Complications of laparoscopic antireflux surgery

Massive subcutaneous emphysema and bilateral tension pneumothorax following laparoscopic inguinal hernia repair under general anesthesia: A case report

The escalating adoption of laparoscopic surgical techniques has demonstrated their capacity to yield improved clinical outcomes. However, concomitant with the advantages of this minimally invasive approach, certain adverse complications have been reported. In this report, we present a noteworthy case involving a 72-year-old male patient who underwent laparoscopic inguinal hernia repair. The surgical procedure proceeded without noteworthy complications, and the patient maintained hemodynamic stability throughout. However, the post-anesthetic recovery was compromised by the onset of subcutaneous emphysema and bilateral tension pneumothorax. Immediate intervention was imperative, prompting the performance of an emergent needle thoracostomy, subsequently followed by the implementation of a closed drainage system within the thoracic cavity. These interventions proved efficacious in mitigating the patient's distressing symptoms. Although pneumothorax complications in the context of laparoscopic surgery are infrequent, it is imperative for anesthetists to remain vigilant regarding the potential occurrence of subcutaneous emphysema and pneumothorax in the perioperative period. This case underscores the significance of meticulous perioperative monitoring and rapid intervention, particularly in laparoscopic procedures, where the insufflation of carbon dioxide into the abdominal cavity can predispose patients to these rare yet potentially life-threatening complications. Heightened awareness among healthcare providers regarding the possibility of such events is pivotal in ensuring the safety and well-being of surgical patients.

Severe dysphagia after antireflux surgery: a rare case of esophageal hiatal stenosis

Severe and persistent dysphagia (PD) due to a stenosis of the esophageal hiatus is a serious and rare complication after antireflux procedures. In the case report presented here, the treatment of dysphagia, which arose eight weeks after surgery and progressively worsened, required a new laparoscopic approach. The re-intervention undertaken allowed us to identify the cause of the dysphagia, a tight hiatal stenosis, and to treat it successfully.

Laparoscopic Fundoplication Is Effective Treatment for Patients with Gastroesophageal Reflux and Absent Esophageal Contractility

BACKGROUND

Anti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, particularly in individuals with an aperistaltic esophagus (absent esophageal contractility). This study determined the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility.

METHODS

A prospective database was used to identify all (40) patients with absent esophageal contractility who subsequently underwent fundoplication (36 anterior partial, 4 Nissen). Cases were propensity matched based on age, gender, and fundoplication type with another 708 patients who all had normal motility. Groups were assessed using prospective symptom assessment questionnaires to assess heartburn, dysphagia for solids and liquids, regurgitation, and satisfaction with surgery, and outcomes were compared.

RESULTS

Across follow-up to 10 years, no significant differences were found between the two groups for any of the assessed postoperative symptoms. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5- and 10-year follow-up. No differences in overall patient satisfaction were identified across the follow-up period.

CONCLUSION

Laparoscopic partial fundoplication in patients with absent esophageal contractility achieves acceptable symptom control without significantly worse dysphagia compared with patients with normal contractility. Patients with absent contractility should still be considered for surgery.

Complete Fundus Mobilization Reduces Dysphagia After Nissen Procedure

Background. Anti-reflux surgery is an effective treatment for gastroesophageal reflux disease (GERD). Nevertheless, surgery is still indicated with great caution in relation to the risk of complications, and in particular to postoperative dysphagia (PD). Objective. To compare the clinical outcomes, with particular focus on the incidence and severity of PD, of laparoscopic Nissen-Rossetti fundoplication (NRF) and floppy Nissen fundoplication (FNF) with complete fundus mobilization, in the surgical treatment of GERD. Methods. Ninety patients with GERD were enrolled. Forty-four patients (21[47.7%] men, 23[52.2%] women; mean age 42.4 ± 14.3 years) underwent NRF (Group A), and 46 patients (23[50%] men, 23[50%] women; mean age 43.3 ± 15.4 years) received laparoscopic FNF with complete fundus mobilization (Group B). Clinical assessment was performed using a structured questionnaire and SF-36 quality of life (QoL) score. PD was assessed using a validated classification, and an overall outcome was also determined by asking the patient to score it. Results. At 24-month follow-up, 38 (88.3%) patients in Group A vs 39 (86.6%) in Group B reported to be completely satisfied with reflux relief and free of protonic pump inhibitors (PPIs), while 3 (6.9%) in Group A vs 2(4.4%) in Group B reported occasional PPI intake and 2(4.6%) in Group A vs 4(8.8%) in Group B needed regular PPI use. Persistent PD was observed in 8(18.6%) patients in Group A and in 2(4.4%) in Group B (P = .03). No significant differences were found in the QoL score and in the overall outcome perceived by the patients. Conclusion. FNF, with complete fundus mobilization, appears to be associated with a lower rate of postoperative persistent dysphagia.

A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication?

BACKGROUND

Nearly 20% of patients who undergo hiatal hernia (HH) repair and anti-reflux surgery (ARS) report recurrent HH at long-term follow-up and may be candidates for redo surgery. Current literature on redo-ARS has limitations due to small sample sizes or single center experiences. This type of redo surgery is challenging due to rare but severe complications. Furthermore, the optimal technique for redo-ARS remains debatable. The purpose of the current multicenter study was to review the outcomes of redo-fundoplication and to identify the best ARS repair technique for recurrent HH and gastroesophageal reflux disease (GERD).

