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Allaix ME, Rebecchi F, Bellocchia A, Morino M, Patti MG. LAPAROSCOPIC ANTIREFLUX SURGERY: WERE OLD QUESTIONS ANSWERED? PARTIAL OR TOTAL FUNDOPLICATION? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1741. [PMID: 37436210 DOI: 10.1590/0102-672020230023e1741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/28/2021] [Indexed: 07/13/2023]
Abstract
Laparoscopic total fundoplication is currently considered the gold standard for the surgical treatment of gastroesophageal reflux disease. Short-term outcomes after laparoscopic total fundoplication are excellent, with fast recovery and minimal perioperative morbidity. The symptom relief and reflux control are achieved in about 80 to 90% of patients 10 years after surgery. However, a small but clinically relevant incidence of postoperative dysphagia and gas-related symptoms is reported. Debate still exists about the best antireflux operation; during the last three decades, the surgical outcome of laparoscopic partial fundoplication (anterior or posterior) were compared to those achieved after a laparoscopic total fundoplication. The laparoscopic partial fundoplication, either anterior (180°) or posterior, should be performed only in patients with gastroesophageal reflux disease secondary to scleroderma and impaired esophageal motility, since the laparoscopic total fundoplication would impair esophageal emptying and cause dysphagia.
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Affiliation(s)
| | - Fabrizio Rebecchi
- University of Torino, Department of Surgical Sciences - Torino, Italy
| | - Alex Bellocchia
- University of Torino, Department of Surgical Sciences - Torino, Italy
| | - Mario Morino
- University of Torino, Department of Surgical Sciences - Torino, Italy
| | - Marco Giuseppe Patti
- University of North Carolina at Chapel Hill, Department of Medicine and Surgery - Chapel Hill, United States of America
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Ruan N, Chen H, Wang Z, Mao J, Xia J, Zhao F, Zhang T. Sources of information on surgical options for patients undergoing antireflux surgery: a single-center questionnaire-based survey. BMC Gastroenterol 2023; 23:73. [PMID: 36918773 PMCID: PMC10012573 DOI: 10.1186/s12876-023-02712-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND To explore the sources of information on antireflux surgery for patients undergoing this surgery in China. METHODS Patients who underwent antireflux surgery in the Gastroesophageal Reflux Center of the Zhejiang Provincial People's Hospital from January 2016 to June 2021 were selected as survey subjects, and a questionnaire survey was conducted by telephone. RESULTS A total of 358 questionnaires were distributed, and 320 valid questionnaires were recovered, yielding a 89.4% completion rate. Among patients' sources of information about antireflux surgery, the media was the primary source (33.8%) followed by recommendations from relatives or friends (27.8%), referrals from physicians (23.4%) and other sources (15.0%). Patients of different ages and educational levels have different sources for obtaining information about the procedure. Most of the information on surgery for patients aged 20 to 49 years was derived from recommendations from friends or relatives, whereas most of the information on surgery for patients aged 50 to 80 years was obtained from the media. Most of the information on surgery for patients with a primary school education or less was derived from physicians' recommendations, whereas most of the information for patients with a junior secondary school education or higher was obtained from the media. The recommendation of patients for surgery varied among the different departments (X2 = 36.011, p < 0.001), and a two-to-two comparison found that the recommended rates for cardiology and gastroenterology differed from the rates of other groups (p < 0.001, Table 2). CONCLUSIONS The results of this investigation show that a large number of patients who underwent antireflux surgery learned about the operation through the media and recommendations from relatives or friends rather than physicians at the hospital. Notably, physicians specializing in GERD need to increase their knowledge of the disease and surgical treatment options to provide correct medical information to patients and to conduct media campaigns.
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Affiliation(s)
| | - Hao Chen
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhifei Wang
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China.
| | - Jinlei Mao
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jianfu Xia
- Wenzhou Central Hospital, Wenzhou, China
| | - Fei Zhao
- Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Ting Zhang
- Zhejiang Provincial People's Hospital, Hangzhou, China
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Slater BJ, Collings A, Dirks R, Gould JC, Qureshi AP, Juza R, Rodríguez-Luna MR, Wunker C, Kohn GP, Kothari S, Carslon E, Worrell S, Abou-Setta AM, Ansari MT, Athanasiadis DI, Daly S, Dimou F, Haskins IN, Hong J, Krishnan K, Lidor A, Litle V, Low D, Petrick A, Soriano IS, Thosani N, Tyberg A, Velanovich V, Vilallonga R, Marks JM. Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD). Surg Endosc 2023; 37:781-806. [PMID: 36529851 DOI: 10.1007/s00464-022-09817-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. METHODS Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. CONCLUSION Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.
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Affiliation(s)
- Bethany J Slater
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA.
| | - Amelia Collings
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rebecca Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jon C Gould
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alia P Qureshi
- Division of General & GI Surgery, Foregut Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Ryan Juza
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - María Rita Rodríguez-Luna
- Research Institute Against Digestive Cancer (IRCAD) and ICube Laboratory, Photonics Instrumentation for Health, Strasbourg, France
| | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Shanu Kothari
- Department of Surgery, Prisma Health, Greenville, SC, USA
| | | | | | - Ahmed M Abou-Setta
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Mohammed T Ansari
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | | | - Shaun Daly
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | | | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, USA
| | - Julie Hong
- Department of Surgery, New York Presbyterian/Queens, Queens, USA
| | | | - Anne Lidor
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Virginia Litle
- Section of Thoracic Surgery, Department of Cardiovascular Surgery, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Donald Low
- Virginia Mason Medical Center, Seattle, WA, USA
| | - Anthony Petrick
- Department of General Surgery, Geisinger School of Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Ian S Soriano
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Nirav Thosani
- McGovern Medical School, Center for Interventional Gastroenterology at UTHealth, Houston, TX, USA
| | - Amy Tyberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Vic Velanovich
- Division of Gastrointestinal Surgery, Tampa General, Tampa, FL, USA
| | - Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron University Hospital, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jeffrey M Marks
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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FalcÃo AM, Nasi A, Szachnowicz SÉ, Santa-Cruz F, Seguro FCBC, Sena BF, Duarte A, Sallum RA, Cecconello I. Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett's esophagus? Rev Col Bras Cir 2020; 47:e20202637. [PMID: 33263652 DOI: 10.1590/0100-6991e-20202637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/20/2020] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE to evaluate esophageal dysmotility (ED) and the extent of Barrett's esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. METHODS twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. RESULTS : sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). CONCLUSION LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED.
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Affiliation(s)
- Angela M FalcÃo
- - Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo - SP - Brasil.,- Universidade Federal de Pernambuco, Faculdade de Medicina, Departamento de Cirurgia, Recife - PE - Brasil
| | - Ary Nasi
- - Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo - SP - Brasil
| | - SÉrgio Szachnowicz
- - Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo - SP - Brasil
| | - Fernando Santa-Cruz
- - Universidade Federal de Pernambuco, Faculdade de Medicina, Recife - PE - Brasil
| | - Francisco C B C Seguro
- - Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo - SP - Brasil
| | - Brena F Sena
- - Departamento de Epidemiologia, Escola de Saúde Pública T.H. Chan de Harvard, Boston - MA - EUA
| | - AndrÉ Duarte
- - Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo - SP - Brasil
| | - Rubens A Sallum
- - Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo - SP - Brasil
| | - Ivan Cecconello
- - Universidade de São Paulo, Faculdade de Medicina, Departamento de Gastroenterologia, São Paulo - SP - Brasil
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Effect of electrical stimulation therapy of the lower esophageal sphincter in GERD patients with ineffective esophageal motility. Surg Endosc 2020; 35:6101-6107. [PMID: 33128080 PMCID: PMC8523464 DOI: 10.1007/s00464-020-08104-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/16/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND Electrical stimulation therapy (EST) of the lower esophageal sphincter (LES) is a novel technique in antireflux surgery. Due to the minimal alteration at the LES during surgery, LES-EST is meant to be ideal for patients with gastroesophageal reflux disease (GERD) and ineffective esophageal motility (IEM). The aim of this prospective trial (NCT03476265) is to evaluate health-related quality of life and esophageal acid exposure after LES-EST in patients with GERD and IEM. METHODS This is a prospective non-randomized open-label study. Patients with GERD and IEM undergoing LES-EST were included. Follow-up (FUP) at 12 months after surgery included health-related quality of life (HRQL) assessment with standardized questionnaires (GERD-HRQL) and esophageal functional testing. RESULTS According to the study protocol, 17 patients fulfilled eligibility criteria. HRQL score for heartburn and regurgitation improved from 21 (interquartile range (IQR) 15-27) to 7.5 (1.25-19), p = 0.001 and from 17 (11-23.5) to 4 (0-12), p = 0.003, respectively. There was neither significant improvement of esophageal acid exposure nor reduction of number of reflux events in pH impedance measurement. Distal contractile integral improved from 64 (11.5-301) to 115 (IQR 10-363) mmHg s cm, p = 0.249. None of the patients showed any sign of dysphagia after LES-EST. One patient needed re-do surgery and re-implantation of the LES-EST due to breaking of the lead after one year. CONCLUSION Although patient satisfaction improved significantly after surgery, this study fails to demonstrate normalization or significant improvement of acid exposure in the distal esophagus after LES-EST.
