopic Nissen fundoplication: 11-year outcomes

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure since its introduction in 1991. There are few studies with greater than 5-year outcomes. Herein we report a series of 312 consecutive patients who underwent primary LNF before 1996. Follow-up of more than 6 years was available in 166 patients, and the mean follow-up was 11 years (median 11.1 years, range 6.1-13.3 years). Prospective data collection included preoperative and current symptom scores (scale 0 = none to 3 = severe), as well as the level of patient satisfaction and use of antireflux medications. Total symptom score for each patient was summed from seven symptoms for a maximum value of 21. Heartburn and regurgitation were the most improved symptoms; however, all symptoms were significantly improved (P < 0.01). The total symptom score at follow-up was 2.6 down from 7.5 at baseline, with a mean difference of -4.9 (range -12 to 3). The percentage of patients stating they would have the procedure again was 93.3%, and 70% were off daily antireflux medications. Outcomes at a mean of 11 years after LNF are excellent, and the majority of patients had their symptoms resolved or significantly improved and are satisfied with their results.

An anterior or posterior approach to partial fundoplication? Long-term results of a randomized trial

BACKGROUND

Partial fundoplications have been popularized by their lower risk of mechanical side effects. The question then emerges whether a similar partial wrap should be done posterior or anterior to the distal esophagus? We therefore conducted a study to compare the long-term outcome of laparoscopic partial fundoplications constructed either as anterior (AF) or posterior (PF) repairs.

PATIENTS AND METHODS

Ninety-five patients were enrolled in a randomized clinical trial. After a mean follow up of 65 months, 43 AF and 45 PF patients remained in the study. The levels of reflux control and postfundoplication complaints were assessed by use of validated instruments.

RESULTS

A posterior fundoplication was found to provide significantly better control of reflux related symptoms (heartburn p < 0.0001, acid regurgitation p < 0.0001). This was also reflected in a significantly lower number of reoperations and need for antisecretory drug therapy. The earlier postoperative difference in postfundoplication symptoms had disappeared.

CONCLUSIONS

A laparoscopic posterior partial fundoplication offers a high and durable level of disease control with few side effects. The current anterior type of repair cannot be recommended due to insufficient reflux control.

Gas-related symptoms after laparoscopic 360 degrees Nissen or 270 degrees Toupet fundoplication in gastrooesophageal reflux disease patients with aerophagia as comorbidity

BACKGROUND

Aerophagia is a rare but well-known comorbidity in patients with gastrooesophageal reflux disease. Particularly after laparoscopic Nissen fundoplication, it has proven to result in worse symptomatic outcome and a lower postoperative quality of life in comparison to patients without preoperative gas-related symptoms.

AIMS

Aim of the study was to compare the postoperative outcome in gastrooesophageal reflux disease patients with aerophagia as comorbidity after either laparoscopic 360 degrees 'floppy' Nissen fundoplication or 270 degrees Toupet fundoplication with main focus on the frequency and subjective impairment of gas-related symptoms.

PATIENTS AND METHODS

In 56 gastrooesophageal reflux disease patients, the comorbidity of aerophagia was diagnosed prior to laparoscopic antireflux surgery. Irrespective of their preoperative manometric findings, the patients were either scheduled to a laparoscopic 360 degrees 'floppy' Nissen (n=28) or a laparoscopic 270 degrees Toupet fundoplication (n=28). All patients have been analysed concerning the presence of gas-related symptoms preoperatively as well as 3 months after surgery. Additionally, the subjective degree of impairment was evaluated using a numerous rating scale (0=no perception/impairment, 100=most severe perception/impairment). The following symptoms have been analysed: ability/inability to belch, 'gas bloat', flatulence, postprandial fullness and epigastric pain.

RESULTS

Before surgery, there were no significant differences between both surgical groups. Three months after surgery, significant differences (p<0.05-0.01) were found: patients who underwent a laparoscopic 270 degrees Toupet fundoplication suffered from less impairing gas bloat, flatulence and postprandial fullness when compared with patients with a 360 degrees 'floppy' Nissen fundoplication. The majority of these patients were able to belch postoperatively but felt no impairment due to this symptom. In contrast, patients of the Nissen group felt a significant impairment due to the inability to belch.

CONCLUSION

Gas-related symptoms are very common in gastrooesophageal reflux disease patients with aerophagia as a comorbidity. Patients who undergo a laparoscopic Toupet fundoplication show less impairment in relation to gas-related problems compared with patients treated with a Nissen fundoplication for a follow-up period of at least 3 months. In the Toupet group, the ability to belch postoperatively seems to be a positive aspect from the patients' view which also improves the percentage of gas-related problems. However, long-term results are necessary.

Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing

BACKGROUND

For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans.

METHODS

The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting.

RESULTS

The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods.

CONCLUSION

According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

Quality of life and patient satisfaction after laparoscopic antireflux surgery using the QOLARS questionnaire

BACKGROUND

Currently, evaluation of patient satisfaction and quality-of-life data to estimate the outcome of laparoscopic antireflux surgery is an important issue. This study aimed first to report the midterm results for the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic fundoplication and to evaluate surgical outcome, including quality of life and patient satisfaction. The second aim was to determine whether preoperative quality-of-life measurement can predict which patients will be satisfied with antireflux surgery.

METHODS

The current prospective study evaluated the outcome of the quality-of-life data for 41 patients (13 men and 28 women) who underwent laparoscopic fundoplication in the author's department of surgery between 1 January 2002 and 31 May 2003. The mean age of the patients was 41 years. Quality of life was measured by using a new quality-of-life instrument (QOLARS) developed and validated by the author's study group. The patients completed the QOLARS questionnaire before surgery, then 6 weeks, 1 year, and 3 years after surgery.

RESULTS

Before surgery, all the patients had a poor quality of life. The general quality-of-life and heartburn scores improved significantly within 6 weeks after surgery and showed further improvement by the end of the first postoperative year, then remained stable 3 years after surgery. The patients who became completely free of reflux-related symptoms were divided into two groups according to their satisfaction with the operative result. The patients dissatisfied with surgery had significantly worse median preoperative scores in four domains (physical functioning, emotional functioning, sleep disturbance, constipation) than the patients satisfied with the procedure.

CONCLUSIONS

The findings show that QOLARS is a sensitive tool for assessing surgical outcome after laparoscopic antireflux surgery. The quality-of-life response closely follows the clinical outcome of surgical treatment, reflecting its side effects as well. This study suggests that a generic quality-of-life scale can preoperatively identify patients with GERD who are likely to be dissatisfied with antireflux surgery.

Gastrectomy as a remedial operation for failed fundoplication

The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997-2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients' overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty.

Effect of partial and total laparoscopic fundoplication on esophageal body motility

BACKGROUND

Abnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis.

METHODS

The pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14).

RESULTS

The LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B.

CONCLUSIONS

Laparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients.