Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease

Systematic review of the perioperative classification, diagnosis, description and repair of hiatus hernias in randomized controlled trials

Hiatus hernias (HH) are a common cause of symptoms and complications, with considerable variation in anatomy, function, diagnosis and treatment. We undertook the first systematic review to appraise how HH are diagnosed and classified in the literature, using randomized controlled trials as a sample. A search was performed in July 2021of the PubMed, EMBASE and Cochrane Central Register of Controlled Trials, and 2832 articles were identified and 64 were included. Median Jadad score was 2. Studies demonstrated considerable variation in diagnosis, classification and minimum surgical steps. The commonest classifications before surgery were axial length and the Type I-IV classification, variably assessed by endoscopy and contrast swallow. Intra-operatively, the commonest classification was type I-IV. A minority used more than one classification, or alternatives such as defect size and Hill classification. Most studies reported minimum steps, but these varied. Only a minority reported criteria for diagnosing recurrence. Using randomized controlled trials to appraise the highest quality evidence in the literature, we found considerable variation and inconsistency in the way HH are diagnosed and classified. This lack of a 'common language' has significant impacts for the generalizability of evidence, study synthesis and design. We propose the development of an internationally accepted classification. We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

Secondary peristalsis and esophagogastric junction distensibility in symptomatic post-fundoplication patients

BACKGROUND

The impact of esophageal dysmotility among patients with post-fundoplication esophageal symptoms is not fully understood. This study aimed to investigate secondary peristalsis and esophagogastric junction (EGJ) opening biomechanics using functional lumen imaging probe (FLIP) panometry in symptomatic post-fundoplication patients.

METHODS

Eighty-seven adult patients post-fundoplication who completed FLIP for symptomatic esophageal evaluation were included. Secondary peristaltic contractile response (CR) patterns and EGJ opening metrics (EGJ distensibility index (EGJ-DI) and maximum EGJ diameter) were evaluated on FLIP panometry and analyzed against high-resolution manometry (HRM), patient-reported outcomes, and fundoplication condition seen on esophagram and/or endoscopy.

KEY RESULTS

FLIP CR patterns included 14 (16%) normal CR, 30 (34%) borderline CR, 28 (32%) impaired/disordered CR, 13 (15%) absent CR, and 2 (2%) spastic reactive CR. Compared with normal and borderline CRs (i.e., CR patterns with distinct, antegrade peristalsis), patients with impaired/disordered and absent CRs demonstrated significantly greater time since fundoplication (2.4 (0.6-6.8) vs. 8.9 (2.6-14.5) years; p = 0.002), greater esophageal body width on esophagram (n = 50; 2.3 (2.0-2.8) vs. 2.9 (2.4-3.6) cm; p = 0.013), and lower EGJ-DI (4.3 (2.7-5.4) vs. 2.6 (1.7-3.7) mm2/mmHg; p = 0.001). Intact fundoplications had significantly higher rates of normal CRs compared to anatomically abnormal (i.e., tight, disrupted, slipped, herniated) fundoplications (9 (28%) vs. 5 (9%); p = 0.032), but there were no differences in EGJ-DI or EGJ maximum diameter.

CONCLUSIONS & INFERENCES

Symptomatic post-fundoplication patients were characterized by frequent abnormal secondary peristalsis after fundoplication, potentially worsening with time after fundoplication or related to EGJ outflow resistance.

Initial 30 cholecystectomy procedures performed with the Senhance digital laparoscopy system

PURPOSE

The Senhance digital laparoscopy system (SDLS) is a novel platform developed for digitization in endoscopic surgery. This retrospective study aimed to evaluate the short-term outcome in the initial 30 consecutive patients.

METHODS

SDLS cholecystectomies were performed in 30 consecutive patients (13 male, 17 female) by a single surgeon from September 2020 to March 2022. The patients' median age (range) was 77.5 (27-82) years, and median body mass index was 23.3 (19-38) kg/m² . Four trocars were used, three of which were docked to manipulator arms of the SDLS. Surgical procedures performed with the SDLS were almost the same as those by conventional surgery.

RESULTS

Median docking time, cockpit time, and operation time in minutes were 4 (3-13), 34 (13-81), and 69 (47-201), respectively. Operation time after the sixth case tended to shorten compared with that for the initial five cases. Three cases (10%) were converted to conventional laparoscopic surgery due to severe cholecystitis, but none required conversion to open surgery. Postoperative complications of Clavien-Dindo grade ≥II were not observed.

CONCLUSION

This retrospective study showed that cholecystectomy using the SDLS appeared to be safe and feasible in limited cases without severe inflammation.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF).

SUMMARY OF BACKGROUND DATA

Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair.

METHODS

A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%).

CONCLUSIONS

LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

Survival after antireflux surgery versus medication in patients with reflux oesophagitis or Barrett's oesophagus: multinational cohort study

BACKGROUND

The aim was to examine the hypothesis that antireflux surgery with fundoplication improves long-term survival compared with antireflux medication in patients with reflux oesophagitis or Barrett's oesophagus.

METHOD

Individuals aged between 18 and 70 years with reflux oesophagitis or Barrett's oesophagus (intestinal metaplasia) documented from in-hospital and specialized outpatient care were selected from national patient registries in Denmark, Finland, Iceland, and Sweden from 1980 to 2014. The study investigated all-cause mortality and disease-specific mortality, comparing patients who had undergone open or laparoscopic antireflux surgery with fundoplication versus those using antireflux medication. Multivariable Cox regression analysis was used to estimate hazard ratios (HRs) with 95 per cent confidence intervals for all-cause mortality and disease-specific mortality, adjusted for sex, age, calendar period, country, and co-morbidity.

RESULTS

Some 240 226 patients with reflux oesophagitis or Barrett's oesophagus were included, of whom 33 904 (14.1 per cent) underwent antireflux surgery. The risk of all-cause mortality was lower after antireflux surgery than with use of medication (HR 0.61, 95 per cent c.i. 0.58 to 0.63), and lower after laparoscopic (HR 0.56, 0.52 to 0.60) than open (HR 0.80, 0.70 to 0.91) surgery. After antireflux surgery, mortality was decreased from cardiovascular disease (HR 0.58, 0.55 to 0.61), respiratory disease (HR 0.62, 0.57 to 0.66), laryngeal or pharyngeal cancer (HR 0.35, 0.19 to 0.65), and lung cancer (HR 0.67, 0.58 to 0.80), but not from oesophageal cancer (HR 1.05, 0.87 to 1.28), compared with medication, The decreased mortality rates generally remained over time.

CONCLUSION

In patients with reflux oesophagitis or Barrett's oesophagus, antireflux surgery is associated with lower mortality from all causes, cardiovascular disease, respiratory disease, laryngeal or pharyngeal cancer, and lung cancer, but not from oesophageal cancer, compared with antireflux medication.

Short-term parent reported recovery following open and laparoscopic fundoplication

BACKGROUND

It is assumed that children recover faster after laparoscopic (LF) than after open fundoplication (OF). As this has not been confirmed in any randomized study (RCT), we have in a subsection of a larger RCT compared parent reported recovery of children after LF and OF.

METHODS

Postoperative symptoms, use of analgesics, overall well-being, and time to return to school/day-care were recorded in a subsection of children enrolled in a RCT comparing LF and OF. Ethical approval and parental consent were obtained.

RESULTS

Fifty-five children (LF: n = 27, OF: n = 28) of the 88 enrolled in the RCT, were included in the short term follow up on parent reported recovery. Caregivers were interviewed median 28 days [interquartile range (IQR) 22-36] postoperatively. There was no significant difference regarding improvement in overall well-being (LF: 63%, OF: 68%, p = 0.70), new-onset dysphagia (LF: 30%, OF: 18%, p = 0.08), use of analgesics (LF: 15%, OF: 14%, p = 1.00), or time to return to school/day-care (LF: median 7 days [IQR 5-14] vs. OF: 12 days [IQR 7-15], p = 0.35).

CONCLUSION

We could not demonstrate faster recovery after LF than after OF. Most children had returned to school/day-care after 2 weeks and had improved overall well-being 1 month after surgery.

TYPE OF STUDY

Randomized controlled trial.

LEVEL OF EVIDENCE

Level II.

Non-active implantable device treating acid reflux with a new dynamic treatment approach: 1-year results : RefluxStop™ device; a new method in acid reflux surgery obtaining CE mark

Background

RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected.

Methods

In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction.

Results

There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects.

Conclusion

The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced.

Trial registration

ClinicalTrials.gov, NCT02759094. Registered 3 May, 2016,

Comparison of the outcome of laparoscopic procedures for GERD

A total laparoscopic fundoplication has become the procedure of choice for the surgical treatment of gastroesophageal reflux disease in patients with normal esophageal motility, with reduced postoperative pain, faster recovery and similar long-term outcomes compared to conventional open total fundoplication. Most controversial surgical aspects are the division of the short gastric vessels and the insertion of a bougie to calibrate the wrap. The anterior 180° and the posterior partial fundoplications lead to similar control of heartburn when compared to total fundoplication with lower risk of dysphagia. However, when performed, 24-h pH monitoring shows pathologic reflux more frequently after partial than total fundoplication. Disappointing results are achieved by anterior 90° partial fundoplication. More recently, a magnetic sphincter augmentation with the LINX Reflux Management System (Torax Medical) and the lower esophageal sphincter Electrical Stimulation (EndoStim) have been developed, seeking for a durable and effective minimally invasive alternative to laparoscopic fundoplication for the treatment of reflux. Both devices seem to be promising, with very low postoperative complications and good short-term functional outcomes. Large randomized controlled trials comparing them with laparoscopic fundoplication over a long period of follow-up are needed to verify their indications and outcomes.

"The missing LINX" for gastroesophageal reflux disease: Operative techniques video for the Linx magnetic sphincter augmentation procedure

In 2012 the FDA approved a magnetic sphincter augmentation (MSA) device (LINX, Torax Medical, Inc) for placement around the lower esophageal sphincter as an alternative approach to fundoplication for gastroesophageal reflux disease (GERD). This is a relatively new procedure and there is not widespread familiarization with the standard indications and techniques of device placement. We present two operative videos to highlight the standard surgical technique and technical points needed for successful LINX placement. First will be placement in a standard indications setting of uncomplicated GERD with no hiatal hernia. Second will be placement with complicated anatomy due to alterations from prior gastric surgery and a hiatal hernia. Our experience has revealed that the LINX device can be placed safely in patients with normal or significantly altered anatomy but requires adherence to several key principles and technical points. This procedure offers a new option that is anatomically and physiologically unique compared to standard fundoplication, and that offers highly effective control of GERD with a less invasive approach.

Comparative Analysis of Perioperative Outcomes and Costs Between Laparoscopic and Open Antireflux Surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) has proven to be as effective as open antireflux surgery (OARS), but it is associated with a shorter hospital stay and a faster recover. The aims of this study were to assess the national use of LARS in the US and to compare the perioperative outcomes between laparoscopic and open antireflux procedures in a national cohort.

STUDY DESIGN

A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000 to 2013. The study included adult patients (18 years and older) diagnosed with gastroesophageal reflux disease (GERD), who underwent either laparoscopic or open fundoplication. Multivariable linear and logistic regression, adjusted for patient demographics, comorbidities, and hospital characteristics were used to assess the effect of the laparoscopic approach on patient outcomes.