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Dell'Acqua-CassÃO B, Mardiros-Herbella FA, Farah JF, Bonadiman A, Silva LC, Patti MG. Outcomes of Laparoscopic Nissen Fundoplication in Patients with Manometric Patterns of Esophageal Motility Disorders. Am Surg 2020. [DOI: 10.1177/000313481307900423] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The manometric pattern of either diffuse esophageal spasm (DES), nutcracker esophagus (NE), or hypertensive lower esophageal sphincter (HLES) in the presence of gastroesophageal reflux disease (GERD) is considered a secondary finding and treatment should be directed toward GERD. This study aims to evaluate the outcomes of laparoscopic Nissen fundoplication (LNF) in patients with manometric patterns of esophageal motility disorders. Patients with GERD confirmed by pH monitoring and manometric pattern of DES (simultaneous contractions 20 to 90% of wet swallows), NE (increased mean distal amplitude greater than 180 mmHg), or HLES (lower esophageal sphincter pressure greater than 45 mmHg) who underwent LNF were studied. A group of 50 consecutive patients with normal esophageal motility who underwent LNF were used as control subjects. Groups were comparable to control subjects for age, gender, preoperative symptoms, hiatal hernia, and Barrett's esophagus, except for NE that had younger individuals and a lower rate of hiatal hernia. Symptomatic outcome was similar when groups were compared with control subjects. Transient dysphagia was present in the postoperative period in 33, 7, 0, and 20 per cent of the patients with HLES, DES, NE, and control subjects, respectively. LNF is an adequate treatment for patients with GERD and manometric patterns of esophageal motility disorders.
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Affiliation(s)
- Bruna Dell'Acqua-CassÃO
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil; the
| | | | - JosÉ F. Farah
- Department of Surgery, Department of Surgery, Hospital do Servidor Público Estadual de São Paulo Francisco Morato de Oliveira, São Paulo, SP, Brazil; and the
| | - Adorisio Bonadiman
- Department of Surgery, Department of Surgery, Hospital do Servidor Público Estadual de São Paulo Francisco Morato de Oliveira, São Paulo, SP, Brazil; and the
| | - Luciana C. Silva
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil; the
| | - Marco G. Patti
- Department of Surgery, University of Chicago, Chicago, Illinois
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DeMeester SR. Laparoscopic Hernia Repair and Fundoplication for Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:309-324. [PMID: 32146948 DOI: 10.1016/j.giec.2019.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Antireflux surgery is challenging, and has become even more challenging with the introduction of alternative endoscopic and laparoscopic options for patients with gastroesophageal reflux disease (GERD). The Nissen fundoplication remains the gold standard for the durable relief of GERD symptoms and esophagitis. All antireflux procedures have a failure rate, and it is important to minimize factors that are associated with failure. The selection of patients for antireflux surgery as well as the choice of the procedure requires a thorough understanding of esophageal physiology and the pros and cons of various options.
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Affiliation(s)
- Steven R DeMeester
- Thoracic and Foregut Surgery, General and Minimally Invasive Surgery, The Oregon Clinic, 4805 Northeast Glisan Street, Suite 6N60, Portland, OR 97213, USA.
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Arcerito M, Perez MG, Kaur H, Annoreno KM, Moon JT. Robotic Fundoplication for Large Paraesophageal Hiatal Hernias. JSLS 2020; 24:JSLS.2019.00054. [PMID: 32206010 PMCID: PMC7065729 DOI: 10.4293/jsls.2019.00054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose: Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique. Methods: Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus. Results: All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (7–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically. Conclusions: The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.
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Affiliation(s)
- Massimo Arcerito
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Martin G Perez
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Harpreet Kaur
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - Kenneth M Annoreno
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - John T Moon
- Shawnee Mission Medical Center, Shawnee Mission, Kansas
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Csendes A, Orellana O, Cuneo N, Martínez G, Figueroa M. Long-term (15-year) objective evaluation of 150 patients after laparoscopic Nissen fundoplication. Surgery 2019; 166:886-894. [PMID: 31227185 DOI: 10.1016/j.surg.2019.04.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/01/2019] [Accepted: 04/23/2019] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Laparoscopic Nissen fundoplication is the preferred operative treatment for patients with gastroesophageal reflux disease. The most recent published results only refer to clinical evaluations and few discuss objective measurements. Our purpose was to determine the late results of laparoscopic Nissen fundoplication, performing clinical, endoscopic, histologic, and functional studies. MATERIAL AND METHODS A total of 179 patients were included in a prospective study. All had gastroesophageal reflux disease symptoms of at least 5-year duration, daily dependence on proton pump inhibitors, and a type I hiatal hernia less than 5 cm. Exclusion criteria included Barrett's esophagus, hiatal hernia >5 cm, failed antireflux surgery, and obesity (body mass index >30). We performed a radiologic study, 3 or more endoscopic procedures with biopsy samples of the antrum and esophagogastric junction, esophageal manometry, and 24-hour pH monitoring. RESULTS We found that 4 patients (2.2%) died 3-4 years after operation from nonoperatiove reasons. A total of 25 patients (14%) were lost to follow-up, and 150 patients (83.8%) submitted to late objective evaluations (15 years). Visick I-II symptoms were observed in 79.3% and III-IV (failures) in 20.7%. Endoscopy showed a normal positioning of the esophagogastric junction in the Visick I-II patients and a type III cardia or hiatal hernia with erosive esophagitis in Visick III-IV patients. Short-segment Barrett's esophagus developed in 5.3% of patients. Lower esophageal sphincter pressure remained increased over the preoperative value in all groups. The 24-hour pH monitoring also was decreased over the preoperative value in Visick I-II patients but showed no significant change in Visick III-IV patients. Carditis at the esophagogastric junction regressed to fundic mucosa in 50% of Visick I-II patients. CONCLUSION Laparoscopic Nissen fundoplication produces control of symptoms in 80% of patients late (up to 15 years) after surgeries corroborated by endoscopic, histologic examinations, and functional studies. It is essential to perform these objective evaluations to demonstrate the "antireflux effect" after laparoscopic Nissen fundoplication.
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Affiliation(s)
- Attila Csendes
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile.
| | - Omar Orellana
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
| | - Nicole Cuneo
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
| | - Gustavo Martínez
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
| | - Manuel Figueroa
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
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Armijo PR, Hennings D, Leon M, Pratap A, Wheeler A, Oleynikov D. Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility. J Gastrointest Surg 2019; 23:36-42. [PMID: 30288691 DOI: 10.1007/s11605-018-3968-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients. METHODS A single-institution prospective database was reviewed (2007-2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05. RESULTS Fifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0 ± 18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1-7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia. CONCLUSIONS A tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.