METHODS

Data on 975 consecutive patients undergoing hiatal hernia and GERD repair were retrospectively collected in five European high-volume centers. Patient data included demographics, BMI, techniques of the first and redo surgeries (mesh/type of ARS), perioperative morbidity, perioperative complications, duration of hospitalization, time to recurrence, and follow-up. We analyzed the independent risk factors associated with recurrent symptoms and complications during the last ARS. Statistical analysis was performed using GraphPad Prism^® and R software^®.

RESULTS

Seventy-three (7.49%) patients underwent redo-ARS during the last decade; 71 (98%) of the surgeries were performed using a minimally invasive approach. Forty-two (57.5%) had conversion from Nissen to Toupet. In 17 (23.3%) patients, the initial Nissen fundoplication was conserved. The initial Toupet fundoplication was conserved in 9 (12.3%) patients, and 5 (6.9%) had conversion of Toupet to Nissen. Out of the 73 patients, 10 (13%) underwent more than one redo-ARS. At 8.5 (1-107) months of follow-up, patients who underwent reoperation with Toupet ARS were less symptomatic during the postoperative period compared to those who underwent Nissen fundoplication (p = 0.005, OR 0.038). Patients undergoing mesh repair during the redo-fundoplication (21%) were less symptomatic during the postoperative period (p = 0.020, OR 0.010). The overall rate of complications (Clavien-Dindo classification) after redo surgery was 11%. Multivariate analysis showed that the open approach (p = 0.036, OR 1.721), drain placement (p = 0.0388, OR 9.308), recurrence of dysphagia (p = 0.049, OR 8.411), and patient age (p = 0.0619, OR 1.111) were independent risk factors for complications during the last ARS.

CONCLUSIONS

Failure of ARS rarely occurs in the hands of experienced surgeons. Redo-ARS is feasible using a minimally invasive approach. According to our study, in terms of recurrence of symptoms, Toupet fundoplication is a superior ARS technique compared to Nissen for redo-fundoplication. Therefore, Toupet fundoplication should be considered in redo interventions for patients who initially underwent ARS with Nissen fundoplication. Furthermore, mesh repair in reoperations has a positive impact on reducing the recurrence of symptoms postoperatively.

Endoscopic Fundoplication: Effectiveness for Controlling Symptoms of Gastroesophageal Reflux Disease

OBJECTIVE

Transoral incisionless fundoplication (TIF) is a completely endoscopic approach to treat gastroesophageal reflux disease (GERD). We previously reported our initial results demonstrating safety and early effectiveness. We now present an updated experience describing outcomes with longer follow-up.

METHODS

For a three-year period, TIF procedures were performed on 80 patients. Preoperative workup routinely consisted of contrast esophagram and manometry. PH testing was reserved for patients with either atypical symptoms or typical symptoms unresponsive to proton-pump inhibitors (PPIs). Heartburn severity was longitudinally assessed using the GERD health-related quality of life index. Safety analysis was performed on all 80 patients, and an effectiveness analysis was performed on patients with at least 6-month follow-up.

RESULTS

Mean procedure time was 75 minutes. There were seven (8.75%) grade 2 complications and one (1.25%) grade 3 complication (aspiration pneumonia). The median length of stay was 1 day (mean, 1.4). Forty-one patients had a minimum of 6-month of follow-up (mean, 24 months; range, 6-68 months). The mean satisfaction scores at follow-up improved significantly from baseline (P < 0.001). Sixty-three percent of patients had completely stopped or reduced their PPI dose. Results were not impacted by impaired motility; however, the presence of a small hiatal hernia or a Hill grade 2/4 valve was associated with reduced GERD health-related quality of life scores postoperatively.

CONCLUSIONS

At a mean follow-up of 24 months, TIF is effective. Although symptoms and satisfaction improved significantly, many patients continued to take PPIs. Future studies should focus on longer-term durability and comparisons with laparoscopic techniques.

Laparoscopic anterior gastropexy for type III/IV hiatal hernia in elderly patients

Introduction

Large esophageal hiatal hernias occur most commonly in elderly patients with comorbidities, in whom even an elective surgery cannot be performed without high risks. Although fundoplication is recommended for esophageal hiatal hernia repair, we prefer not to limit our options to fundoplication, as obstruction is a frequent main complaint. We favor an anterior gastropexy approach instead to perform anti-reflux surgery and prevent recurrent protrusion and torsion of the incarcerated organ with minimal risk. The aim was to evaluate the safety and effectiveness of anterior gastropexy for large hiatal hernia in elderly patients with comorbidities.

Case presentation

We retrospectively evaluated 8 patients who underwent laparoscopic anterior gastropexy for large hiatal hernia (type III or IV) since 2006. All patients were women with a median age of 82 years (range, 74–87 years). The major complaint was obstruction in all patients, with relatively mild reflux symptoms. They underwent successful laparoscopic surgery with no conversion to laparotomy.

Fundoplication was performed in 4 cases. No perioperative complications occurred, and the main complaint resumed rapidly in all patients, without recurrence during postoperative follow-up of median 48 months (range, 5–77 months).

Conclusion

Laparoscopic anterior gastropexy is safe and effective and can be considered as one of the practical surgical options for large hiatal hernias in elderly patients, whom surgical intervention should be minimized due to their comorbidities.

Surgical treatment of gastroesophageal reflux disease

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.

Pain after laparoscopic antireflux surgery

INTRODUCTION

The benefits of antireflux surgery are well established. Laparoscopic techniques have been shown to be generally safe and effective. The aim of this paper was to review the subject of pain following laparoscopic antireflux surgery.

