Laparoscopic surgery for gastroesophageal reflux disease patients with impaired esophageal peristalsis: total or partial fundoplication?

Laparoscopic Nissen Versus Toupet Fundoplication for Short- and Long-Term Treatment of Gastroesophageal Reflux Disease: A Meta-Analysis and Systematic Review

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is the most common standard technique worldwidely for Gastroesophageal reflux disease (GERD). Another type of fundoplication, laparoscopic Toupet fundoplication (LTF), intends to reduce incidence of postoperative complications. A systematic review and meta-analysis are required on short- and long-term outcomes based on randomized controlled trials (RCTs) between LNF and LTF.

METHODS

We searched databases including PubMed, Cochrane, Embase, and Web of Knowledge for RCTs comparing LNF and LTF. Outcomes included postoperative reflux recurrence, postoperative heartburn, dysphagia and postoperative chest pain, inability to belch, gas bloating, satisfaction with intervention, postoperative esophagitis, postoperative DeMeester scores, operating time (min), in-hospital complications, postoperative use of proton pump inhibitors, reoperation rate, postoperative lower oesophageal sphincter (LOS) pressure (mmHg). We assessed data using risk ratios and weighted mean differences in meta-analyses.

RESULTS

Eight eligible RCTs comparing LNF (n = 605) and LTF (n = 607) were identified. There were no significant differences between the LNF and LTF in terms of postoperative reflux recurrence, postoperative heartburn, postoperative chest pain, satisfaction with intervention, reoperation rate in short and long term, in-hospital complications, esophagitis in short term, and gas bloating, postoperative DeMeester scores, postoperative use of proton pump inhibitors, reoperation rate in long term. LTF had lower LOS pressure (mmHg), fewer postoperative dysphagia and inability to belch in short and long term and gas bloating in short term compared to LNF.

CONCLUSION

LTF were equally effective at controlling reflux symptoms and improving the quality of life, but with lower rate of complications compared to LNF. We concluded that LTF surgical treatment was superior for over 16 years old patients with typical symptoms of GERD and without upper abdominal surgical history upon high-level evidence of evidence-based medicine.

Prolapse of duodenal bulb from esophageal hiatal hernia: A case report

INTRODUCTION

The number of patients with hiatal hernia has increased. Paraesophageal and mixed hiatal hernias are absolute indications for surgical treatment due to the possibility of blood flow disturbances to the stomach and other organs.

CASE PRESENTATION

A 77-year-old woman with a history of type IV esophageal hiatal hernia (under observation), multiple operations presented with a chief complaint of vomiting. She was diagnosed with a type IV esophageal hiatal hernia with incarceration of the duodenal bulb into the mediastinum. Although the incarceration was relieved with conservative treatment, the patient was at a high risk for recurrence; therefore, surgical hernia repair was performed. Intraoperatively, the hernia portal was severely dilated and the duodenal bulb was easily accessible to the mediastinum due to its high mobility. Fundoplication was performed using the Toupet procedure. No stenosis at the fundoplication site was observed on intraoperative upper gastrointestinal endoscopy.

DISCUSSION

The causes of prolapse and incarceration of the duodenal bulb into the mediastinum were speculated to be weakening of the tissue due to aging, adhesion of the omentum to the hernia portal due to chronic prolapse of the stomach toward the mediastinum, increased intra-abdominal pressure due to a rounded back, and anatomical shortening of the distance between the esophageal hiatus and the duodenal bulb. The Toupet method was used as it is associated with a lower incidence of dysphagia.

CONCLUSION

Further investigation is needed to determine the best surgical technique.

LAPAROSCOPIC ANTIREFLUX SURGERY: WERE OLD QUESTIONS ANSWERED? PARTIAL OR TOTAL FUNDOPLICATION?

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.