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Affiliation(s)
- Priscila R Armijo
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA
| | - Dietric Hennings
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA.,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Melissa Leon
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA
| | - Akshay Pratap
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA.,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Austin Wheeler
- College of Medicine, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Dmitry Oleynikov
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA. .,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
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Rebecchi F, Allaix ME, Cinti L, Nestorović M, Morino M. Comparison of the outcome of laparoscopic procedures for GERD. Updates Surg 2018; 70:315-321. [PMID: 30027381 DOI: 10.1007/s13304-018-0572-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/08/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Marco Ettore Allaix
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy.
| | - Lorenzo Cinti
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Milica Nestorović
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
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Allaix ME, Rebecchi F, Morino M, Schlottmann F, Patti MG. Gastroesophageal Reflux and Idiopathic Pulmonary Fibrosis. World J Surg 2018; 41:1691-1697. [PMID: 28258461 DOI: 10.1007/s00268-017-3956-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown origin that affects about 40,000 new patients every year in the USA. Albeit the disease is labelled as idiopathic, it is thought that pathologic reflux, often silent, plays a role in its pathogenesis through a process of microaspiration of gastric contents. AIMS The aim of this study was to review the available evidence linking reflux to IPF, and to study the effect of medical and surgical therapy on the natural history of this disease. RESULTS Medical therapy with acid-reducing medications controls the production of acid and has some benefit. However, reflux and aspiraion of weakly acidic or alkaline gastric contents can still occur. Better results have been reported after laparoscopic anti-reflux surgery, as this form of therapy re-establishes the competence of the lower esophageal sphincter, therefore stopping any type of reflux. CONCLUSIONS A phase II NIH study in currently in progress in the USA to determine the role of antireflux surgery in patients with GERD and IPF. The hope is that this simple operations might alter the natural history of IPF, avoiding progression and the need for lung transplantation.
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Affiliation(s)
- Marco E Allaix
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | | | - Mario Morino
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Francisco Schlottmann
- Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Marco G Patti
- Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, USA.
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Schietroma M, Colozzi S, Pessia B, Carlei F, Di Furia M, Amicucci G. Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial. J Minim Access Surg 2018; 14:221-229. [PMID: 29582795 PMCID: PMC6001299 DOI: 10.4103/jmas.jmas_120_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF). Materials and Methods Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated. Results A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiO2group patients in comparison with the 80% FiO2group (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO2group; no changes were noted in 80% FiO2group (P < 0.05). Conclusions This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.
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Affiliation(s)
| | - Sara Colozzi
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | - Beatrice Pessia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | | | - Marino Di Furia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
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Kummerow Broman K, Phillips SE, Faqih A, Kaiser J, Pierce RA, Poulose BK, Richards WO, Sharp KW, Holzman MD. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial. Surg Endosc 2017; 32:1668-1674. [PMID: 29046957 DOI: 10.1007/s00464-017-5845-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term. METHODS We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) instrument. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records. RESULTS Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores and GERD-HRQL scores were slightly worse for Heller than Heller plus Dor but were not statistically different (6 vs 3, p = 0.08 for dysphagia, 15 vs 13, p = 0.25 for reflux). Five patients in the Heller group and 6 in Heller plus Dor underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo operation again. CONCLUSIONS Long-term patient-reported outcomes after Heller alone and Heller plus Dor for achalasia are comparable, providing support for either procedure.
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Affiliation(s)
- Kristy Kummerow Broman
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA. .,Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA.
| | - Sharon E Phillips
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Adil Faqih
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Joan Kaiser
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Richard A Pierce
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Benjamin K Poulose
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - William O Richards
- Department of Surgery, University of South Alabama Health System, Mobile, AL, USA
| | - Kenneth W Sharp
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Michael D Holzman
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
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Abstract
Operative treatment of GERD has become more common since the introduction of LARS. Careful patient selection based on symptoms, response to medical therapy, and preoperative testing will optimize the chances for effective and durable postoperative control of symptoms. Complications of the LARS are rare and generally can be managed without reoperation. When reoperation is necessary for failed antireflux surgery, it should be performed by high-volume gastroesophageal surgeons.
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Affiliation(s)
- Robert B Yates
- Department of General Surgery, Center for Videoendoscopic Surgery, University of Washington, 1959 NE Pacific Street, Box 356410/Suite BB-487, Seattle, WA 98195, USA.
| | - Brant K Oelschlager
- Division of General Surgery, Department of Surgery, Center for Esophageal and Gastric Surgery, University of Washington, 1959 NE Pacific Street, Box 356410/Suite BB-487, Seattle, WA 98195, USA
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Abstract
BACKGROUND The topic of "when and what" for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the "when") and on the right antireflux operation to perform once the ideal candidate is identified (the "what"). AIMS The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.
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Idiopathic pulmonary fibrosis and gastroesophageal reflux. Implications for treatment. J Gastrointest Surg 2014; 18:100-4; discussion 104-5. [PMID: 24002768 DOI: 10.1007/s11605-013-2333-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 08/20/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Even though the pathogenesis of idiopathic pulmonary fibrosis (IPF) is unknown, there is mounting evidence that abnormal reflux (GERD) and aspiration of gastric contents may play a role in the pathogenesis of this disease. AIMS The aims of this study were to determine in patients with GERD and IPF: (a) the clinical presentation, (b) the esophageal function, and (c) the reflux profile. METHODS We compared the clinical presentation, the esophageal function (as defined by high-resolution manometry), and the reflux profile (by dual sensor pH monitoring) in 80 patients with GERD (group A) and in 22 patients with GERD and IPF (group B). RESULTS Heartburn was present in less than 60 % of patients with GERD and IPF. Lower esophageal sphincter pressure and peristalsis were normal in both groups, while the upper esophageal sphincter (UES) was more frequently hypotensive in IPF patients (p = 0.008). In patients with GERD and IPF, the proximal esophageal acid exposure was higher (p = 0.047) and the supine acid clearance was slower as compared with patients with GERD only (p < 0.001). CONCLUSIONS The results of this study show that in patients with GERD and IPF: (a) reflux is frequently silent, (b) with the exception of a weaker UES, the esophageal function is preserved, and (c) proximal reflux is more common, and in the supine position, it is coupled with a slower acid clearance. Because these factors predisposing IPF patients to the risk of aspiration, antireflux surgery should be considered early after the diagnosis of IPF and GERD is established.
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18
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A prospective randomized study of systemic inflammation and immune response after laparoscopic nissen fundoplication performed with standard and low-pressure pneumoperitoneum. Surg Laparosc Endosc Percutan Tech 2013; 23:189-96. [PMID: 23579517 DOI: 10.1097/sle.0b013e3182827e51] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to compare changes in the systemic inflammation and immune response in the early postoperative (p.o.) period after laparoscopic Nissen fundoplication (LNF) was performed with standard-pressure and low-pressure carbon dioxide pneumoperitoneum. MATERIALS AND METHODS We studied 68 patients with documented gastroesophageal reflux disease and who underwent a LNF: 35 using standard-pressure (12 to 14 mmHg) and 33 low-pressure (6 to 8 mmHg) pneumoperitoneum. White blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR, neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein were investigated. RESULTS A significantly higher concentration of neutrophil elastase, IL-6 and IL-1, and C-reactive protein was detected postoperatively in the standard-pressure group of patients in comparison with the low-pressure group (P<0.05). A statistically significant change in human leukocyte antigen-DR expression was recorded p.o. at 24 hours, as a reduction of this antigen expressed on monocyte surface in patients from standard group; no changes were noted in low-pressure group patients (P<0.05). CONCLUSIONS This study demonstrated that reducing the pressure of the pneumoperitoneum to 6 to 8 mm Hg during LNF is reduced p.o. inflammatory response and avoided p.o. immunosuppression.