METHODS

A systematic review of the literature was conducted using the PubMed database to identify all studies reporting pain after laparoscopic antireflux surgery. Publications were included for the main analysis if they contained at least 30 patients. Operations in children, Collis gastroplasty procedures, endoluminal fundoplication and surgery for paraoesophageal hernias were excluded. The frequency of postoperative pain was calculated and the causes/management were reviewed. An algorithm for the investigation of patients with pain following laparoscopic fundoplication was constructed.

RESULTS

A total of 17 studies were included in the main analysis. Abdominal pain and chest pain following laparoscopic fundoplication were reported in 24.0% and 19.5% of patients respectively. Pain was mild or moderate in the majority and severe in 4%. Frequency of pain was not associated with operation type. The authors include their experience in managing patients with persistent, severe epigastric pain following laparoscopic anterior fundoplication.

CONCLUSIONS

Pain following laparoscopic antireflux surgery occurs in over 20% of patients. Some have an obvious complication or a diagnosis made through routine investigation. Most have mild to moderate pain with minimal effect on quality of life. In a smaller proportion of patients, pain is severe, persistent and can be disabling. In this group, diagnosis is more difficult but systematic investigation can be rewarding, and can enable appropriate and successful treatment.

Laparoscopic surgery of esophageal hiatus hernia - single center experience

Introduction

Esophageal hiatal hernias are the most frequent types of internal hernias. This condition involves disturbance of normal functioning of the stomach cardiac mechanism and reflux of the gastric contents to the esophagus.

Aim: To evaluate postoperative results in our Clinic and the comparison of these results to data from the literature.

Material and methods

One hundred and seventy-eight patients underwent surgery due to esophageal hiatal hernia at the Clinic of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Torun, Poland, from 2006 to 2011. All operations were performed using laparoscopy. Fundoplication by means of the Nissen-Rossetti method was carried out in 172 patients while Toupet's and Dor's methods were applied in 4 and 2 patients, respectively.

Results

Average time of the surgery was 82 min (55–140 min). Conversion was performed in 4 cases. No serious intraoperative complications were noted. In the postoperative period, dysphagia was reported in 20 patients (11.2%). Postoperative wound infection was observed in 1 patient (0.56%). Hernias in the trocar insertion area were reported in 3 patients (1.68%). Ailments recurred in 6 patients. The recurrence of esophageal hiatal hernia was confirmed in 2 patients. Patients with recurrent hernia were re-operated using a laparoscopic approach.

Conclusions

Laparoscopic surgery is a simple and effective approach for patients with gastroesophageal reflux symptoms due to diaphragmatic esophageal hiatus hernia. The number of complications is lower after laparoscopic procedures than after “open” operations.

Aortic injury during laparoscopic esophageal hiatoplasty

A 75-year-old female patient with a type III hiatal hernia was submitted to laparoscopic mesh hiatoplasty. Soon after the last suture fixed the mesh to the left crura, a hemorrhage was observed. Conversion to open surgery was not performed. The most common sources of bleeding (liver, phrenic arteries, crura, spleen, and short gastric vessels) were discarded as the cause of the hemorrhage. The mesh was set free in order to explore the lower mediastinum. The source of the hemorrhage was identified: it was the last suture fixing the mesh to the left crura, which was found passing through the aortic wall. The hemorrhage stopped as soon as the suture was removed. When facing a hemorrhage during this kind of surgery, it is essential to be methodical to discover the source of the bleeding. First of all, the most common sources of bleeding must be checked out. Injury of the inferior vena cava must also be ruled out, because it is an uncommon but potentially lethal complication. Afterwards, the lower mediastinum must be explored. Conversion to an open approach is needed if the patient becomes unstable or the surgeon does not have enough laparoscopic skills to find and solve the bleeding. Most of the reported cases of aortic injury during laparoscopic hiatoplasty are secondary to vascular injuries during port insertion. When a suture is the cause of bleeding, the removal of the stitch should be enough to stop the bleeding. If there is a tear of the aortic wall, a patch should be employed for the repair. In conclusion, left crura and thoracic aorta are very close to one another. The surgeon must be very careful when working near the left crura, mostly in old patients with a dilated and aneurysmatic aorta.

A prospective nonrandomized comparison of laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication in Indian population using detailed objective and subjective criteria

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.

Novel surgical concept in antireflux surgery: long-term outcomes comparing 3 different laparoscopic approaches

BACKGROUND

The Nissen fundoplication procedure is the most widely used type of antireflux surgery. The results are not always as good as expected, and several modifications to the original technique have been proposed. Long-term effectiveness studies comparing different techniques of antireflux surgery are limited. Our group developed a new concept in antireflux surgery (complete fixed "nondeformable" fundoplication) in order to improve its outcome; we present the long-term comparative results of this novel concept/technique.

METHODS

Overall, 512 patients were included in the study and assigned into 1 of 3 fundoplications groups: partial (131), Nissen (133), and fixed "nondeformable" (121). We compared the groups with each other and with a group who chose to receive medical treatment (MT) (127). All patients underwent clinical evaluation, upper gastrointestinal endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and the SF-36 health status survey prior to operation and at 1, 5, 10, and 15 years of follow-up.