Efficacy of laparoscopic Toupet fundoplication compared to endoscopic and surgical procedures for GERD treatment: a randomized trials network meta-analysis

PURPOSE

We aim to review and quantitatively compare laparoscopic Toupet fundoplication (LTF), Nissen fundoplication (LNF), anterior partial fundoplication (APF), magnetic augmentation sphincter (MSA), radiofrequency ablation (RFA), transoral incisionless fundoplication (TIF), proton pump inhibitor (PPI), and placebo for the treatment of GERD. A number of meta-analyses compared the efficacy of surgical and endoscopic procedures for recalcitrant GERD, but considerable debate on the effectiveness of operative strategies remains.

METHODS

A systematic review of MEDLINE databases, EMBASE, and Web of Science for randomized controlled trials (RCTs) comparing the aforementioned surgical and endoscopic GERD treatments was performed. Risk ratio and weighted mean difference were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference.

RESULTS

Thirty-three RCTs were included. Surgical and endoscopic treatments have similar RR for heartburn, regurgitation, bloating. LTF has a lower RR of post-operative dysphagia when compared to APF (RR 3.3; Crl 1.4-7.1) and LNF (RR 2.5; Crl 1.3-4.4). The pooled network meta-analysis did not observe any significant improvement regarding LES pressure and pH < from baseline. LTF, APF, LNF, MSA, RFA, and TIF had have a similar post-operative PPI discontinuation rate.

CONCLUSION

LTF has a lower rate of post-operative dysphagia when compared to APF and LNF. The pre-post effects, such as GERD-HQRL, LES pressure, and pH <4, should be avoided in meta-analyses because results may be biased. Last, a consensus about the evaluation of GERD treatments' efficacy and their outcomes is needed.

A Tailored Approach to Laparoscopic Fundoplication: Outcomes in Patients with Esophageal Dysmotility

BACKGROUND

Esophageal dysmotility is a common finding in patients being evaluated for antireflux surgery, although its implication remains unclear. We aimed to evaluate outcomes of patients with esophageal dysmotility after fundoplication.

METHODS

A retrospective review of a prospective quality-database was performed. All patients who underwent laparoscopic Nissen (NF) or Toupet (TF) fundoplication were included. Esophageal dysmotility was defined using the Chicago Classification v4.0 and conventional metrics, creating three sub-groups: ineffective esophageal motility (IEM), distal/diffuse esophageal spasm (DES), and hypercontractile esophagus (HE). Quality of life (QOL) outcomes were measured by the Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Scores.

RESULTS

Of 487 patients included, 99 (20.3%) had esophageal dysmotility (49 IEM, 40 DES, 10 HE). While a majority in the dysmotility group (81.8%) underwent TF, most patients in the normal group (76.5%) underwent NF (p < 0.001). On multivariable analysis controlling for sex, age, BMI, hiatal hernia, and surgery type, the normal group had higher Dysphagia Scores at 3 weeks (2.2 ± 0.9 vs. 1.7 ± 0.8, p < 0.001), but not at 6-month, 1-year, 2-year, or 5-year follow-up. There were no differences between normal and dysmotility groups in terms of RSI or GERD-HRQL scores at any time point. Patients with different sub-types of esophageal dysmotility had similar QOL outcomes at all time points.

CONCLUSION

Patients with esophageal dysmotility had similar outcomes compared to those with normal motility after fundoplication, suggesting the tailored approach favoring partial fundoplication for patients with dysmotility as part of an appropriate treatment algorithm.

Impedance planimetry (EndoFLIP™) after magnetic sphincter augmentation (LINX®) compared to fundoplication

INTRODUCTION

Functional luminal imaging probe (FLIP) use during laparoscopic fundoplication (LF) for gastroesophageal reflux disease is well described. However, there is a lack of data on FLIP measurements during magnetic sphincter augmentation (MSA). This study aims to report our institutional experience in performing FLIP during MSA and to compare these measurements to those obtained during Nissen and Toupet fundoplication.