RESULTS

A total of 75,544 patients were included, with 44,089 having LARS (58.4%) and 31,455 having OARS (41.6%). The rate of laparoscopic procedures increased from 24.8 LARS per 100 procedures in 2000, to 84.3 LARS per 100 procedures in 2013 (p < 0.0001). Patients undergoing laparoscopic surgery were less likely to experience postoperative venous thromboembolism, wound complications, infection, esophageal perforation, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality. On average, the laparoscopic approach reduced length of stay by 2.1 days, and decreased hospital charges by $9,530.

CONCLUSIONS

The use of the laparoscopic approach for the surgical treatment of GERD has increased significantly in the last decade in the US. This approach is associated with lower morbidity and mortality, shorter hospital stay, and lower costs for the health care system.

Short- and Long-Term, 11-22 Years, Results after Laparoscopic Nissen Fundoplication in Obese versus Nonobese Patients

BACKGROUND

Some studies suggest that obesity is associated with a poor outcome after Laparoscopic Nissen Fundoplication (LNF), whereas others have not replicated these findings. The effect of body mass index (BMI) on the short- and long-term results of LNF is investigated.

METHODS

Inclusion criteria were only patients who undergone a LNF with at least 11-year follow-up data available, patients with preoperative weight and height data available for calculation of BMI (Kg/m²), and patients with a BMI up to a maximum of 34.9.

RESULTS

201 patients met the inclusion criteria: 43 (21.4%) had a normal BMI, 89 (44.2%) were overweight, and 69 (34.4%) were obese. The operation was significantly longer in obese patients; the use of drains and graft was less in the normal BMI group (p < 0.0001). The hospital stay, conversion (6,4%), and intraoperative and early postoperative complications were not influenced by BMI.

CONCLUSIONS

BMI does not influence short-term outcomes following LNF, but long-term control of reflux in obese patients is worse than in normal weight subjects.

Incidence, reasons, and risk factors for readmission after surgery for benign distal esophageal disease

BACKGROUND

Our aim was to ascertain the incidence of, reasons for, and risk factors associated with hospital readmission after an operation for benign distal esophageal disease.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2014), patients with a primary diagnosis of gastroesophageal reflux disease, paraesophageal hiatal hernia, or achalasia who underwent fundoplication, paraesophageal hernia repair, or Heller myotomy were identified. The primary outcome was hospital readmission. Multivariable logistic regression analysis was used to identify risk factors associated with hospital readmission.

RESULTS

Of the 14,478 patients included in this study, 801 (5.5%) were readmitted at a median of 11 days (interquartile range 6-17) postprocedure. Intolerance of oral intake (21.8%), respiratory complications (11.6%), abdominal pain (6.0%), and venous thromboembolic events (4.7%) were some of the most common reasons for readmission. Open operative approach (odds ratio 1.34, 95% confidence interval 1.05-1.71), chronic steroid use (odds ratio 1.48, 95% confidence interval 1.10-2.00), emergency admission (odds ratio 1.50, 95% confidence interval 1.01-2.21), and predischarge complication (odds ratio 1.91, 95% confidence interval 1.42-2.59) were associated most strongly with hospital readmission.

CONCLUSION

Implementing standardized perioperative strategies, such as nutritional counseling, early ambulation, intensive pulmonary toilet, and deep vein thrombosis prophylaxis, may help decrease the number of preventable readmissions and enhance the overall quality of care in this patient population.

Laparoscopic gastric tube formation with pyloromyotomy for reconstruction in patients with esophageal cancer

PURPOSE

To analyze the benefit and feasibility of this procedure compared with those of open method.

METHODS

Abdominal procedure includes laparoscopic gastric mobilization, celiac axis lymph node dissection, formation of the gastric tube, and pyloromyotomy. The actual procedure performed during open surgery is the same as those of laparoscopic surgery except for the main incision. Minimally invasive esophagectomy (MIE) was performed on 54 patients with esophageal cancer. The short-term outcomes, including postoperative complications were analyzed and compared with 44 cases of open method.

RESULTS

Although the total operative time was not different between 2 groups (349.8 minutes vs. 374.8 minutes, P = 0.153), the operation time of abdominal procedure was shorter in laparoscopic group (90.6 minutes vs. 162.1 minutes, P < 0.001). Operation related complications and hospital stay were not significantly different between the 2 groups. The number of transfused patients was significantly smaller in laparoscopic group (11.1% vs. 27.9%, P = 0.030).

CONCLUSION

Laparoscopic gastric tubing with pyloromyotomy is a feasible and safe treatment option for patients with esophageal cancer.

Robotic surgery for colorectal cancer: systematic review of the literature

INTRODUCTION

Surgical practice has been changed since the introduction of robotic techniques and robotic colorectal surgery is an emerging field. Innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery. Herein, we review the clinical studies regarding the application of surgical robots in resections for colorectal cancer.

METHODS

A systematic review of the literature was conducted for articles published up to September 9, 2012, using the MEDLINE database. The keywords that were used in various combinations were: "surgical robotics," "robotic surgery," "computer-assisted surgery," "colectomy," "sigmoid resection," "sigmoidectomy," and "rectal resection."

RESULTS

Fifty-nine articles reporting on robot-assisted resections of colon and/or rectum were identified and 41 studies were finally included in the analysis. A total of 1635 colorectal procedures were performed: 254 right colectomies, 185 left colectomies/sigmoid resections, 969 anterior resections, 182 abdominoperineal or intersphincteric resections, 34 colectomies (without being specified as right or left), and 11 total/subtotal colectomies. In general, blood loss, conversion rates, and complications were low but the operative time was longer than the open procedures, whereas the duration of hospitalization was shorter. The number of harvested lymph nodes was also quite satisfactory.