RESULTS

At the 15-year follow-up, we were able to complete the protocol in 319 patients: 103 patients from the partial group, 102 patients from the Nissen group, 97 patients from the fixed "nondeformable" group, and 17 patients from the medical treatment group. A lower prevalence of erosive gastroesophageal reflux disease (GERD) was observed in the fixed "nondeformable" group (7.20%) versus 21.56% for Nissen, 39.80% for partial, and 47.05% for MT (P < .01). Lower esophageal sphincter (LES) pressure and LES length were more constant in the fixed "nondeformable" group (14.7 mm Hg/2.2 cm) compared with the Nissen (9 mm Hg/0.7 cm), partial (7 mm Hg/2 cm), and MT (5.64 mm Hg/1.3 cm) groups (P < .01). Reflux recurrence was observed in 168 patients (13 in fixed "nondeformable," 41 in Nissen, and 98 in partial (P < .01).

CONCLUSION

The complete fixed "nondeformable" fundoplication showed best results in studied parameters and had a lower long-term recurrence compared with Nissen and partial techniques.

Post-fundoplication contrast studies: is there room for improvement?

OBJECTIVE

Since the mid-1990s, laparoscopic fundoplication for gastro-oesophageal reflux disease has become the surgical procedure of choice. Several surgical groups perform routine post-operative contrast studies to exclude any (asymptomatic) anatomical abnormality and to expedite discharge from hospital. The purpose of this study was to determine the accuracy and interobserver reliability for surgeons and radiologists in contrast study interpretation.

METHODS

11 surgeons and 13 radiologists (all blinded to outcome) retrospectively reviewed the contrast studies of 20 patients who had undergone a laparoscopic fundoplication. Each observer reported on fundal wrap position, leak or extravasation of contrast and contrast hold-up at the gastro-oesophageal junction (on a scale of 0-4). A κ coefficient was used to evaluate interobserver reliability.

RESULTS

Surgeons were more accurate than radiologists in identifying normal studies (specificity = 91.6% vs 78.9%), whereas both groups had similar accuracy in identifying abnormal studies (sensitivity = 82.3% vs 85.2%). There was higher agreement amongst surgeons than amongst radiologists when determining wrap position (κ = 0.65 vs 0.54). Both groups had low agreement when classifying a wrap migration as partial or total (κ = 0.33 vs 0.06). Radiologists were more likely to interpret the position of the wrap as abnormal (relative risk = 1.25) while surgeons reported a greater degree of hold-up of contrast at the gastro-oesophageal junction (mean score = 1.17 vs 0.86).

CONCLUSION

Radiologists would benefit from more information about the technical details of laparoscopic anti-reflux surgery. Standardised protocols for performing post-fundoplication contrast studies are needed.

Left hepatic vein injury during laparoscopic antireflux surgery for large para-oesophageal hiatus hernia

Although the advent of laparoscopic fundoplication has increased both patient and physician acceptance of antireflux surgery, it has become apparent that the laparoscopic approach is associated with an increased risk of some complications and as well as the occurrence of new complications specific to this approach. One such complication occurred in our patient who had intra-operative left hepatic vein injury during laparoscopic floppy Nissen fundoplication for large para-oesophageal rolling hernia. With timely conversion to open procedure, the bleeding was controlled and the antireflux and the procedure were completed uneventfully. However, this suggests that even with an experience in advanced laparoscopy surgery, complications can occur. Clear understanding of the normal and pathologic anatomy and its variations facilitates laparoscopic surgery and should help the surgeon avoid complications. The incidence of some of these complications decreases as surgeons gain experience; however, new complications can arise due to the increase in such procedures.

Partial or total fundoplication (with or without division of the short gastric vessels): which is the best laparoscopic choice in GERD surgical treatment?

BACKGROUND

Gastroesophageal reflux disease (GERD) has emerged as one of the most common diseases in the modern civilization.The immense success of laparoscopic surgery as an effective treatment of GERD has established the minimally invasive surgery as the gold standard for this condition with lower morbidity and mortality, shorter hospital stay, faster recovery, and reduced postoperative pain.

METHODS

Articles were sourced from PubMed and Medline, using the MeSH terms "gastroesophageal reflux disease" and "laparoscopic surgery" and "fundoplication technique." The selection of articles was based on peer review, journal, relevance, and English language.

RESULTS AND CONCLUSIONS

There are some controversies with regard to the technique. First, whether total or partial fundoplication is the more appropriate treatment for GERD; second, if a total fundoplication (360 degrees) is performed, what is the effect of fundic mobilization and the division of short gastric vessels. In this review article the authors evaluate the most recent articles to establish the parameters for a "gold standard technique" in antireflux surgery.

Complications of esophageal surgery: role of imaging in diagnosis and treatments

Esophageal surgery is a common and integral component in the management of hiatal hernias, esophageal carcinoma, and esophageal perforation. Understanding the expected postsurgical imaging features of these common esophageal surgeries and postoperative complications is essential. Image-guided intervention can be used to aid the surgeon in the management of many post esophageal surgical complications. We discuss the imaging features of the postoperative esophagus and the use of imaging, including fluoroscopy and computed tomography, in the diagnosis of post esophageal surgical complications and treatment.

Population-based trend analysis of laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

BACKGROUND

The Nissen and Toupet fundoplications are the most commonly used techniques for surgical treatment of gastroesophageal reflux disease. To date, no population-based trend analysis has been reported examining the choice of procedure and short-term outcomes. This study was designed to analyze trends in the use of Nissen versus Toupet fundoplications, and corresponding short-term outcomes during a 10-year period between 1995 and 2004.

METHODS

A trend analysis was performed of 873 patients (Toupet: 254 patients, Nissen: 619 patients) prospectively enrolled in the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery.