METHODS AND PROCEDURES

A retrospective review of a prospectively maintained quality database was performed. Patients who underwent MSA or LF and had FLIP measurements between April 2018 and June 2021 were included. FLIP measurements at the gastroesophageal junction (GEJ) were recorded without pneumoperitoneum at 40 mL balloon fill after hernia reduction, cruroplasty, and MSA or fundoplication. Reflux symptom index (RSI), GERD-HRQL, and dysphagia score were collected up to 2 years. Group comparisons were made using two-tailed Wilcoxon rank-sum and χ² tests, with statistical significance of p < 0.05.

RESULTS

Twenty-seven patients underwent MSA and 100 patients underwent LF (66% Toupet, 34% Nissen). Type III hiatal hernia was present in 3.7% of MSA patients versus over 50% for fundoplication patients. Minimum diameter, cross-sectional area, and distensibility index (DI) were lower after MSA device placement compared to Nissen or Toupet fundoplication (p < 0.05). Postoperative follow-up showed no differences in RSI, GERD-HRQL, and dysphagia score between MSA and Nissen fundoplication (p > 0.05).

CONCLUSION

Intraoperative impedance planimetry provided objective information regarding the geometry of the GEJ during MSA. The ring of magnetic beads restores the anti-reflux barrier and transiently opens with food bolus and belching. The magnetic force of the beads may explain why the DI after MSA is lower yet postoperative quality of life is no different than Nissen fundoplication.

Impedance Planimetry (Endoflip™) Shows That Length of Narrowing After Fundoplication Does Not Impact Dysphagia

INTRODUCTION

A short floppy fundoplication has been the surgical dogma to prevent dysphagia and gas-bloat after laparoscopic fundoplication while adequately addressing gastroesophageal reflux disease. The literature on the ideal length of narrowing (LON) of the gastroesophageal junction after fundoplication is sparse. The functional luminal imaging probe (FLIP) can be used during anti-reflux surgery to produce a visual representation of the LON. We hypothesize that a longer LON provides relief of GERD symptoms, however worse dysphagia and gas-bloat.

METHODS AND PROCEDURES

Prospectively collected data was analyzed. Patients with FLIP measurements during laparoscopic fundoplication between August 2018 and December 2020 were included. FLIP measurements at the gastroesophageal junction were recorded without pneumoperitoneum at 40-mL balloon fill after fundoplication. Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire (GERD-HRQL), gas-bloat score, and Dysphagia Score were collected. Comparisons were made using Spearman correlation coefficients (r) and two-tailed Wilcoxon rank-sum tests, with statistical significance set at p < 0.05.

RESULTS

One hundred and eleven patients underwent laparoscopic fundoplication (26% Nissen, 74% Toupet) and had FLIP measurements. Mean LON in this cohort was 2.7 ± 0.8 cm and mean DI was 3.5 ± 1.3 mm²/mmHg. LON is inversely associated with RSI (r =  - 0.29, p = 0.04) and gas-bloat (r =  - 0.30, p = 0.04). There was no association with Dysphagia Score. Patients with a LON of 2.5-4.5 cm and DI of 2.5-3.6 mm²/mmHg after fundoplication reported lower RSI (p = 0.03) and GERD-HRQL (p = 0.04) compared to patients outside of these ranges. There were no significant differences in patient-reported dysphagia or gas-bloat scores at 1 year between these groups.

CONCLUSIONS

Impedance planimetry provides objective real-time measurements and images during anti-reflux surgery, which allows surgeons to measure the length of narrowing after fundoplication. A LON of 2.5-4.5 cm and DI of 2.5-3.6 mm²/mmHg after fundoplication led to better postoperative quality of life at 1 year without an increase in postoperative dysphagia or gas-bloat.

Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility

Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100-450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.

Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett's esophagus?

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.

Randomized Trial of Laparoscopic Nissen vs. Anterior 180 Degree Partial Fundoplication - Late Clinical Outcomes at 15-20 years

OBJECTIVE

To determine very late clinical outcomes at up to 20 years follow-up from a randomized controlled trial of Nissen vs. anterior 180-degree partial fundoplication.