CONCLUSIONS

Robotic colorectal operations provide favorable results, with acceptable operative times and low conversion rates and morbidity. Surgical robots may provide additional benefits treating challenging pathologies, such as rectal cancer. Further clinical studies and long-term follow-up are required to better evaluate the outcomes of robotic colorectal surgery.

Minimally invasive esophagectomy for benign disease

MIE can provide patients with reduced morbidity and a rapid recovery in the treatment of benign conditions. There is few data examining the long-term outcomes of MIE specifically in the context of benign disease. At present, MIE should be performed in centers with experience in advanced minimally invasive esophageal surgery, and it requires a team approach. Multicenter, prospective randomized controlled trials will be required to determine the superiority of MIE compared with open esophagectomy. Further investigation will be required to determine the effect of MIE on quality of life and long-term outcomes in the treatment of benign conditions.

A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age

AIMS

The surgery of gastroesophageal reflux disease (GERD) is common in modern pediatric surgical practice. Any differences in perioperative and long-term clinical outcomes following laparoscopic (LN) or open Nissen (ON) fundoplication have not been comprehensively described in young children. This randomized, prospective study examines outcomes following LN versus ON in children<2 years of age.

METHODS

Four surgeons at a single institution enrolled patients under 2 years of age that required surgical management of GERD, who were then randomized to LN or ON between 2005 and 2012. A universal surgical dressing was employed for blinding. Analgesia and enteral feeding pathways were standardized. The primary outcome was postoperative length of stay. Perioperative outcomes and long-term follow up were collected as secondary outcomes and used to compare groups.

RESULTS

Of 39 enrolled patients, 21 were randomized to ON and 18 to LN. Length of postoperative hospital stay, time of advancement to full enteral feeds, and analgesic requirements were not significantly different between treatment cohorts. The LN group experienced longer median operating times (173 vs 91 min, P<0.001) and higher surgical charges ($4450 vs $2722, P=0.002). The incidence of post-discharge complications did not differ significantly between the groups at last follow-up (median 42 months).

CONCLUSIONS

This randomized trial comparing postoperative outcomes following LN vs ON did not detect statistically significant differences in short- or long-term clinical outcomes between these approaches. LN was associated with longer surgical time and higher operating room costs. The benefits, risks, and costs of laparoscopy should be carefully considered in clinical pediatric surgical practice.

Dysphagia after antireflux fundoplication: endoscopic, radiological and manometric evaluation

BACKGROUND

The transient dysphagia after fundoplication is common and most often disappears until six weeks postoperatively.

AIM

Analyze a group of patients who presented late and persistent dysphagia postoperatively.

METHODS

Forty-one patients after Nissen fundoplication, 14 male and 27 female, mean age 48 year, were evaluated based on medical history, esophagogastroduodenoscopy, contrast radiographic examination and esophageal manometry. The results were compared with another 19 asymptomatic individuals.

RESULTS

Contrast radiographic examination of the esophagus revealed in six cases delayed emptying, characterizing that four patients had achalasia and two diffuse spasm of the esophagus. Esophageal manometry showed that maximal expiratory pressure of the lower sphincter ranged from 10 to 38 mmHg and mean respiratory pressure from 14 to 47 mmHg, values similar to controls. Residual pressure ranged from 5 to 31 mmHg, and 17 patients had the same values as the control group.

CONCLUSION

The residual pressure of the lower sphincter was higher and statistically significant in patients with dysphagia compared with those operated without dysphagia. Future studies individualizing and categorizing each motility disorder, employing other techniques of manometry, and the analysis of the residual pressure may contribute to understand of persistent dysphagia in the postoperative fundoplication.

Short- and long-term results of laparoscopic versus open anti-reflux surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

There is an ongoing debate about whether laparoscopic anti-reflux surgery (LARS) or open anti-reflux surgery (OARS) is the better option for the surgical treatment of gastroesophageal reflux disease (GERD). This study was aimed to evaluate and compare the short- and long-term results of both surgical strategies by means of a systematic review and meta-analysis.

METHODS

A systematic search of electronic databases (PubMed, Embase, The Cochrane Library) for studies published from 1970 to 2013 was performed. All randomized controlled trials (RCTs) that compared LARS with OARS were included. We analyzed the outcomes of each type of surgery over short- and long-term periods.

RESULTS

Twelve studies met final inclusion criteria (total n = 1,067). A total of 510 patients underwent OARS and 557 had LARS. The pooled analyses showed, despite of longer operation time, the hospital stay and sick leave were significantly reduced in the LARS group. Significant reductions were also observed in complication rates for the LARS group in both short (odds ratio (OR) 0.31, 95 % CI 0.17 to 0.56) and long-term periods (OR 0.24, 95 % CI 0.07 to 0.80). Although complaints of reflux symptoms were more frequent among LARS patients in the short-term follow-up, LARS achieved better control of reflux symptoms in the long-term period (P < 0.05). Reoperation rate, patient's satisfaction, and 24-h pH monitoring were all comparable between the two groups (all P > 0.05).

CONCLUSIONS

LARS is an effective and safe alternative of OARS for the surgical treatment of GERD, which enables a faster convalescence, better control of long-term reflux symptoms, and with reduced risk of complications.

Four year follow-up of a randomised controlled trial comparing open and laparoscopic Nissen fundoplication in children

OBJECTIVE

To evaluate the 4-year results following a randomised controlled trial (RCT) comparing open (ONF) and laparoscopic (LNF) Nissen fundoplication in children.

BACKGROUND

It is assumed that long-term results of ONF and LNF are comparable. No randomised studies have been performed in children.

METHODS

A follow-up study was performed in children randomised to ONF or LNF (clinicaltrials.gov identifier NCT00259961). Recurrent gastro-oesophageal reflux (GER) was documented by upper gastrointestinal contrast study and/or 24-h pH study. Nutritional status, retching and other symptoms were investigated. A questionnaire was used to assess the quality of life before and after surgery.