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Fei L, Rossetti G, Moccia F, Marra T, Guadagno P, Docimo L, Cimmino M, Napolitano V, Docimo G, Napoletano D, Guerriero L, Pascotto B. Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up. BMC Surg 2013; 13 Suppl 2:S13. [PMID: 24267613 PMCID: PMC3851262 DOI: 10.1186/1471-2482-13-s2-s13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background In this prospective non randomized observational cohort study we have
evaluated the influence of age on outcome of laparoscopic total
fundoplication for GERD. Methods Six hundred and twenty consecutive patients underwent total laparoscopic
fundoplication for GERD. Five hundred and twenty-four patients were younger
than 65 years (YG), and 96 patients were 65 years or older (EG). The
following parameters were considered in the preoperative and postoperative
evaluation: presence, duration, and severity of GERD symptoms, presence of a
hiatal hernia, manometric and 24 hour pH-monitoring data, duration of
operation, incidence of complications and length of hospital stay. Results Elderly patients more often had atypical symptoms of GERD and at manometric
evaluation had a higher rate of impaired esophageal peristalsis in
comparison with younger patients. The duration of the operation was similar
between the two groups. The incidence of intraoperative and postoperative
complications was low and the difference was not statistically significant
between the two groups. An excellent outcome was observed in 93.0% of young
patients and in 88.9% of elderly patients (p = NS). Conclusions Laparoscopic antireflux surgery is a safe and effective treatment for GERD
even in elderly patients, warranting low morbidity and mortality rates and a
significant improvement of symptoms comparable to younger patients.
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20
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Allaix ME, Herbella FA, Patti MG. Laparoscopic total fundoplication for gastroesophageal reflux disease. How I do it. J Gastrointest Surg 2013; 17:822-8. [PMID: 23129120 DOI: 10.1007/s11605-012-2068-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/15/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD). DISCUSSION Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis. CONCLUSION This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, Room G-207, Chicago, IL 60637, USA
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Importance of ineffective esophageal motility in patients with erosive reflux disease on the long-term outcome of Nissen fundoplication. Eur Surg 2012. [DOI: 10.1007/s10353-012-0187-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Lal P, Leekha N, Chander J, Dewan R, Ramteke VK. A prospective nonrandomized comparison of laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication in Indian population using detailed objective and subjective criteria. J Minim Access Surg 2012; 8:39-44. [PMID: 22623824 PMCID: PMC3353611 DOI: 10.4103/0972-9941.95529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 03/23/2011] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND: Laparoscopic Nissen fundoplication (LNF) is a commonly performed procedure for the treatment of gastro esophageal reflux disease (GERD) worldwide. However, unfavourable postoperative sequel, including gas bloat and dysphagia, has encouraged surgeons to perform alternative procedures such as laparoscopic Toupet fundoplication (LTF). This prospective nonrandomized study was designed to compare LNF with LTF in patients with GERD. MATERIALS AND METHODS: Hundred and ten patients symptomatic for GERD were included in the study after having received intensive acid suppression therapy for a minimum of 8 weeks. A 24-hour pH metry was done on all patients. Fifty patients having reflux on 24-hour pH metry were taken up for the surgery. Patients were further divided into group-A (LNF) and group-B (LTF). RESULTS: The median percentage time with esophageal pH < 4 decreased from 10.18% and 12.31% preoperatively to 0.85% and 1.94% postoperatively in LNF and LTF-groups, respectively. There was a significant and comparable increase in length of lower esophageal sphincter (LES), length of intraabdominal part of LES and LES pressure at respiratory inversion point in both the groups. In LNF-group, five patients had early dysphagia that improved afterwards. There were no significant postoperative complications. CONCLUSION: LNF and LTF are highly effective in the management of GERD with significant improvement in symptoms and objective parameters. LNF may be associated with significantly higher incidence of short onset transient dysphagia that improves with time. Patients in both the groups showed excellent symptom and objective control on 24-hour pH metry on short term follow-up.
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Affiliation(s)
- Pawanindra Lal
- Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
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Wee JO. Redo laparoscopic repair of benign esophageal disease. J Thorac Cardiovasc Surg 2012; 144:S71-3. [PMID: 22608677 DOI: 10.1016/j.jtcvs.2012.03.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 03/22/2012] [Indexed: 01/11/2023]
Abstract
Laparoscopic fundoplication for gastroesophageal reflux disease has been associated with excellent symptom control. Compared with medical treatment, laparoscopic Nissen fundoplication has shown favorable control of typical reflux symptoms. However, in approximately 2% to 17% of patients, surgical treatment fails. The role of reoperative repair for reflux disease and the factors that contribute to it are examined.
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Affiliation(s)
- Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Is there an association between hiatal hernia and ineffective esophageal motility in patients with gastroesophageal reflux disease? J Gastrointest Surg 2011; 15:1756-61. [PMID: 21830151 DOI: 10.1007/s11605-011-1619-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 07/12/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The pathophysiology of gastroesophageal reflux disease is multifactorial, where esophageal motility is one of the factors implicated in its genesis. However, there is still no consensus on the existence of an association between esophageal dysmotility and hiatal hernia in patients with gastroesophageal reflux disease. The objective of this study was to establish the prevalence of esophageal dysmotility in patients with hiatal hernia and to determine if herniation is a factor related to esophageal dysmotility in patients with gastroesophageal reflux disease. METHODS The study included 356 patients with a clinical diagnosis of gastroesophageal reflux disease submitted to upper digestive endoscopy and esophageal functional diagnostics. Hiatal hernia was defined endoscopically by a distance equal to or greater than 2 cm between the diaphragmatic constriction and the squamocolumnar junction and esophageal dysmotility when the esophageal manometry identified the amplitude of the peristaltic waves in the distal esophagus as <30 mmHg and/or less than 80% of effective contractions. For univariate statistical analysis, the patients were divided into two groups: with and without hiatal hernia. Poisson regression models were used to estimate crude and adjusted prevalence ratios (PR) of esophageal dysmotility according to hiatal hernia. RESULTS Gastroesophageal reflux disease patients with hiatal hernia had a prevalence of esophageal dysmotility equal to 14.8% and those without hiatal hernia, a prevalence of 7.7% (p = 0.041). Patients with hiatal hernia also showed a higher frequency of erosive esophagitis (47.5% versus 24.2%, p < 0.001), lower low esophageal sphincter pressure (10.4 versus 13.10; p < 0.001), and higher frequency of individuals with abnormal pH-metry values (p < 0.001). The crude PR for esophageal dysmotility, according to the presence of hiatal hernia, was 1.92 (confidence interval (CI), 1.04-3.53; p = 0.037), but this association did not persist when controlled for age, esophagitis, altered pH-metry, and altered low esophageal sphincter (adjusted PR, 1.69; CI, 0.68-4.15; p = 0.257). CONCLUSION Despite the prevalence of esophageal dysmotility in the hiatal hernia group being higher than that in the group without hiatal hernia, the association between these variables in individuals with gastroesophageal reflux disease disappeared when controlling for age, esophagitis, altered pH-metry, and altered low esophageal sphincter, leading us to believe that in these patients, hiatal hernia is not an independent risk factor for dysmotility.
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Is Toupet fundoplication the procedure of choice for treating gastroesophageal reflux disease? Results of a prospective randomized experimental trial comparing three major antireflux operations in a porcine model. Surg Endosc 2011; 25:3235-44. [DOI: 10.1007/s00464-011-1699-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 03/25/2011] [Indexed: 12/13/2022]
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Davis CS, Baldea A, Johns JR, Joehl RJ, Fisichella PM. The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease. JSLS 2011; 14:332-41. [PMID: 21333184 PMCID: PMC3041027 DOI: 10.4293/108680810x12924466007007] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND For nearly 2 decades, the laparoscopic correction of gastroesophageal reflux disease (GERD) has demonstrated its utility. However, the surgical technique has evolved over time, with mixed long-term results. We briefly review the evolution of antireflux surgery for the treatment of GERD, provide an update specific to the long-term efficacy of laparoscopic antireflux surgery (LARS), and analyze the factors predictive of a desirable outcome. MATERIALS AND METHODS PubMed and Medline database searches were performed to identify articles regarding the laparoscopic treatment of GERD. Emphasis was placed on randomized control trials (RCTs) and reports with follow-up >1 year. Specific parameters addressed included operative technique, resolution of symptoms, complications, quality of life, division of short gastric vessels (SGVs), mesh repair, and approximation of the crura. Those studies specifically addressing follow-up of <1 year, the pediatric or elderly population, redo fundoplication, and repair of paraesophageal hernia and short esophagus were excluded. RESULTS LARS has varied in technical approach through the years. Not until recently have more long-term, objective studies become available to allow for evidenced-based appraisals. Our review of the literature found no long-term difference in the rates of heartburn, gas-bloat, antacid use, or patient satisfaction between laparoscopic Nissen and Toupet fundoplication. In addition, several studies have shown that more patients had an abnormal pH profile following laparoscopic partial as opposed to total fundoplication. Conversely, dysphagia was more common following laparoscopic total versus partial fundoplication in 50% of RCTs at 12-month follow-up, though this resolved over time, being present in only 20% with follow-up >24 months. We confirmed that preoperative factors, such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Last, no trial disfavored division of the short gastric vessels (SGVs), closure of the crura, or mesh repair for hiatal defects. CONCLUSION LARS has significantly evolved over time. The laparoscopic total fundoplication appears to provide more durable long-term results than the partial approach, as long as the technical elements of the operation are respected. Division of the SGVs, closure of the crura, and the use of mesh for large hiatal defects positively impacts long-term outcome. Hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting are potential predictors of failure in LARS.