SUMMARY BACKGROUND DATA

Nissen fundoplication for gastroesophageal reflux can be followed by troublesome side effects. To address this, partial fundoplications have been proposed. Previously reports from a randomized controlled trial of Nissen vs. anterior 180-degree partial fundoplication at up to 10 years follow-up showed good outcomes for both procedures.

METHODS

107 participants were randomized to Nissen vs. anterior 180-degree partial fundoplication. 15-20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardized questionnaire with 0-10 analogue scores and yes/no questions to determine reflux symptoms, side-effects and satisfaction with surgery.

RESULTS

After anterior fundoplication heartburn (mean score 3.2 vs 1.4, p = 0.001) and proton pump inhibitor use (41.7% vs 17.1%, p = 0.023) were higher, offset by less dysphagia for solids (mean score 1.8 vs 3.3, p = 0.015), and better ability to belch (84.2% vs 65.9%, p = 0.030). Measures of overall outcome were similar for both groups (mean satisfaction score 8.4 vs 8.0, p = 0.444; 86.8% vs 90.2% satisfied with outcome). Six participants underwent revision following anterior fundoplication (Nissen conversion for reflux - 6), and 7 underwent revision following Nissen fundoplication (Nissen to partial fundoplication for dysphagia - 5; redo Nissen for reflux - 1; paraesophageal hernia -1).

CONCLUSIONS

At 15-20 years follow-up Nissen and anterior 180-degree partial fundoplication achieved similar success, but with trade-offs between better reflux control vs. more side-effects after Nissen fundoplication.

Minor esophageal functional disorders: are they relevant?

PURPOSE OF REVIEW

High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear.

RECENT FINDINGS

Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility.

SUMMARY

Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.

Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis

BACKGROUND

Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease.

METHODS

Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease.

RESULTS

Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270°, 360°, anterior 180° and anterior 90°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 270° (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180°, and anterior 90° were equally effective as 360° for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270° (OR 0.38, 95%, CI 0.24-0.60), anterior 90° (moderate quality evidence), and anterior 180° (low-quality evidence) compared to 360°. The odds for gas-bloat were lower after 270° (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90° compared to 360° (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence.

CONCLUSION

Laparoscopic 270° fundoplication achieves a better outcome than 360° total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective.

REGISTRATION NO

CRD42017074783.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

BACKGROUND

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals.

PURPOSE

A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

Long-term (15-year) objective evaluation of 150 patients after laparoscopic Nissen fundoplication

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.

Persistent Dysphagia Rate After Antireflux Surgery is Similar for Nissen Fundoplication and Partial Fundoplication

BACKGROUND

Laparoscopic fundoplication is the gold standard operation for treatment of gastroesophageal reflux disease (GERD). It has been suggested that persistent postoperative dysphagia is increased following Nissen fundoplication compared to partial fundoplication. This study aimed to determine risk factors for persistent postoperative dysphagia, specifically examining the type of fundoplication.

METHODS

Patients experiencing GERD symptoms who underwent laparoscopic Nissen, Toupet, or Dor fundoplication from 2009 to 2016 were identified from a single-institutional database. A dysphagia score was obtained as part of the GERD health-related quality of life questionnaire. Persistent dysphagia was defined as a difficulty swallowing score ≥1 (noticeable) on a scale from 0 to 5 at least 1 y postoperatively. Odds ratios of persistent dysphagia among those who underwent antireflux surgery were calculated in a multivariate logistic regression model adjusted for fundoplication type, sex, age, body mass index, and redo operation.

RESULTS

Of the 441 patients who met inclusion criteria, 255 had ≥1 y of follow-up (57.8%). The median duration of follow-up was 3 y. In this cohort, 45.1% of patients underwent Nissen fundoplication and 54.9% underwent partial fundoplication. Persistent postoperative dysphagia was present in 25.9% (n = 66) of patients. On adjusted analysis, there was no statistically significant association between the type of fundoplication (Nissen versus partial) and the likelihood of postoperative dysphagia.