RESULTS

Thirty-nine children were randomised to ONF (n=20) or LNF (n=19). There were 15 ONF and 16 LNF neurologically impaired children. One patient (ONF group) was lost to follow-up. Follow-up was 4.1 years (3.1-5.3) for ONF group and 4.1 years (2.6-5.1) for LNF group (p=0.9). Seven neurologically impaired children had died by the time of follow-up (3 ONF, 4 LNF). Incidence of recurrent GER was 12.5% in the ONF and 20% in the LNF (p=ns). One patient in each group underwent redo-Nissen fundoplication. Nutritional status improved in both groups, as indicated by a significant increase in weight Z-score (p<0.01). Gas bloat and dumping syndrome were present in both groups (p=ns). Incidence of retching was lower in the laparoscopic group (p=0.01). Quality of life improved in both groups (p=ns).

CONCLUSIONS

Open and laparoscopic Nissen provide similar control of reflux and quality of life at follow-up. LNF is associated with reduced incidence of retching persisting at 4-year follow-up.

TRIAL REGISTRATION NUMBER

NCT00259961.

Total and low-density lipoprotein cholesterol in high-risk patients treated with atorvastatin monotherapy in the United Kingdom: analysis of a primary-care database

OBJECTIVE

British clinical guidelines recommend statins as first-line lipid-modifying treatment (LMT) for patients at high risk of cardiovascular disease (CVD). We undertook an observational study to assess total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels in high-risk patients who were treated with atorvastatin monotherapy by UK general practitioners.

METHODS

This retrospective database study included patients with a prescription for atorvastatin monotherapy between November 30, 2008, and November 30, 2011, with the index date defined as the first atorvastatin prescription during this period. Eligible high-risk patients with evidence of coronary heart disease (CHD), atherosclerotic vascular disease (AVD), diabetes mellitus (DM), or familial hypercholesterolemia (FH) were required to have ≥1 TC and LDL-C measurement between 3 and 12 months after the index date, and continuous enrollment 1 year before and 1 year after the index date. Cholesterol levels were assessed using the National Institute for Health and Care Excellence (NICE) guidelines: TC <4.0 mmol/L or LDL-C <2.0 mmol/L.

RESULTS

Of 2999 high-risk patients (60.2% men; mean [SD] age = 67.9 [10.6] years) meeting selection criteria, 23.9% 28.2%, 36.2%, and 11.6% received prescriptions for atorvastatin 10, 20, 40, and 80 mg, respectively (percentages do not sum to 100 because of rounding). Across all doses, the mean (SD) follow-up TC was 4.08 (0.80) mmol/L and LDL-C 2.08 (0.65) mmol/L. A large proportion of patients (88.8%) had TC < 5.0 mmol/L. However, only 45.8% had TC < 4.0 mmol/L, and 46.5% had LDL-C < 2.0 mmol/L. Although a larger proportion of patients with CHD/AVD + DM reached guideline-recommended lipid levels, only 63.7% of such patients had TC < 4.0 or LDL-C < 2.0 mmol/L, which are the current targets for this subgroup as recommended by NICE.

CONCLUSIONS

Less than half of UK high-CVD-risk patients receiving atorvastatin monotherapy achieved guideline-recommended treatment targets for TC, and less than two-thirds of patients with CHD/AVD + DM had values below TC (4.0 mmol/L) or LDL-C (2.0 mmol/L) targets. More effective lipid-lowering strategies may be warranted to optimize cholesterol lowering and target attainment in high-risk patients. Limitations of this study include its retrospective, observational nature.

[The Mexican consensus on gastroesophageal reflux disease. Part II]

OBJECTIVE

To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002.

METHODS

Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher.

RESULTS

Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%.

CONCLUSION

Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.

Minimally invasive surgery for esophageal cancer

Minimally invasive surgery has revolutionized the surgical management of benign foregut disease, as well as pulmonary and other gastrointestinal malignancies. With the potential to reduce operative morbidity and increase patient satisfaction, minimally invasive esophagectomy for the management of esophageal cancer is gaining in popularity. It is unclear, however, whether the minimally invasive approach to esophageal cancer resection has comparable long-term oncologic results. This article discusses the rationale for minimally invasive esophagectomy, describes the surgical technique, and reviews the published results.

Outcome following management of dysphagia after laparoscopic anti-reflux surgery

BACKGROUND

Some patients develop troublesome dysphagia after laparoscopic antireflux surgery, and a proportion require further intervention. The management of this problem was evaluated.

METHODS

Patients who underwent intervention for dysphagia after laparoscopic fundoplication were identified from a database. Outcomes were prospectively determined from a standardized questionnaire that evaluated symptoms scores for dysphagia for solids and liquids, as well as patient satisfaction with the overall outcome. Outcomes 1 year after reintervention, and at the most recent follow-up were evaluated.

RESULTS

From 1994 to 2009, 121 (6.6%) of 1,821 patients who underwent laparoscopic fundoplication for gastroesophageal reflux also underwent endoscopic or surgical reintervention for dysphagia. Of these 121 patients, 56 underwent endoscopic dilatation, and 24 were satisfied with the outcome of dilatation; 18 progressed to surgery, and dysphagia persisted in 14 of them. Overall, 83 patients underwent revisional surgery, and 47 (62.7%) were satisfied with the outcome. Compared to patients who did not undergo any intervention for dysphagia, patients who underwent reintervention had lower satisfaction scores and higher dysphagia scores.

CONCLUSIONS

Approximately two thirds of patients with troublesome post-fundoplication dysphagia have a satisfactory outcome following either endoscopic dilatation or revisional surgery. However, approximately one third continue to be troubled by symptoms, despite further intervention.

Reflux and sex: what drives testing, what drives treatment?

Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.

