Laparoscopic antireflux surgery improves esophageal body motility in patients with severe reflux esophagitis

Surgical results of laparoscopic Toupet fundoplication for gastroesophageal reflux disease with special reference to recurrence

BACKGROUND

Surgical results of GERD have mainly been reported from the Western countries, with a few reports found in Japan. We examined the surgical results of laparoscopic Toupet fundoplication and clarify the characteristics of recurrent cases.

METHODS

The subjects included 375 patients who underwent laparoscopic Toupet fundoplication from June 1997 to December 2016 as the initial surgery. Patient characteristics, pathophysiology, and surgical results were examined. In addition, we compared the patient characteristics and pathophysiology of recurrent cases in comparison with non-recurrent cases.

RESULTS

Age 59 (43-70) and male 211 (56.3%). The operation time was 141 min (113-180) and intraoperative complications were found to have onset in 13 subjects (3.5%). Dysphagia after surgery was found in 18 cases (4.8%). The A factor (the degree of hiatal hernia), P factor (the degree of esophagitis), and pH < 4 holding time significantly improved after surgery compared with prior to surgery (p < 0.001 for all), while the LES lengths and abdominal LES lengths were extended (p < 0.001 for each). Recurrence was found in 48 patients (15.1%) among the 318 patients for whom we could confirm the presence or absence of recurrence. The A factor, P factor, and pH < 4 holding time prior to surgery were, respectively, higher in the recurrence group (p = 0.031, p < 0.001, p < 0.001).

CONCLUSIONS

Laparoscopic Toupet fundoplication for GERD could be performed safely, with a response rate as good as 85%. Compared with non-recurrent cases, preoperative clinical conditions such as esophageal hiatal hernia, reflux esophagitis, and acid reflux time were all advanced in recurrent cases.

Impact of reflux esophagitis on the esophageal function before and after laparoscopic fundoplication

BACKGROUND

High-resolution manometry (HRM), which is breakthrough testing equipment to evaluate esophageal motor function, was developed in Europe and United State and has garnered attention. Moreover, multichannel intraluminal impedance pH (MII-pH) testing has allowed us to grasp all liquid/gas reflux including not only acid but also non-acid reflux. We examined the impact of the presence of reflux esophagitis (RE) on esophageal motor function before and after laparoscopic fundoplication.

MATERIALS AND METHODS

The subjects included 100 patients (male: 63 patients, mean age: 54.1 ± 15.8) among 145 patients who underwent laparoscopic fundoplication for GERD associated diseases during a 4-year period from October 2012 to September 2016, excluding 6 patients who underwent further surgery, 32 patients on whom HRM was not performed, 3 patients who had technical errors during testing, and 4 patients for whom the status of RE was unknown. Regarding HRM, Mano Scan from Given Imaging Ltd. was used, and for the analysis, Mano View version 3.0 from the same company was used, after which data was calculated based on the Chicago Classification advocated by Pandolfino et al. Moreover, for the MII-pH testing, Sleuth manufactured by Sandhill Scientific. Inc. was used and automatic analysis was conducted by a computer. Postoperative assessments were conducted 3 months following surgery for all. Data was described in the median value and inter-quartile range, with a statistically significant difference defined as p < 0.05 by Chi square, Mann-Whitney, and Wilcoxon tests.

RESULTS

RE+ group (Los Angeles classification A:B:C:D = 7:9:16:12 patients) included 44 patients (44%), of older age compared to the RE- group (62 vs. 50 years, p = 0.012) and a higher Body Mass Index value (24.0 vs. 22.5, p = 0.045); however, no differences were observed in terms of gender and duration of symptoms. In the preoperative findings on MII-pH, the RE+ group demonstrated significantly longer acid reflux time (4.7 vs. 1.3%, p = 0.005), while in the HRM findings, the RE- group demonstrated a significantly longer abdominal esophagus (0 vs. 0.4 cm, p = 0.049) and maintained esophageal body motor function (DCI: 1054 vs. 1407 mmHg s cm, p = 0.021, Intact peristalsis ratio: 90 vs. 100%, p = 0.037). As to the comparison of the treatment effect before and after laparoscopic fundoplication (Toupet fundoplication for all), significant improvements were observed in both groups in various parameters regarding reflux including acid reflux time, total number of liquid reflux episodes and total number of reflux episodes. Moreover, for both groups, the total length of the lower esophageal sphincter (LES) (RE+ group: 2.7 vs. 3.2 cm, p = 0.001, RE- group: 3.0 vs. 3.4 cm, p = 0.003) and the total length of the abdominal esophagus (RE+ group: 0 vs. 1.6 cm, p < 0.001, RE- group: 0 vs. 1.8 cm, p = 0.001) were significantly extended following surgery; however, no change was observed in DCI before and after surgery.

CONCLUSIONS

Regardless of the presence of RE, cardiac function and LES function were improved following laparoscopic Toupet fundoplication, but no changes were observed in esophageal body motor function.

LATE EVALUATION OF PATIENTS OPERATED FOR GASTROESOPHAGEAL REFLUX DISEASE BY NISSEN FUNDOPLICATION

Background:

Surgical treatment of GERD by Nissen fundoplication is effective and safe, providing good results in the control of the disease. However, some authors have questioned the efficacy of this procedure and few studies on the long-term outcomes are available in the literature, especially in Brazil.

Aim:

To evaluate patients operated for gastro-esophageal reflux disease, for at least 10 years, by Nissen fundoplication.

Methods:

Thirty-two patients were interviewed and underwent upper digestive endoscopy, esophageal manometry, 24 h pH monitoring and barium esophagogram, before and after Nissen fundoplication.

Results:

Most patients were asymptomatic, satisfied with the result of surgery (87.5%) 10 years after operation, due to better symptom control compared with preoperative and, would do it again (84.38%). However, 62.5% were in use of some type of anti-reflux drugs. The manometry revealed lower esophageal sphincter with a mean pressure of 11.7 cm H₂O and an average length of 2.85 cm. The average DeMeester index in pH monitoring was 11.47. The endoscopy revealed that most patients had a normal result (58.06%) or mild esophagitis (35.48%). Barium swallow revealed mild esophageal dilatation in 25,80% and hiatal hernia in 12.9% of cases.

Conclusion:

After at least a decade, most patients were satisfied with the operation, asymptomatic or had milder symptoms of GERD, being better and with easier control, compared to the preoperative period. Nevertheless, a considerable percentage still employed anti-reflux medications.

Esophageal manometry in gastroesophageal reflux disease

High-resolution manometry (HRM) allows nuanced evaluation of esophageal motor function, and more accurate evaluation of lower esophageal sphincter (LES) function, in comparison with conventional manometry. Pathophysiologic correlates of gastroesophageal reflux disease (GERD) and esophageal peristaltic performance are well addressed by this technique. HRM may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve and help predict the likelihood of transit symptoms following antireflux surgery. HRM represents a continuously evolving new technology that compliments the evaluation and management of GERD.