CONCLUSIONS

Persistent postoperative dysphagia after antireflux surgery occurred in approximately one-quarter of patients and did not differ by the type of fundoplication. These findings suggest that both Nissen and partial fundoplication are reasonable choices for an antireflux operation for properly selected patients.

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.

Impact of Toupet Versus Nissen Fundoplication on Dysphagia in Patients With Gastroesophageal Reflux Disease and Associated Preoperative Esophageal Dysmotility: A Systematic Review and Meta-Analysis

BACKGROUND

Controversy exists regarding the best surgical approach for the management of gastroesophageal reflux disease (GORD) and associated preoperative esophageal dysmotility. Our aim was to conduct a systematic review and meta-analysis to compare the outcomes of Toupet fundoplication (TF) and Nissen fundoplication (NF) in patients with GORD and coexistent preoperative esophageal dysmotility.

METHODS

We conducted a systematic search of electronic information sources, including MEDLINE, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov , and bibliographic reference lists. We applied a combination of free text search and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above-mentioned databases. Postoperative dysphagia and improvement in dysphagia were primary outcome parameters.

RESULTS

We identified 3 randomized controlled trials and 1 observational study reporting a total of 220 patients, of whom 126 underwent TF and the remaining 94 patients had NF. Despite the existence of significantly higher preoperative dysphagia in the TF group (29.3% vs 4.2%, P = .05), TF was associated with significantly lower postoperative dysphagia (odds ratio [OR] = 0.31, P = .002) with low between-study heterogeneity ( I2 = 11%, P = .34), and significantly higher improved dysphagia (OR = 10.32, P < .0001) with moderate between-study heterogeneity ( I2 = 31%, P = .23) compared with NF.

CONCLUSION

TF may be associated with significantly lower postoperative dysphagia than NF in patients with GORD and associated preoperative esophageal dysmotility. However, no definite conclusions can be drawn as the best available evidence comes mainly from a limited number of heterogeneous randomized controlled trials. Future studies are encouraged to include patients with similar preoperative dysphagia status and report the outcomes with respect to recurrence of acid reflux symptoms.

Paraesophageal Hernia and Reflux Prevention: Is One Fundoplication Better than the Other?

BACKGROUND

The management of paraesophageal hernia (PEH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons tend to perform a laparoscopic PEH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. Nevertheless, very little has been written on which type of fundoplication should be performed in these patients. Therefore, the goal of our study was to provide an evidence-based overview of which type of fundoplication should be performed during a PEH repair and the role of preoperative function tests in the decision-making METHODS: We searched the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases for papers published between 1996 and 2016 pertaining to the surgical treatment of PEH. We hand-searched the bibliographies of included studies and we excluded all reviews and case reports. We selected clinical studies and technical reports. We only considered papers stating rationales for the type of fundoplication performed.

RESULTS

Our search yielded 24 articles: 17 clinical studies and 7 technical reports. In five of the clinical studies, a fundoplication was added only to patients with reflux symptoms. In all clinical studies, the most performed procedure was a total fundoplication (Nissen or Nissen-Rossetti), whereas a partial fundoplication (Toupet more frequently than Dor) or no fundoplication was reserved to those with impaired esophageal motility. All seven technical reports recommended a tailored approach and suggested adding a partial fundoplication (mainly Toupet) when the manometric findings showed esophageal dismotility.

CONCLUSION

The argument of whether or not a fundoplication should be added to a PEH repair in patients without evidence of reflux still persists. However, this review highlights that, when a fundoplication is performed, a tailored approach based on preoperative function tests is almost always preferred.

Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication

Purpose

Laparoscopic total fundoplication is the standard surgery for gastroesophageal reflux disease. However, partial fundoplication may be a viable alternative. Here, we conducted a nationwide survey of partial fundoplication in Korea.