Meta-analysis of robot-assisted versus conventional laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease

BACKGROUND

Conventional laparoscopic Nissen fundoplication (CLF) is generally considered the surgical approach of choice for gastro-oesophageal reflux disease. Robotic-assisted laparoscopic fundoplication (RALF) has recently been introduced into laparoscopic clinical practice with the aim of improving surgical performance by eliminating tremors and fatigue. A meta-analysis of randomized clinical trials (RCTs) was performed to compare RALF and CLF.

METHODS

Medline, Embase, ISI Web of Knowledge CPCI-S and The Cochrane Library were searched and the methodological quality of included trials was evaluated. Outcomes evaluated were intraoperative, dysphagia, flatulence, antisecretory medication, satisfaction with intervention, operation time, hospital stay and total cost. Results were pooled in meta-analyses as risk ratios and weighted mean differences (WMD).

RESULTS

Of 221 patients in six RCTs, 111 were allocated to CLF and 110 to RALF. RALF prolonged total time necessary to carry out fundoplication (WMD 3.17 (95% confidence interval. 2.33-4.00) min; P < 0.00001, χ(2) P = 0.25, I(2) = 24%). Operation complication, antisecretory medication, satisfaction with intervention, the time needed for hiatal dissection, the time from incision to completion of sutures, the total operation time and total cost were similar in both groups.

CONCLUSION

Clinical outcomes from RALF were comparable to CLF approach, but RALF prolonged the operation time. Currently, CLF should be routinely used as costs are lower.

Laparoscopic Nissen fundoplication with or without short gastric vessel division: a meta-analysis

OBJECTIVE

The aim of this work is to systematically analyse the prospective randomised controlled trials on laparoscopic Nissen fundoplication (LNF) with and without short gastric vessel division (SGVD) for management of gastro-oesophageal reflux disease (GORD).

METHODS

After an extensive literature search, all previous trials on laparoscopic Nissen fundoplication with and without SGVD for management of GORD were assessed. Those meeting study quality criteria were analysed to generate summative data expressed by standardised mean difference (SMD) and risk ratio (RR).

RESULTS

Five randomised controlled trials on 388 patients qualified for the meta-analysis. There were 194 patients in the no-SGVD group and 194 patients in the SGVD group. No-SGVD was associated with shorter operative time and length of stay. In both fixed- and random-effects models, there were no statistically significant differences in laparoscopic to open conversion rate or complications between the two groups. Three trials presented data on 1-year follow-up, with 118 patients in the no-SGVD group and 112 patients in the SGVD group. There was no statistically significant difference in heartburn, dysphagia, regurgitation or gas bloat syndrome between these two groups. Two trials presented data on 10-year follow-up, with 84 patients in the no-SGVD group and 86 patients in the SGVD group. There was no significant difference in heartburn, dysphagia, regurgitation or gas bloat syndrome between these two groups either. There was no heterogeneity between trials.

CONCLUSIONS

Based on this review, SGVD in LNF is associated with longer operative time and hospital stay. However, there is no difference in terms of functional outcomes for 1- and 10-year follow-up. Routine use of SGVD may therefore not be necessary in LNF.

Minimally invasive esophagectomy: the evolution and technique of minimally invasive surgery for esophageal cancer

Beginning with the widespread introduction of laparoscopic cholecystectomy in late 1989, minimally invasive surgical technique has been refined in conjunction with the development of advanced instrumentation and have subsequently been applied to increasingly complicated disease processes. Esophageal surgeons have increasingly incorporated minimally invasive surgery into their practice since the first laparoscopic fundoplication was described by Dallemagne et al. in 1991. Esophagectomy is associated with significant morbidity and mortality even in highly experienced centers. Many esophageal surgeons have had a great deal of interest in minimally invasive esophagectomy (MIE), which has the potential advantages of being a less traumatic procedure with a resultant improvement in postoperative convalescence and fewer wound and cardiopulmonary complications compared to the open approaches. Throughout the 1990s, as confidence with laparoscopic surgery of the esophagogastric junction grew, MIE was initially attempted with hybrid operations combining traditional open surgery with minimally invasive approaches. Subsequently, a totally laparoscopic transhiatal approach was described; however, this approach was perceived to be very challenging and has not gained widespread acceptance. Approaches used at present depend on cancer stage, cancer location, body habitus, and pulmonary function. For localized cancer (T1N0) or HGD, we prefer laparoscopic inversion esophagectomy (retrograde or antigrade). This approach may also be used for patients at high risk for thoracotomy. For locally advanced cancer in the middle third of the esophagus or for proximal third esophageal cancer, we prefer 3-field MIE (abdomen, and chest with neck anastomosis). For locally advanced cancer in the distal esophagus, especially in patients with a short thick neck, we prefer thoracoscopic-laparoscopic (2-field) esophagectomy (TLE).

Twenty years of laparoscopic fundoplication for GERD

The first laparoscopic Nissen fundoplication was performed 20 years ago. Surgical management of gastroesophageal reflux disease (GERD) should be offered only to appropriately studied and selected patients, with the ultimate aim of improving the well-being of the individual, the "quality of life." The choice of fundoplication should be dictated by the surgeon's preference and experience.

Dumping syndrome following nissen fundoplication in an adult patient diagnosed by continuous online 13C/12C monitoring of ¹³C-Octanoic acid breath test "a case report"

BACKGROUND

Nissen Fundoplication is a common surgical procedure performed in treating gastroesophageal reflux disease (GERD). Complications include dysphagia, gastric hypersensitivity, abnormal gastric motility, gas bloat syndrome and GERD relapse. Dumping syndrome may occur when a large volume of gastric content is delivered to the duodenum or jejunum, resulting in both gastrointestinal and vasomotor symptoms. Occasionally, dumping syndrome may be a complication in patients that have undergone nissen Fundoplication, especially in adults. The BreathID® continuous online 13C-Octanoicoctanoic acid breath test detects variations of less than 1/100,000 in the 13CO2/12CO2 ratio in exhaled air.