RESULTS

The frequency of the performed techniques remained stable during the observation period (p value for trend 0.206). The average postoperative and total length of hospital stay both significantly decreased during the 10-year period from 5.6 to 4.0 days and 6.8 to 4.8 days, respectively (both p values for trend <0.001). The average duration of surgery decreased significantly from 141 minutes to 121 minutes (p value for trend <0.001). There was a trend towards less complications in later years (2000-2004) compared to early years (1995-1999, p = 0.058). Conversion rates were significantly lower in later years compared with early years (p = 0.004).

CONCLUSIONS

This is the first trend analysis in the literature reporting clinical outcomes of 873 prospectively enrolled patients undergoing Nissen and Toupet fundoplications during a 10-year period. The proportion of laparoscopic Nissen versus Toupet fundoplications remained stable over time, indicating that literature reports of the advantages of one procedure over the other had minimal influence on surgeons' choice of technique. Length of hospital stay, duration of surgery, morbidity, and conversion rate decreased over time, reflecting the learning curve. Clearly, patient outcomes have much improved during the 10-year observation period.

Failed laparoscopic anti-reflux surgery and indications for revision. A retrospective study

Revisional anti-reflux surgery is required in certain patients for either early post-operative complications or recurrence of their original symptoms. The aim of this study is to review our revisional surgeries, learn the lessons and to highlight the treatment options for recurrent gastrooesophageal symptoms.

MATERIALS AND METHODS

Three hundred and fifty one patients underwent laparoscopic anti-reflux surgery through January 2000 to March 2006 at our minimal access unit. Thirty-seven patients were diagnosed with failure of anti-reflux surgery. Patient's data and follow up were retrieved from medical records. All recurrences were investigated for underlying cause and their managements were planned accordingly.

RESULTS

Thirty-seven (10.54%) patients who developed early post-operative complications or recurrence of gastroesophageal symptoms were 25 women and 12 men. Heartburn was the commonest recurrent symptom. The majority of failures occurred in the first two years. Fourteen patients underwent revisional surgery while 23 patients were treated with acid reducing medications and showed a good response. The re-operation rate is 3.98%. There was no mortality and the total morbidity rate for revisional surgery is 7.14%.

CONCLUSION

Early surgical complications of the initial procedures are managed by revisional surgery and the results were satisfactory provided these complications are detected early. Chronic failure of anti-reflux surgery can be managed by revisional surgery or medications depending on clinical symptoms and patients preference.

Is there a role for anything other than a Nissen's operation?

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.

Laparoscopic Nissen fundoplication combined with posterior gastropexy in surgical treatment of GERD

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has become established as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). Postoperative paraesophageal herniation has an incidence range up to 7% in the immediate postoperative period.

AIM

A prospective randomized trial was scheduled to study the role of posterior gastropexy, in combination with LNF, in prevention of paraesophageal herniation and improvement of postoperative results in surgical treatment of GERD.

PATIENTS AND METHODS

Eighty-two patients with GERD were randomized to LNF combined with (group A, n = 40) or without (group B, n = 42) posterior gastropexy. Subjective evaluation using disease-specific and generic questionnaires and structured interviews, and objective evaluation by endoscopy, esophageal manometry, and 24-h pH monitoring, were performed before operation, at 2 and 12 months after surgery, and then every year. Crura approximation was performed by stitches if the diameter was less than 6 cm, or with a patch to reinforce the conventional crural closure or by tension-free technique to close the hiatus. Posterior gastropexy (group A) was performed with one stitch between the posterior wall of the wrap and the crura near the arcuate ligament.

RESULTS

Sixteen patients of group A and 15 patients of group B with concomitant abdominal diseases had simultaneous procedures [cholecystectomy 25, vagotomy 2, ventral hernia repair 1, gastric polypectomy 1, gastric fundus diverticulectomy 1, gastrointestinal stromal tumor (GIST) wedge resection 1]. In mean follow-up of 48 +/- 26 months (range 7-94 months), one patient of group B presented with paraesophageal herniation in the first postoperative month (reoperation), while recurrent gastroesophageal reflux (Visick III or IV), successfully treated by medication, was noted in three patients of group B and in one patient of group A. Only mild dysphagia, during the first two postoperative months, was noted in nine patients of group A and eight patients of group B. Six patients of each group with Barrett's esophagus had endoscopic improvement after the second postoperative month. Visick score in groups A/B was I in 26/11 (P < 0.0001), II in 13/27 (P = 0.037), III in 1/2 (not significant, NS), and IV in 0/2. Generally, Visick score was I or II in 39/38 in groups A/B (97.5%/90.5%, NS) and III or IV in 1/4 (2.5%/9.5%, P < 0.0001).

CONCLUSIONS

LNF combined with posterior gastropexy may prevent postoperative paraesophageal or sliding herniation in surgical treatment of GERD, providing better early and long-term postoperative results. (Registered Clinical Trial number: NCT00872755. www.clinicaltrials.gov .).

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

Functional complications after NF are not avoided with TF.

Long-term comparative outcome between laparoscopic total Nissen and Toupet fundoplication: Symptomatic relief, patient satisfaction and quality of life

BACKGROUND

Laparoscopic antireflux surgery has become an established method of treatment of gastroesophageal reflux disease. This study compares the long-term outcome of total (Nissen) and partial (Toupet) fundoplication, performed in a single institution, by evaluating symptoms and quality of life.

METHODS

266 patients who underwent laparoscopic Nissen or Toupet fundoplication completed a preoperative reflux symptom questionnaire. Postsurgery symptom evaluation, patient satisfaction and quality of life in reflux and dyspepsia (QOLRAD) questionnaires were sent to these patients in December 2004. The two groups were compared for each item nonparametrically.