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Affiliation(s)
- C S Davis
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
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Gouvas N, Tsiaoussis J, Athanasakis E, Zervakis N, Pechlivanides G, Xynos E. Simple suture or prosthesis hiatal closure in laparoscopic repair of paraesophageal hernia: a retrospective cohort study. Dis Esophagus 2011; 24:69-78. [PMID: 20659144 DOI: 10.1111/j.1442-2050.2010.01094.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1-year postoperative follow-up, were included in the study. Pre- and postoperative testing included symptom questionnaires, barium esophagogram, pH-monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty-eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.
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Affiliation(s)
- N Gouvas
- 1st Department of General Surgery, Agia Olga Hospital of Athens, Greece.
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Grommes J, Binnebösel M, Klink CD, von Trotha KT, Junge K, Jansen M. Surgical technique for gastroesophageal reflux disease. J INVEST SURG 2010; 23:273-9. [PMID: 20874483 DOI: 10.3109/08941939.2010.496034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS Laparoscopic fundoplication is the standard surgical therapy for managing gastroesophageal reflux disease. According to the pre-existing esophageal motility of the patient, tailoring antireflux surgery has been proposed in order to avoid postoperative dysphagia. Thus, the aim of this study is to evaluate the long-term results following this tailored concept. METHODS One-hundred sixty patients were included in this prospective study. A 360° Nissen fundoplication (NF) was performed on n = 127 patients with a normal esophageal peristalsis, whereas a 270° Toupet fundoplication (TF) was conducted on n = 33 patients having an esophageal motility disorder. Before surgery, all the patients were subjected to pH-metry, manometry, gastroscopy, and they had to respond to a standardized questionnaire. Postoperatively, pH-metry, and manometry were performed. In addition to the questionnaire, side effects and complications were evaluated. RESULTS The NF cohort and the TF cohort were each followed up for an average of 39 ± 13 months and 43 ± 12 months, respectively. Dysphagia was significantly reduced after NF (p = .033). The TF, however, decreased the intensity but not the incidence of dysphagia (p = .884). Heartburn was significantly diminished in both cohorts. The DeMeester score was significantly reduced after NF, whereas it was not significantly reduced following TF with a still evident, pathological acid reflux occurring postoperatively. CONCLUSION Our data indicate that tailoring antireflux surgery to the esophageal motility of the patient seems unnecessary. In summary, technical surgical aspects appear to be more important for clinical outcome.
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Affiliation(s)
- Jochen Grommes
- Department of Vascular Surgery, RWTH Aachen University Hospital, Germany.
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29
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Fein M, Seyfried F. Is there a role for anything other than a Nissen's operation? J Gastrointest Surg 2010; 14 Suppl 1:S67-74. [PMID: 20012380 DOI: 10.1007/s11605-009-1020-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 08/25/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Nissen fundoplication is the most frequently applied antireflux operation worldwide. The aim of this review was to compare laparoscopic Nissen with partial fundoplication. METHODS Nine randomized trials comparing several types of wraps were analyzed, four for the comparison Nissen vs. Toupet and five for the comparison Toupet or Nissen vs. anterior fundoplication. Similar comparisons in nonrandomized studies were also included. RESULTS Dysphagia rates and reflux recurrence were not related to preoperative esophageal persistalsis independent of the selected procedure. Overall, Nissen fundoplication revealed slightly better reflux control, but was associated with more side effects, such as early dysphagia and gas bloat. Advantages of an anterior approach were only reported by one group. A significantly higher reflux recurrence rate for anterior fundoplication was observed in all other comparisons. CONCLUSION Tailoring antireflux surgery according to esophageal motility is not indicated. At present, the relevant factor for selection of a Nissen or Toupet fundoplication is personal experience. Anterior fundoplication offers less effective long-term reflux control.
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Affiliation(s)
- Martin Fein
- Chirurgische Klinik und Poliklinik I, Klinikum der Universität Würzburg, Würzburg, Germany.
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30
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Montenovo M, Tatum RP, Figueredo E, Martin AV, Vu H, Quiroga E, Pellegrini CA, Oelschlager BK. Does combined multichannel intraluminal esophageal impedance and manometry predict postoperative dysphagia after laparoscopic Nissen fundoplication? Dis Esophagus 2009; 22:656-63. [PMID: 19515186 DOI: 10.1111/j.1442-2050.2009.00988.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic Nissen fundoplication (LNF) is an effective treatment for gastroesophageal reflux disease; however, some patients develop dysphagia postoperatively. Manometry is used to evaluate disorders of peristalsis, but has not been proven useful to identify which patients may be at risk for postoperative dysphagia. Multichannel intraluminal impedance (MII) evaluates the effective clearance of a swallowed bolus through the esophagus. We hypothesized that MII combined with manometry may detect those patients most at risk of developing dysphagia after LNF. Between March 2003 and January 2007, 74 patients who agreed to participate in this study were prospectively enrolled. All patients completed a preoperative symptom questionnaire, MII/manometry, and 24-h pH monitoring. All patients underwent LNF. Symptom questionnaires were administered postoperatively at a median of 18 months (range: 6-46 months), and we defined dysphagia (both preoperatively and postoperatively) as occurring more than once a month with a severity >or=4 (0-10 Symptom Severity Index). Thirty-two patients (43%) reported preoperative dysphagia, but there was no significant difference in pH monitoring, lower esophageal sphincter pressure/relaxation, peristalsis, liquid or viscous bolus transit (MII), or bolus transit time (MII) between patients with and without preoperative dysphagia. In those patients reporting preoperative dysphagia, the severity of dysphagia improved significantly from 6.8 +/- 2 to 2.6 +/- 3.4 (P < 0.001) after LNF. Thirteen (17%) patients reported dysphagia postoperatively, 10 of whom (75%) reported some degree of preoperative dysphagia. The presence of postoperative dysphagia was significantly more common in patients with preoperative dysphagia (P= 0.01). Patients with postoperative dysphagia had similar lower esophageal sphincter pressure and relaxation, peristalsis, and esophageal clearance to those without dysphagia. Neither MII nor manometry predicts dysphagia in patients with gastroesophageal reflux disease or its occurrence after LNF. The presence of dysphagia preoperatively is the only predictor of dysphagia after LNF.
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Affiliation(s)
- M Montenovo
- The Swallowing Center, Department of Surgery, University of Washington, Seattle, Washington 98108, USA
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31
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Chandra KMD, Harding SM. Therapy Insight: treatment of gastroesophageal reflux in adults with chronic cough. ACTA ACUST UNITED AC 2007; 4:604-13. [PMID: 17978817 DOI: 10.1038/ncpgasthep0955] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Accepted: 08/28/2007] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux (GER) is the second most common cause of chronic cough in immunocompetent patients who are nonsmokers, not on angiotensin-converting-enzyme inhibitors and have normal chest radiographs. Identification of GER in chronic cough patients can be difficult; most patients with GER-related cough have no esophageal symptoms and no esophageal test is adequate to make this diagnosis. Post-hoc analysis of four prospective intervention trials has identified a clinical patient profile that can predict the presence of GER-related cough 91% of the time. Clinical practice guidelines from the American College of Chest Physicians and the British Thoracic Society recommend initiating an initial empiric GER therapy trial, with esophageal testing being reserved for nonresponders. The empiric trial should include conservative measures and PPIs twice daily for 3 months. Selected patients who have dysphagia might benefit from the addition of a prokinetic agent. Esophageal manometry and pH testing with impedance monitoring (if available) should be performed in nonresponders while they are on therapy. It can take more than 50 days for cough to respond to medical GER therapy. Surgical fundoplication might be helpful in very carefully selected patients. Careful evaluation and treatment resolves cough in approximately 80% of patients with GER-related cough.