CASE PRESENTATION

We report a case of a 38 year old male who was admitted and diagnosed with dumping syndrome following nissen Fundoplication, who was diagnosed using the BreathID® continuous online 13C-Octanoic acid breath test.

CONCLUSIONS

Early performance of a gastric emptying rate breath test in symptomatic patients, following upper GI tract surgery may help in the prediction or diagnosis of nissen Fundoplication complications such as dumping syndrome.

Robotic redo fundoplication for incompetent wrapping after antireflux surgery: A case report

INTRODUCTION

Incidence of gastroesophageal reflux disease (GERD) is high. antireflux surgery with specific indications could be an option. Nissen fundoplication is the most popular surgical procedure for GERD, and recent results using laparoscopy have reported excellent short- and mid-term results. Regarding surgical outcome of antireflux surgery, the rate of complications has been reported as below 2.4%, but rare cases still require reoperation.

PRESENTATION OF CASE

A 53-year old male patient underwent laparoscopic Nissen fundoplication three years ago owing to gastroesophageal reflux disease (GERD) troubled by dysphagia and heartburn However, despite undergoing surgery, his symptoms did not show improvement .A robotic redo fundoplication was planned. The patient recovered uneventfully, and the esophagography on postoperative day four revealed improvement of previous upward contrast reflux and distension of the distal esophagus during swallowing had disappeared. Dysphagia and heartburn had still not occurred at one year follow-up.

DISCUSSION

Redo antireflux surgery for postoperative stricture is not an easy procedure due to postoperative adhesion and anatomical change. Robotic surgery may be more helpful for precise dissection of the adhesion site by a previous operation and robotic suturing for re-fundoplication was more effective.

CONCLUSION

Re-do fundoplication using a robot, which is a complicated procedure compared with primary anti-reflux surgery would be a general procedure in the near future.

Robot-assisted laparoscopic surgery of the colon and rectum

INTRODUCTION

Laparoscopic techniques have induced a tremendous revolution in the field of general surgery. Recent multicenter trials have demonstrated similar patient-oriented and oncologic outcomes for laparoscopic colon and rectal resections compared with their open counterparts. Meanwhile, robotic technology has gradually entered the field of general surgery, allowing increased dexterity, improved operative view, and optimal ergonomics. The objective of this study was to review the current status of clinical robotic applications in colorectal surgery.

METHODS

A systematic review of the literature using the PubMed search engine was undertaken to identify relevant articles. The keywords used in all possible combinations were: surgical robotics, robotic surgery, computer-assisted surgery, colectomy, sigmoid resection, sigmoidectomy, and rectal resection.

RESULTS

Thirty-nine case series or comparative nonrandomized studies were identified. A specific interest for robot-assisted rectal surgery during the past few years was recorded in the literature. The retrieved articles included 13 ileocecal resections, 220 right colectomies, 190 left colectomies/sigmoid resections, 440 anterior resections, 149 abdominoperineal/intersphincteric resections, and 11 total/subtotal colectomies. The clinical application of the da Vinci robotic system in right and left/sigmoid colectomies yielded satisfactory results in terms of open conversion (1.1 and 3.8%, respectively) and operative morbidity (13.4 and 15.1%, respectively). Robot-assisted anterior resection was accompanied by a considerably low conversion rate (0.4%), morbidity (9.7%), and adequate number of harvested lymph nodes (14.3, mean).

CONCLUSIONS

Robotic applications in colorectal surgery are feasible with low conversion rates and favorable morbidity. Further studies are required to evaluate its oncologic and patient-oriented outcomes.

The evolution of laparoscopic antireflux surgery and its influence on postoperative stay

Laparoscopic fundoplication is an established treatment for refractory gastro-oesophageal reflux disease. This study aims to compare the outcome of two laparoscopic antireflux techniques in a regional specialist unit. A sequential audit was carried out on patients undergoing laparoscopic Nissen (LN: performed May 1994 to November 2000) or laparoscopic anterior (LA: performed March 2001 to December 2004) fundoplication. Patient satisfaction was assessed by postal questionnaire. The cohorts undergoing each operation were also divided into two chronological groups of 51 patients, to study the effect of possible learning curve progression on the number of nights spent in the hospital postoperatively. In all, 142/204 (70%) questionnaires were returned from patients with follow-up ranging from 5 to 40 months postoperation. Overall, 102/142 (72%) reported a good or excellent outcome. Patients who underwent LA had a higher rate of antacid medication use (LN 17.4% versus LA 34.2%, P = 0.036) but there was a higher score for inability to belch following LN (LN 2.03 versus LA 1.53, P = 0.034). When comparing the chronologically divided cohorts, LN was associated with a significantly longer hospital stay than LA (P < 0.001, Mann-Whitney U test). There was a significant decrease in hospital stay from the first to second group of 51 LNs (P < 0.001, Mann-Whitney U test) and a further significant reduction in hospital stay from the first 51 to second 51 LAs (P < 0.001, Mann-Whitney U test). In conclusion, both procedures provide good symptom control. Increased requirement for acid suppression following LA and inability to belch following LN, may suggest more long-term durability of the LN wrap. The decrease in the number of nights spent in hospital may be related to the procedure performed but seems more likely to be an effect of increasing volume of surgical experience.

Reoperative antireflux surgery for dysphagia

BACKGROUND

Troublesome dysphagia is a common indication for redo antireflux surgery (Re-ARS). This study is aimed to analyze the efficacy of Re-ARS in resolving dysphagia and to identify risk factors for persistent or new-onset dysphagia after Re-ARS.