RESULTS

Completed questionnaires were received from 161 patients (61%) of whom 99 had a laparoscopic Nissen fundoplication and 62 laparoscopic Toupet fundoplication. Both procedures were equivalent in improving reflux symptom scores in the long term, 79/99 (80%) and 56/62 (90%) were either symptom free or had obtained significant symptomatic relief. Both groups had equivalent QoL scores on the QOLRAD questionnaire. An equivalent number of patients (86% and 83.9% after Nissen and Toupet, respectively) were sufficiently satisfied to recommend antireflux surgery to a friend or relative complaining of reflux symptoms.

CONCLUSION

In conclusion, in patients who have returned the questionnaire, long-term satisfaction, general symptom scores, and quality of life are equivalent after laparoscopic Nissen (complete) or Toupet (partial) fundoplication. There is however, a significant increased prevalence of persistent heartburn after laparoscopic Toupet fundoplication.

Acute transhiatal migration and herniation of fundic wrap following laparoscopic nissen fundoplication

Acute transhiatal wrap herniation can occur in the early postoperative period following laparoscopic Nissen fundoplication due to events which can raise intra-abdominal pressure. Of a total of 264 patients who underwent laparoscopic Nissen fundoplication in our series, two developed acute transhiatal wrap herniation, 8 and 12 weeks after the procedure, respectively. Prompt referral to our unit with early diagnosis and laparoscopic reduction of the hernia resulted in an uneventful recovery in one patient. Delay in recognition and referral for the other patient resulted in strangulation and perforation of the stomach in the posterior mediastinum, necessitating laparotomy and resection of the gastric fundus. Awareness and a high index of suspicion are necessary to detect and treat the condition early, thereby averting a potentially life-threatening clinical situation. Herniation, if detected early, can be treated by the laparoscopic approach. Satisfactory outcomes in the management of wrap migration following laparoscopic Nissen fundoplication hinge on early recognition and prompt surgical intervention. It is important to recognize and prevent factors that lead to anatomical failure of the operation. Methods to fix the fundic wrap and the benefits of using prosthetic material for crural repair need to be considered.

The extended learning curve for laparoscopic fundoplication: a cohort analysis of 400 consecutive cases

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years. The patients were grouped consecutively into cohorts of 50 patients. The operating time, the length of postoperative hospital stay, the conversion rate to open operation, the postoperative dilatation rate, and the reoperation rate were analyzed. Results showed that the mean length of operative time decreased from 143 min in the first 50 patients to 86 min in the last 50 patients. The mean postoperative length of hospital stay decreased from 3.7 days initially to 1.2 days latterly. There was a 14% conversion to open operation rate in the first cohort compared with a 2% rate in the last cohort. Fourteen percent of patients required reoperation in the first cohort and 6% in the last cohort. Sixteen percent required postoperative dilatation in the first cohort. None of the last 150 patients required dilatation. In conclusion, laparoscopic fundoplication is a safe and effective operation for patients with gastroesophageal reflux disease. New techniques and better instrumentation were introduced in the early era of LNF. The learning curve, however, continues well beyond the first 20 patients.

Laparoscopic antireflux surgery: long-term outcomes and quality of life

BACKGROUND

To evaluate the outcome of antireflux surgery, we assessed disease-specific symptoms and quality of life of all patients treated by laparoscopic fundoplication at our center between 1992 and 2002.

MATERIALS AND METHODS

Preoperative symptoms and details of surgery were evaluated for 186 laparoscopic fundoplications. Disease-specific symptoms and quality of life were assessed using a questionnaire. Of 186 patients, 143 returned the questionnaire.

RESULTS

The most common preoperative symptoms under medical antireflux therapy were regurgitation (54%) and heartburn (30%). Indications for surgery were refractory symptoms (88%) and the patient denying long-term medication (42%). The surgical approaches were Nissen fundoplication (98%) or Toupet fundoplication (2%, for heavy esophageal motility disorder). The conversion rate was 10%. There were no deaths, and 6 patients (3%) had to be reoperated. The questionnaire revealed that in 82% of the patients who responded, the preoperative reflux symptoms were gone, and 94% were satisfied with the result and would undergo surgery again. The average gastrointestinal quality of life index was 115 points (healthy volunteers in the literature, 120.8 points).

CONCLUSION

Laparoscopic fundoplication is a safe antireflux therapy resulting in high levels of patient satisfaction and near-normal quality of life in the long term.

[Relaparoscopy as an alternative to laparotomy for laparoscopic complications]

In the field of visceral surgery, complications requiring reintervention following laparoscopy are currently most likely to be approached with conventional laparotomy. However, relaparoscopy has the theoretical advantage of maintaining the reduced morbidity allowed by the first procedure. Essential to the success of relaparoscopy is a clear understanding of the various specific complications. Should the surgeon decide on relaparoscopy, then prompt action is of central importance. Following laparoscopic cholecystectomy, it is fundamentally technically possible through renewed laparoscopy to treat not only subhepatic abscesses but also smaller lesions of the bile duct, for example from the gall bladder fossa. Revision of complications following fundoplication is technically very demanding and should be performed only by those most experienced in the techniques of laparoscopy. In contrast to interventional drainage, relaparoscopy of abscesses following laparoscopic appendectomy has the theoretical advantage of allowing recognition and treatment of the causes, for example in the case of appendicular stump insufficiency. Relapses very shortly after endoscopic surgery of inguinal herniae result from erroneous technique and may be corrected endoscopically in most cases. Complications following colon surgery have so far been dealt with using open surgery for technical reasons and also for patient safety. Given the uncertainty in the literature, patient safety must be paramount, when deciding on which technique is best to employ, particularly in cases of haemorrhage.