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Affiliation(s)
- K M Dinesh Chandra
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-0006, USA
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32
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Bochkarev V, Iqbal A, Lee YK, Vitamvas M, Oleynikov D. One hundred consecutive laparoscopic Nissen’s without the use of a bougie. Am J Surg 2007; 194:866-70; discussion 870-1. [DOI: 10.1016/j.amjsurg.2007.08.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Revised: 08/13/2007] [Accepted: 08/13/2007] [Indexed: 12/26/2022]
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Roorda AK, Marcus SN, Triadafilopoulos G. Early experience with radiofrequency energy ablation therapy for Barrett's esophagus with and without dysplasia. Dis Esophagus 2007; 20:516-22. [PMID: 17958728 DOI: 10.1111/j.1442-2050.2007.00728.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Radiofrequency (RF) ablation using the HALO(360) system combined with proton pump inhibitor (PPI) therapy is a new treatment for Barrett's esophagus (BE). We assessed the safety and effectiveness of this combination therapy at a community-based, BE referral center. After symptom evaluation, endoscopy and histologic assessment, esophageal motility, pH monitoring on PPI, computed tomography, endoscopic ultrasonography and mucosal resection for nodules, we performed HALO(360) ablation followed by twice daily PPI and 3-monthly surveillance for up to 12 months. If metaplasia or dysplasia were present at follow-up, the patients received a second ablation. Thirteen patients (12 male) were treated, three with high-grade dysplasia, four with low-grade and six with non-dysplastic intestinal metaplasia. The mean baseline BE length was 6 cm (range 2-12); nine patients had an hiatal hernia and two had a prior fundoplication. Esophageal pH < 4.0 for < 4% of time was achieved only in 5/13 patients. A mean of 1.4 ablation sessions were performed, without serious adverse events or strictures. Complete eradication of BE was achieved in 6/13 (46%) patients. The mean endoscopic surface regression was 84% (from a mean length of 6 +/- 1 cm to 1.2 +/- 0.5 cm, P < 0.001). Complete elimination of dysplasia was achieved in 5/7 (71%) patients. Ablation efficacy was better in those patients who had maximal pH control (P < 0.05). HALO(360) ablation of BE with or without dysplasia is safe, well-tolerated and effective in the community setting. Follow-up ablation further reverses residual BE or dysplasia.
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Affiliation(s)
- A K Roorda
- Department of Internal Medicine, St Mary's Medical Center, San Francisco, California, USA
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Richter JE. The many manifestations of gastroesophageal reflux disease: presentation, evaluation, and treatment. Gastroenterol Clin North Am 2007; 36:577-99, viii-ix. [PMID: 17950439 DOI: 10.1016/j.gtc.2007.07.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common problem that is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world, with important risk factors being obesity and the eradication of Helicobacter pylori. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory esophageal pH testing is the most sensitive test for GERD, whereas endoscopy is the most specific test. Medical treatment with proton pump inhibitors (PPIs) has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic anti-reflux surgery and PPIs have similar efficacy in the few available long-term trials. This article reviews the presentation, evaluation, and treatment of GERD.
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Affiliation(s)
- Joel E Richter
- The Richard L. Evans Chair, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, 801 Parkinson Pavilion, Philadelphia, PA 19140, USA.
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35
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Abstract
Gastrooesophageal reflux disease, GERD, is a common problem which is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world with important risk factors being obesity and the eradication of Helicobacter pylori. Increasing research points to transient LES relaxation and spatial separation of the diaphragm and LES (hiatal hernia in chest) being the critical mechanisms of acid reflux. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory oesophageal pH testing is the most sensitive test for GERD, while endoscopy is the most specific test. Medical treatment with PPIs has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic antireflux surgery and PPIs have similar efficacy in the few available long-term trials. Currently, endoscopic treatments for GERD should not be a clinical alternative outside of research trials. New drug therapies should be directed at modulating transient LES relaxation.
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Affiliation(s)
- Joel E Richter
- Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, 801 Parkinson Pavilion, Philadelphia, PA 19140, USA.
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36
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Pizza F, Rossetti G, Limongelli P, Del Genio G, Maffettone V, Napolitano V, Brusciano L, Russo G, Tolone S, Di Martino M, Del Genio A. Influence of age on outcome of total laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol 2007; 13:740-7. [PMID: 17278197 PMCID: PMC4066007 DOI: 10.3748/wjg.v13.i5.740] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To demonstrate that age does not influence the choice of treatment for gastroesophageal reflux disease (GERD). We hypothesized that the outcome of total fundoplication in patients > 65 years is similar to that of patients aged ≤ 65 years.
METHODS: Four hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Three hundred and fifty-five patients were younger than 65 years (group Y), and 65 patients were 65 years or older (group E). The following elements were considered: presence, duration, and severity of GERD symptoms; presence of a hiatal hernia; manometric evalu-ation, 24 h pH-monitoring data, duration of operation; incidence of complications; and length of hospital stay.
RESULTS: Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in compari-son with younger patients. A mild intensity of heartburn often leads physicians to underestimate the severity of erosive esophagitis. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 92.9% young patients and 91.9% elderly patients.
CONCLUSION: Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.
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Affiliation(s)
- F Pizza
- 1st Division of General and Gastrointestinal Surgery, Second University of Naples, Via Villa Albertini, 39 bis, Nola 80037, Naples, Italy.
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37
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Novitsky YW, Wong J, Kercher KW, Litwin DEM, Swanstrom LL, Heniford BT. Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication. Surg Endosc 2006; 21:950-4. [PMID: 17177077 DOI: 10.1007/s00464-006-9126-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Revised: 09/25/2006] [Accepted: 11/20/2006] [Indexed: 12/16/2022]
Abstract
BACKGROUND Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. METHODS A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. RESULTS In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 +/- 5.2 mmHg (range, 6.0-30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% +/- 8.3% (range, 70-100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett's progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1-46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. CONCLUSION The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360 degrees fundoplication should not be contraindicated for patients with severe esophageal dysmotility.
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Affiliation(s)
- Y W Novitsky
- Department of Surgery, Carolinas Medical Center, Charlotte, NC 28202, USA.
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38
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Herbella FAM, Tedesco P, Nipomnick I, Fisichella PM, Patti MG. Effect of partial and total laparoscopic fundoplication on esophageal body motility. Surg Endosc 2006; 21:285-8. [PMID: 17122978 DOI: 10.1007/s00464-006-0108-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 06/07/2006] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Yigit T, Quiroga E, Oelschlager B. Multichannel intraluminal impedance for the assessment of post-fundoplication dysphagia. Dis Esophagus 2006; 19:382-8. [PMID: 16984537 DOI: 10.1111/j.1442-2050.2006.00591.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Dysphagia often occurs after fundoplication, although its pathophysiology is not clear. We sought to better understand postfundoplication dysphagia by measuring esophageal clearance with multichannel intraluminal impedance (MII) along with more traditional work-up (manometry, upper gastrointestinal imaging [UGI], endoscopy). We evaluated 80 consecutive patients after laparoscopic fundoplication between April 2002 and November 2004. Patients were evaluated clinically and underwent simultaneous manometry and MII, 24-hour pH monitoring, endoscopy, and UGI. For analysis, patients were divided into the following groups based on the presence of dysphagia and fundoplication anatomy (by UGI/endoscopy): (1) Dysphagia and normal anatomy; (2) Dysphagia and abnormal anatomy; (3) No dysphagia and abnormal anatomy; and (4) No dysphagia and normal anatomy. Patients with dysphagia (Groups 1 & 2) had similar peristalsis (manometry), but were more likely to have impaired clearance by MII (32 pts, 62%) than those without dysphagia (9 pts, 32%, P = 0.01). Patients with abnormal anatomy (Groups 2 & 3) were also more likely to have impaired esophageal clearance (66%vs. 38%, P = 0.01). Finally, of patients that had normal fundoplication anatomy, those with dysphagia were much more likely to have impaired clearance (12 pts, 52%) than those with dysphagia (4 pts, 21%, P = 0.03). MII after fundoplication provides objective evidence of esophageal clearance, and is commonly abnormal in patients with abnormal fundoplication anatomy and/or dysphagia. Esophageal clearance is impaired in the majority of patients with postoperative dysphagia, even with normal fundoplication anatomy and normal peristalsis. MII may detect disorders in esophageal motility not detected by manometry.