METHODS

A prospectively maintained database was retrospectively reviewed to identify patients after Re-ARS. Dysphagia severity was graded on a scale of 0 to 3 before and after Re-ARS based on responses to a standardized questionnaire. Patients reporting grade 2 or 3 symptoms were considered to have significant dysphagia. Satisfaction was graded using a 10-point analog scale.

RESULTS

Between December 2003 and July 2008, 106 patients underwent Re-ARS. Significant preoperative dysphagia was reported by 54 patients, and impaired esophageal motility was noted in 31 patients. Remedial surgery included redo fundoplication (n = 87), Collis gastroplasty with redo fundoplication (n = 16), and takedown of the fundoplication or hiatal closure alone (n = 3). At least 1 year follow-up period (mean 21.8 months) was available for 92 patients. For patients with significant preoperative dysphagia (n = 46), the mean symptom score declined from 2.35 to 0.78 (p < 0.0001). Persistent dysphagia was reported by 13 patients and new-onset dysphagia by 4 patients. No patients reported grade 3 dysphagia after Re-ARS. Dilations were used to treat 11 patients. Multivariate logistic regression analysis identified Collis gastroplasty (p = 0.03; adjusted odds ratio [OR], 5.74) and preoperative dysphagia (p = 0.01; adjusted OR, 6.80) as risk factors for significant postoperative dysphagia. The overall satisfaction score was 8.3, but certain subsets had significantly lower satisfaction scores. These subsets included patients with esophageal dysmotility (7.1; p = 0.04), patients who required Collis gastroplasty (7.0; p = 0.09), and patients with esophageal dysmotility who required Collis gastroplasty (5.0; p < 0.01).

CONCLUSION

Although dysphagia is a common symptom among patients requiring Re-ARS, intervention provides a significant benefit. Patients with preoperative dysphagia, especially those requiring Collis gastroplasty, are at increased risk for persistent dysphagia and decreased satisfaction after Re-ARS.

Controversial technology: the Chunnel and the laparoscopic retroperitoneal lymph node dissection (RPLND)

• Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was first introduced in 1992, initially as a staging procedure. • With advances in instrumentation and laparoscopic techniques, as well as improved understanding of laparoscopic anatomy, L-RPLND has developed to duplicate open RPLND. • Unlike the relatively rapid adoption of laparoscopy for other applications including nephrectomy and prostatectomy, L-RPLND has been slow to be universally accepted. • The limited numbers of patients requiring RPLND and technical challenges in performing the dissection have undoubtedly contributed to its delayed reception. • This review will present available data on this technique and discuss issues potentially inhibiting acceptance by traditional surgeons.

Does laparoscopy lower the threshold for the surgical treatment of gastroesophageal reflux disease in children?

OBJECTIVE

To assess whether laparoscopic surgery lowers the threshold for surgical intervention, we examined whether the introduction of the laparoscopic technique at our institution in 1997 has resulted in an increase in antireflux surgery in children at our clinic.

PATIENTS AND METHODS

The number of annual fundoplications between 1997 and 2008 at a single institution was assessed in children younger than 18 years. The number of fundoplications was compared with the number of pyloromyotomies and appendicectomies per year in the same period of time to prove or exclude a general increase in the referral of children.

RESULTS

Since 1997, the proportion of laparoscopic fundoplications increased from 60% in 1997 to 100% in 2008. During this period, 109 laparoscopic fundoplications were performed: 31 in the period from 1997 to 2002 and 78 from 2003 to 2008. Regression analysis shows a significant increase in the number of performed fundoplications (slope: 1.03 ± 0.28, P = 0.0043), whereas both the number of pyloromyotomies and appendicectomies remained stable (slopes: -0.14 ± 0.40, P = 0.73, and -0.75 ± 0.47, P = 0.14, respectively).

CONCLUSIONS

Since the introduction of minimally invasive surgery at our tertiary referral center in 1997, the number of patients referred for an antireflux operation has increased. This cannot be explained by an increase of referrals from outside the region or a change in the indication for surgery. We conclude that laparoscopy lowers the threshold for the surgical treatment of gastroesophageal reflux disease in children.

Safety, efficacy, and cost-effectiveness of common laparoscopic procedures

BACKGROUND

Laparoscopic surgery has been shown to offer superior surgical outcomes for most abdominal surgical procedures. However, there is hardly any evidence on surgical outcomes with patient risk stratification. This study aimed to compare outcomes of common laparoscopic and open surgical procedures for varying illness severity.

METHODS

A retrospective analysis of surgical outcomes for six commonly performed surgical procedures including cholecystectomy, appendectomy, reflux surgery, gastric bypass surgery, ventral hernia repair, and colectomy was performed using the University HealthSystem Consortium (UHC) Clinical Database/Resource Manager (CDB/RM). The 3-year discharge data for the six commonly performed laparoscopic surgical procedures were analyzed for outcome measures including observed mortality, overall patient morbidity, intensive care unit (ICU) admissions, 30-day readmissions, length of hospital stay, and hospital costs.

RESULTS

In this study, 208,314 patients underwent one of six common surgical procedures by either the open or the laparoscopic approach. Overall, the laparoscopic approach showed significantly lower mortality, reduced morbidity, fewer ICU admissions and 30-day readmissions, shorter hospital stay, and significantly reduced hospital costs for all the procedures. At stratification by illness severity, the laparoscopic group showed better or comparable surgical outcomes across all the illness severity groups. However, the observed mortality was comparable for the minor and moderate severity patients between laparoscopic and open surgery for most procedures. The 30-day readmission rate for major/extreme severity patients was comparable between the two groups for most surgical procedures.

CONCLUSIONS

This study demonstrated the superiority of laparoscopy over conventional open surgery across all illness severity risk groups for common surgical procedures. The results in general show that laparoscopic surgery is safe, efficacious, and cost-effective compared with open surgery and suggest that laparoscopic surgery should be the procedure of choice for all common surgical procedures, regardless of illness severity.