Laparoscopic fundoplication in patients with an aperistaltic esophagus and gastroesophageal reflux

A minority of patients with severe gastroesophageal reflux who present to surgeons for antireflux surgery have absent esophageal peristalsis when investigated before surgery with esophageal manometry. Some of these patients also have systemic sclerodema. While conventional wisdom suggests that these patients are at risk of a poor outcome if they proceed to fundoplication, some will have severe reflux symptoms, which are poorly controlled by medical therapy, and surgery will therefore offer the only chance of 'cure'. We performed this study to determine the outcome of laparoscopic fundoplication in the subset of patients with gastroesophageal reflux and an aperistaltic esophagus. From 1991 to 2003, the operative and follow-up details for all 1443 patients who underwent a laparoscopic fundoplication in our Departments have been prospectively collected on a database. These patients were then followed yearly using a standardized symptom assessment questionnaire. A subset of patients whose preoperative esophageal manometry demonstrated complete absence of esophageal body peristalsis and absent lower esophageal sphincter tone (aperistaltic esophagus) were identified from this database, and their outcome following laparoscopic fundoplication was determined. Twenty-six patients with an aperistaltic esophagus who underwent a laparoscopic fundoplication were identified. Six of these had a systemic connective tissue disease (scleroderma), and 20 had an aperistaltic esophagus without a systemic disorder. A Nissen fundoplication was performed in four patients, and an anterior partial fundoplication in 22. Follow-up extended up to 12 years (median, 6). A good overall symptomatic outcome was achieved in 88% at 1 year, 83% at 2 years and 93% at 5-12 years follow-up. Reflux symptoms were well controlled by surgery alone in 79% at 1 year, and 79% at 5-12 years. At 2 years, 87% were eating a normal diet. Two patients underwent further surgery - one at 1 week postoperatively for a tight esophageal hiatus, and one at 1 year for recurrent reflux. Patients with troublesome reflux and an aperistaltic esophagus can be effectively treated by laparoscopic fundoplication. An acceptable outcome will be achieved in the majority of patients.

Complications After Surgery for Gastroesophageal Reflux Disease

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

Techniques and results of laparoscopic antireflux surgery in Germany

BACKGROUND

This study aimed to evaluate the development and outcomes of laparoscopic antireflux surgery in Germany using a nationwide representative survey.

METHODS

A written questionnaire including 34 detailed questions and 288 structured items about diagnostic and therapeutic approaches, number of procedures, complications, and mortality was sent to 546 randomly selected German surgeons (33% of the registered general surgeons) at the end of 2000.

RESULTS

The response rate was 72%, and a total of 2,540 antireflux procedures were reported. According to the survey, 81% of all procedures were performed laparoscopically, and 0.1% were performed thoracoscopically. As reported, 65% were total fundoplications, 31% were partial fundoplications, and 4% were other procedures. Of the surgeons who had experience with laparoscopic antireflux techniques (29%), 71% preferred a 5-trocar technique, and 91% used the Harmonic Scalpel for dissection. There were significant technical variations among the surgical procedures (e.g., use and size of the bougie, length of the wrap, additional gastropexy, fixation of the wrap). The overall complication rate for laparoscopic fundoplication was 7.7% (5.7% surgical and 2% nonsurgical complications), including rates of 0.6% for esophageal perforations and 0.6% for splenic lesions. The conversion rate was 2.9%; the reoperation rate was 1.6%; and the overall hospital mortality rate was 0.13%. The authors observed a striking learning curve difference in complication rates between hospitals performing fewer than 10 laparoscopic antireflux techniques annually and those performing more than 10 fundoplications per year (14% vs 5.1%, p < 0.001). Long-term dysphagia and interventions occasioned by dysphagia occurred significantly more often after total fundoplications than after partial fundoplications (6.6% vs 2.4%; p < 0.001). Similar findings were reported for Nissen versus floppy Nissen procedures. The overall failure rate, however, was similar for both groups (Nissen 8.7%; partial 9%, difference not significant).

CONCLUSIONS

Until now, no unique laparoscopic antireflux technique has been accepted, and a number of different antireflux procedures with numerous modifications have been reported. The morbidity and mortality rates reported in this article compare very well with those in the literature, and 1-year-follow-up results are promising.

Changes in functional gastrointestinal symptoms as a result of antireflux surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term outcome of surgically and medically treated patients with gastroesophageal reflux disease: a matched-pair follow-up study

OBJECTIVE

A recent randomized study has shown that the long-term effects of continuous medical treatment of gastroesophageal reflux disease (GERD) with a proton-pump inhibitor are comparable to those of open fundoplication. We compared the long-term effects of anti-reflux surgery with those of medical care according to clinical practice.

MATERIAL AND METHODS

This is a questionnaire-based 3-10 years follow-up study of 373 patients with GERD operated on in two hospitals with either open or laparoscopic fundoplication, and pair-matched non-operated controls treated medically according to clinical practice. The controls were matched for hospital, age, sex, follow-up time, degree of esophagitis, presence of hiatus hernia and Barrett's esophagus. The questionnaires used for symptoms and health-related quality of life (QoL) were the Gastrointestinal Symptoms Rating Scale and the Psychological General Well-Being Index, respectively.