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Affiliation(s)
- T Yigit
- The Swallowing Center, Department of Surgery, University of Washington, Seattle, WA, USA
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40
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Oh DS, Hagen JA, Fein M, Bremner CG, Dunst CM, Demeester SR, Lipham J, Demeester TR. The impact of reflux composition on mucosal injury and esophageal function. J Gastrointest Surg 2006; 10:787-96; discussion 796-7. [PMID: 16769534 DOI: 10.1016/j.gassur.2006.02.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Accepted: 02/01/2006] [Indexed: 02/06/2023]
Abstract
The components of refluxed gastric juice are known to cause mucosal injury, but their effect on esophageal function is less appreciated. Our aim was to determine the effect of acid and/or bile on mucosal injury and esophageal function. From 1993-2004, 402 patients with reflux symptoms had 24-hour pH and Bilitec monitoring, manometry, and endoscopy with biopsies. Mucosal injury (esophagitis or Barrett's esophagus) and esophageal function (lower esophageal sphincter [LES] characteristics and body contractility) in patients with acid reflux, bile reflux, or both were compared with patients without reflux. Reflux was present in 273/402 patients; of these, 37 (13.5%) had increased exposure to bile, 82 (30.0%) had increased exposure to acid, and 154 (56.4%) had increased exposure to both. Mucosal injury was most common with increased mixed acid and bile exposure, followed by acid alone, and was uncommon with bile alone (P < 0.0001). Functional deterioration paralleled mucosal injury (P < 0.0001). Mixed acid and bile exposure was present in more than half of patients with reflux and was associated with the most severe mucosal injury and the greatest deterioration of esophageal function. This suggests that composition of gastric juice is the primary determinant of inflammatory mucosal injury and subsequent loss of esophageal function.
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Affiliation(s)
- Daniel S Oh
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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Oleynikov D, Ringley C, Bochkarev V. How effective is Enteryx implantation for the treatment of patients with GERD? NATURE CLINICAL PRACTICE. GASTROENTEROLOGY & HEPATOLOGY 2005; 2:508-9. [PMID: 16355153 DOI: 10.1038/ncpgasthep0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Accepted: 09/15/2005] [Indexed: 05/05/2023]
Affiliation(s)
- Dimitry Oleynikov
- Education and Training Center for Minimally Invasive and Computer Assisted Surgery Initiative, USA.
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Abstract
Given the anatomic and functional defects almost universally present in patients who have BE, antireflux surgery is the most reliable means of stopping acid and nonacid (alkaline) reflux. Because patients who have BE have end-stage GERD, they require durable and reliable control of reflux, and the Hill procedure and partial fundoplication are associated with unacceptably high failure rates. In addition, there is mounting evidence that the success rates for Nissen fundoplication are lower in patients who have BE than in patients who have less severe GERD. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, patients who have BE must be considered at risk for having a short esophagus. The failure rate may be reduced by the liberal addition of a Collis gastroplasty, but the long-term consequences of acid-secreting mucosa left above the fundoplication in patients who have BE remain unclear. Patients suspected of having a short esophagus on the basis of a large hiatal hernia, stricture, or long-segment BE should be considered for a transthoracic approach to their fundoplication, as this affords good esophageal mobilization and may obviate the need for a gastroplasty. Surgeons must pay particular attention to their own and published results and continue to refine the operation to maximize the likelihood of a good outcome in this difficult group of patients. It is only with excellent control of reflux that any differences in the risk of progression to dysplasia and cancer become apparent, and significant, between medically and surgically treated patients.
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Affiliation(s)
- Carl-Christian A Jackson
- Department of Surgery, The University of Southern California, Keck School of Medicine, 1510 San Pablo Street, Suite 514, Los Angeles, CA 90033, USA
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Hartwig MG, Appel JZ, Davis RD. Antireflux Surgery in the Setting of Lung Transplantation: Strategies for Treating Gastroesophageal Reflux Disease in a High-Risk Population. Thorac Surg Clin 2005; 15:417-27. [PMID: 16104132 DOI: 10.1016/j.thorsurg.2005.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In lung transplant recipients, GERD is associated with increased incidence of acute rejection, earlier onset of chronic rejection, and higher mortality. Surgical treatment of GERD in lung recipients seems to prevent early allograft dysfunction and improve overall survival. A total (360 degrees) fundoplication is shown to be a safe and effective method for treating GERD in lung transplant recipients and is the authors' procedure of choice, in most cases, for this high-risk patient population. The principal goal should be to minimize reflux of enteric contents that may lead to micro- or macroaspiration events in this complicated group of patients. Perioperative care should involve a multidisciplinary approach, including physicians and other health care providers familiar with the complexities of lung transplant recipients.
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Affiliation(s)
- Matthew G Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Department of Surgery, Box 3864, Durham, NC 27710, USA
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Limpert PA, Naunheim KS. Partial Versus Complete Fundoplication: Is There a Correct Answer? Surg Clin North Am 2005; 85:399-410. [PMID: 15927640 DOI: 10.1016/j.suc.2005.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Gastroesophageal reflux disease is a common disorder, and patients diagnosed with GERD face a lifelong treatment requirement. A surgical antireflux procedure may be offered as an alternative to lifelong treatment with proton-pump inhibitors. Many investigations have been performed to help discover the best surgical alternative to medical management. An ideal antireflux procedure should be safe, effective, durable, and result in minimal complications. Total fundoplication in the form of Nissen fundoplication is the most widely used antireflux operation worldwide. Although its efficacy is well documented, the clinical success rate in terms of reflux control is occasionally compromised by troublesome mechanical side effects. Because of these unsatisfactory symptoms and continued hindered quality of life, the Nissen fundoplication has undergone many modifications. The current standard appears to be the 2 cm floppy Nissen; however, the alternative approach has been the use of a partial fundoplication, most frequently the Toupet procedure. Both the Nissen and Toupet fundoplications have proven to provide relief in the majority of patients, but each has its own drawback. Patients undergoing Nissen fundoplication have a higher incidence of dysphagia early after operation, although this appears to resolve in most. The Toupet, on the other hand, may not be as durable, and may lead to the early re-emergence of symptoms. The problem of post-Nissen dysphagia led many surgeons to believe that the Nissen night be contraindicated in patients who have dysmotility,because it would cause even greater dysphagia; however, recent articles have not demonstrated this to be the case. It seems that the floppy Nissen performed over a large bougie (56-60 Fr) with division of short gastrics and crural closure is an acceptable operation for reflux in both those who have normal motility and those who have mild to moderate dysmotility. Thus, for most patients who have GERD and normal motility, either procedure appears effective in the majority of patients; however, those patients who have severe dysmotilty disorders and who require an antireflux procedure(ie, scleroderma, postmyotomy achalasia) are likely best served with a partial fundoplication.
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Affiliation(s)
- Patricia A Limpert
- Division of Cardiothoracic Surgery, Department of Surgery, St. Louis University Health Sciences Center, 3635 Vista Avenue, St. Louis, MO 63110-0250, USA
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Wykypiel H, Gadenstaetter M, Klaus A, Klingler P, Wetscher GJ. Nissen or partial posterior fundoplication: which antireflux procedure has a lower rate of side effects? Langenbecks Arch Surg 2005; 390:141-7. [PMID: 15711819 DOI: 10.1007/s00423-004-0537-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2004] [Accepted: 12/02/2004] [Indexed: 11/27/2022]
Abstract
INTRODUCTION In patients with gastroesophageal reflux disease (GERD) it is still controversial as to which type of antireflux procedure-the Nissen or the partial posterior fundoplication-offers the lower rate of side effects in the long term. PATIENTS AND METHODS In this follow-up study the Nissen fundoplication was performed only in GERD patients with normal oesophageal peristalsis. The partial posterior fundoplication was preserved for patients with weak peristalsis. Only patients with effective postoperative control of GERD were included in the study. The study groups consisted of 77 patients who underwent the Nissen fundoplication and 132 patients who underwent partial posterior fundoplication. Clinical assessment of side effects was performed after a median of 52 months following surgery. Manometric assessment of the lower esophageal sphincter (LES) and of esophageal peristalsis was achieved 6 months after surgery. RESULTS Side effects such as dysphagia, bloating, inability to belch and vomit, epigastric pain and early satiety were significantly more common after the Nissen fundoplication than after partial posterior fundoplication. Improvement of the antireflux barrier was equal in both groups; however, LES relaxation was incomplete following the Nissen fundoplication but normal after partial posterior fundoplication. Partial posterior fundoplication resulted in improved oesophageal peristalsis, whereas the Nissen fundoplication caused slight impairment of peristalsis. CONCLUSIONS Partial posterior fundoplication is a more physiological antireflux procedure than the Nissen fundoplication, and, therefore, this operation has now become our preferred technique for all GERD patients.
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Affiliation(s)
- Heinz Wykypiel
- Department of General and Transplant Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Abstract
Gastroesophageal reflux disease is a very common disorder, and both medical and surgical treatments have shown outstanding results. Whereas proton pump inhibitors are the mainstay of treatment, laparoscopic fundoplication has become a very attractive alternative due to its efficacy and low morbidity. There are defined patient categories that may benefit more from laparoscopy than medical therapy, but a conclusive comparison between the two is lacking. Robotic laparoscopic fundoplication can be performed safely without increased morbidity. Potential advantages include enhanced precision, improved dexterity, and remote telesurgical applications. Disadvantages include increased cost and prolonged operative times. Further studies and more long-term outcome data are needed to fully evaluate the procedure. Robotic surgery is currently in its infancy and not cost effective but has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.
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Affiliation(s)
- Dimitrios Stefanidis
- Tulane Center for Minimally Invasive Surgery, Tulane University Health Sciences Center, 1430 Tulane Ave., SL-22, New Orleans, LA 70112-2699, USA..
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Abstract
Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.
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Affiliation(s)
- Kenneth R DeVault
- Department of Medicine, Mayo Clinic College of Medicine, Jacksonville, FL, USA
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Chrysos E, Athanasakis E, Pechlivanides G, Tzortzinis A, Mantides A, Xynos E. The effect of total and anterior partial fundoplication on antireflux mechanisms of the gastroesophageal junction. Am J Surg 2004; 188:39-44. [PMID: 15219483 DOI: 10.1016/j.amjsurg.2003.10.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2003] [Revised: 10/31/2003] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication. METHODS Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension. RESULTS Both types of fundoplication resulted in significant increases in LES resting (P <0.001) and postdeglutition relaxation pressure (P <0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04). CONCLUSIONS Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.
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Affiliation(s)
- Emmanuel Chrysos
- Laboratory of Gastrointestinal Motility, University Hospital of Heraklion, GR-711 10 Heraklion, Crete, Greece.
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Patti MG, Robinson T, Galvani C, Gorodner MV, Fisichella PM, Way LW. Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak1 1No competing interests declared. J Am Coll Surg 2004; 198:863-9; discussion 869-70. [PMID: 15194064 DOI: 10.1016/j.jamcollsurg.2004.01.029] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Revised: 01/14/2004] [Accepted: 01/14/2004] [Indexed: 02/09/2023]
Abstract
BACKGROUND About a decade ago, partial (240 degrees) fundoplication became popular for treating gastroesophageal reflux disease in cases where the patient's primary esophageal peristalsis was weak. A total (360 degrees) fundoplication was reserved for patients with normal peristalsis (tailored approach). The theory was that partial fundoplication was an adequate antireflux measure, and by posing less resistance for the weak esophageal peristalsis to overcome, it would give rise to less dysphagia. Short-term results seemed to confirm these ideas. STUDY DESIGN This study reports the longterm followup of patients in whom a tailored approach (type of wrap chosen to match esophageal peristalsis) was used, and the results of a nonselective approach, using a total fundoplication regardless of the amplitude of esophageal peristalsis. We analyzed clinical and laboratory findings in 357 patients who had an operation for gastroesophageal reflux disease between October 1992 and November 2002. Group 1 was composed of 235 patients in whom a tailored approach was used between October 1992 and December 1999 (141 patients, partial fundoplication and 94 patients, total fundoplication). Group 2 contained 122 patients in whom a nonselective approach was used (total fundoplication regardless of quality of peristalsis). RESULTS In group 1, heartburn from reflux (ie, pH monitoring test was abnormal) recurred in 19% of patients after partial fundoplication and in 4% after total fundoplication. In group 2, heartburn recurred in 4% of patients after total fundoplication. The incidence of postoperative dysphagia was similar in the two groups. CONCLUSIONS These data show that laparoscopic partial fundoplication was less effective than total fundoplication in curing gastroesophageal reflux disease, and compared with a partial (240 degrees) fundoplication, a total (360 degrees) fundoplication was not followed by more dysphagia, even when esophageal peristalsis was weak.
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Affiliation(s)
- Marco G Patti
- Department of Surgery and Swallowing Center, University of California, San Francisco, CA 94143-0788, USA
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Catarci M, Gentileschi P, Papi C, Carrara A, Marrese R, Gaspari AL, Grassi GB. Evidence-based appraisal of antireflux fundoplication. Ann Surg 2004; 239:325-37. [PMID: 15075649 PMCID: PMC1356230 DOI: 10.1097/01.sla.0000114225.46280.fe] [Citation(s) in RCA: 238] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To highlight the current available evidence in antireflux surgery through a systematic review of randomized controlled trials (RCTs). SUMMARY BACKGROUND DATA Laparoscopic fundoplication is currently suggested as the gold standard for the surgical treatment of gastroesophageal reflux disease, but many controversies are still open concerning the influence of some technical details on its results. METHODS Papers related to RCTs identified via a systematic literature search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes were abstracted and summarized across studies. Defined outcomes were examined for 41 papers published from 1974 to 2002 related to 25 RCTs. A meta-analysis was performed pooling the results as odds ratios (OR), rate differences (RD), and number needed to treat (NNT). Data given as mean and/or median values were pooled as a mean +/- SD (SD). RESULTS No perioperative deaths were found in any of the RCTs. Immediate results showed a significantly lower operative morbidity rate (10.3% versus 26.7%, OR 0.33, RD -12%, NNT 8), shorter postoperative stay (3.1 versus 5.2 days, P = 0.03), and shorter sick leave (20.1 versus 35.8 days, P = 0.03) for laparoscopic versus open fundoplication. No significant differences were found regarding the incidence of recurrence, dysphagia, bloating, and reoperation for failure at midterm follow-up. No significant differences in operative morbidity (13.1% versus 9.4%) and in operative time (90.2 versus 84.2 minutes) were found in partial versus total fundoplication. A significantly lower incidence of reoperation for failure (1.6% versus 9.6%, OR 0.21, RD -7%, NNT 14) was found after partial fundoplication, with no significant differences regarding the incidence of recurrence and/or dysphagia. Routine division of short gastric vessels during total fundoplication showed no significant advantages regarding the incidence of postoperative dysphagia and recurrence when compared with no division. The use of ultrasonic scalpel compared with clips or bipolar cautery for the division of short gastric vessels showed no significant effect on operative time, postoperative complications, and costs. CONCLUSIONS Laparoscopic antireflux surgery is at least as safe and as effective as its open counterpart, with reduced morbidity, shortened postoperative stay, and sick leave. Partial fundoplication significantly reduces the risk of reoperations for failure over total fundoplication. Routine versus no division of short gastric vessels showed no significant advantages. A word of caution is needed when implementing these results derived from RCTs performed in specialized centers into everyday clinical practice, where experience and skills may be suboptimal.
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Affiliation(s)
- Marco Catarci
- Department of Surgery, San Filippo Neri Hospital, Rome, Italy.
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