RESULTS

Response rates were about 80%, and 179 pairs of operated patients and controls remained for analysis (102 based on laparoscopic and 77 on open fundoplication). Independently of the surgical technique, the operated patients suffered at the follow-up from significantly (p <0.001) fewer reflux symptoms than the non-operated controls, the mean scores being 1.34 and 2.51, respectively. The operated patients suffered from slightly more symptoms of indigestion (p <0.05). No consistent significant differences between the groups were found for QoL. Significant differences in QoL in favor of the operated patients were found when dealing only with the 43 pairs with no concurrent disease.

CONCLUSION

The study shows that in our area anti-reflux surgery is more effective in relieving reflux symptoms than medical care according to clinical practice.

Robotic Laparoscopic Fundoplication

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

Evidence-based appraisal of antireflux fundoplication

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.

Circulatory and respiratory complications of carbon dioxide insufflation

BACKGROUND

Although providing excellent outcome results, laparoscopy also induces particular pathophysiological changes in response to pneumoperitoneum. Knowledge of the pathophysiology of a CO(2) pneumoperitoneum can help minimize complications while profiting from the benefits of laparoscopic surgery without concerns about its safety.

METHODS

A review of articles on the pathophysiological changes and complications of carbon dioxide pneumoperitoneum as well as prevention and treatment of these complications was performed using the Medline database.

RESULTS

The main pathophysiological changes during CO(2) pneumoperitoneum refer to the cardiovascular system and are mainly correlated with the amount of intra-abdominal pressure in combination with the patient's position on the operating table. These changes are well tolerated even in older and more debilitated patients, and except for a slight increase in the incidence of cardiac arrhythmias, no other significant cardiovascular complications occur. Although there are important pulmonary pathophysiological changes, hypercarbia, hypoxemia and barotraumas, they would develop rarely since effective ventilation monitoring and techniques are applied. The alteration in splanchnic perfusion is proportional with the increase in intra-abdominal pressure and duration of pneumoperitoneum.

CONCLUSION

A moderate-to-low intra-abdominal pressure (<12 mm Hg) can help limit the extent of the pathophysiological changes since consecutive organ dysfunctions are minimal, transient and do not influence the outcome.

Feasibility of surgical technique and evaluation of postoperative quality of life after laparoscopic treatment of intrathoracic stomach

BACKGROUND

Because of the risk of life-threatening complications, the discovery of a complete intrathoracic stomach demands urgent surgery with the aim of repositioning the stomach and gastropexy, and secondarily, to improve life quality. In this study the feasibility of surgical technique and postoperative quality of life after laparoscopic treatment of complete intrathoracic stomach has been evaluated.

METHODS

From June 1999 to December 2001 16 patients with an intrathoracic stomach (hiatus hernia Types IIB and III) were treated by laparoscopic techniques, including the repositioning of the stomach, hemi-fundoplication and anterior gastropexy. During the postoperative follow-up the recurrence rate and quality of life (Eypasch index) were evaluated.

RESULTS

All operations were performed laparoscopically without conversion, with a mean operating time of 155 min. Pleural injuries occurred in 31% of patients and pleural effusions in 38%, which required puncture in three cases. Complete follow-up showed no recurrences at a median of 14 months. The median quality of life index was 84.6 preoperatively and had significantly improved to 117.8 after the operation.

CONCLUSION

Laparoscopic access for the treatment of intrathoracic stomach represents a minimally invasive and safe treatment option for complete intrathoracic stomach, with a low level of perioperative morbidity and significant improvement in quality of life.

Antireflux surgery for Barrett's oesophagus

Barrett's oesophagus is usually the result of severe reflux disease. Relief of reflux symptoms is the primary aim of treatment in patients with Barrett's oesophagus who do not have high-grade dysplasia. Some studies with medium-term (2-5 years) follow up show that antireflux surgery can provide good or excellent symptom control, with normal oesophageal acid exposure, in more than 90% of patients with Barrett's oesophagus. Antireflux surgery, but not medical therapy, can also reduce duodenal nonacid reflux to normal levels. There is no conclusive evidence that antireflux surgery can prevent the development of dysplasia or cancer, or that it can reliably induce regression of dysplasia, and patients with Barrett's oesophagus should therefore remain in a surveillance programme after operation. Some data suggest that antireflux surgery can prevent the development of intestinal metaplasia (IM) in patients with reflux disease but no IM. The combination of antireflux surgery plus an endoscopic ablation procedure is a promising treatment for patients with Barrett's oesophagus with low-grade dysplasia.

Patient Outcomes and Dysphagia after Laparoscopic Antireflux Surgery Performed without Use of Intraoperative Esophageal Dilators

Esophageal dilators (EDs) are commonly used during antireflux surgery but are a known cause of esophageal perforation. We hypothesized that the usage of ED during laparoscopic fundoplications (LFs) would not improve dysphagia rates or outcome. A retrospective review of 268 consecutive patients and a postoperative patient survey were performed to compare outcomes in patients undergoing LF. Eighty-nine patients had an ED placed and 179 did not. Significant postoperative dysphagia occurred in seven (8%) and six (3%), respectively ( P = 0.123) and postoperative heartburn in five (6%) and three (2%), respectively ( P = 0.865), in a mean 26.8-month follow-up. Patient survey results demonstrated good to excellent satisfaction in 89 per cent of patients in both groups. We conclude that the results of LF are equivalent with respect to control of heartburn and risk of dysphagia regardless of ED usage. Selective rather than routine use of EDs is recommended.