Methods

The Korean Anti-Reflux Surgery study group recorded 32 cases of partial fundoplication at eight hospitals between September 2009 and January 2016. The surgical outcomes and postoperative adverse symptoms in these cases were evaluated and compared with 86 cases of total fundoplication.

Results

Anterior partial fundoplication was performed in 20 cases (62.5%) and posterior in 12 (37.5%). In most cases, partial fundoplication was a secondary procedure after operations for other conditions. Half of patients who underwent partial fundoplication had typical symptoms at the time of initial diagnosis, and most of them showed excellent (68.8%), good (25.0%), or fair (6.3%) symptom resolution at discharge. Compared to total fundoplication, partial fundoplication showed no difference in the resolution rate of typical and atypical symptoms. However, adverse symptoms such as dysphagia, difficult belching, gas bloating and flatulence were less common after partial fundoplication.

Conclusion

Although antireflux surgery is not popular in Korea and total fundoplication is the primary surgical choice for gastroesophageal reflux disease, partial fundoplication may be useful in certain conditions because it has less postoperative adverse symptoms but similar efficacy to total fundoplication.

Long-Term Quality of Life Outcomes Following Nissen Versus Toupet Fundoplication in Patients with Gastroesophageal Reflux Disease

INTRODUCTION

Laparoscopic fundoplication is the gold standard treatment for gastroesophageal reflux disease (GERD) refractory to medical management. Although many studies have compared Nissen fundoplication (NF) to Toupet fundoplication (TF), it is unclear which operation provides the best long-term reflux control. The objective of this study was to evaluate long-term quality-of-life (QoL) outcomes after NF versus TF.

METHODS

Clinical data from our single academic institutional foregut database were used to identify patients who underwent NF or TF (June 2010 to May 2016). Postoperative QoL was assessed through telephone at 1, 3, or 5 years postsurgery, using GERD-health related quality of life (GERD-HRQL), Gastroparesis Cardinal Symptom Index (GCSI), and Eckardt Dysphagia scores. Proton pump inhibitor (PPI) use and satisfaction with surgery were also obtained. Trends in outcomes over time were analyzed by logistic regression or Cochran-Armitage trend test.

RESULTS

Our cohort included 155 TF and 161 NF patients. TF patients reported baseline dysphagia at higher rates (42.6% versus 19.9%; P < .001) and had worse preoperative esophageal dysmotility than NF patients. There were no significant differences in GERD-HRQL or GCSI scores between TF and NF patients at any time point postoperatively. Long-term satisfaction was equivalent between TF and NF patients 5 years postoperatively (70.0% versus 77.4%; P = .67). NF patients had higher Eckardt dysphagia scores 1 year after surgery compared to TF patients, but this difference was not present at 3 or 5 years postoperatively. Over time, PPI use increased and there was a trend toward increased GERD-HRQL scores in the TF group.

CONCLUSIONS

Both TF and NF provide excellent long-term satisfaction for patients with GERD. NF and TF patients reported similar postoperative QoL scores. Our finding of increasing PPI use and a trend toward worsening GERD scores following TF warrants additional investigation regarding the long-term durability of TF.

Long-term symptom control of gastro-oesophageal reflux disease 12 years after laparoscopic Nissen or 180° anterior partial fundoplication in a randomized clinical trial

BACKGROUND

Laparoscopic 180° anterior fundoplication has been shown to achieve similar reflux control to Nissen fundoplication, with fewer side-effects, up to 5 years. However, there is a paucity of long-term follow-up data on this technique and antireflux surgery in general. This study reports 12-year outcomes of a double-blind RCT comparing laparoscopic Nissen versus 180° laparoscopic anterior fundoplication for gastro-oesophageal reflux disease (GORD).

METHODS

Patients with proven GORD were randomized to laparoscopic Nissen or 180° anterior fundoplication. The 12-year outcome measures included reflux control, dysphagia, gas-related symptoms and patient satisfaction. Measures included scores on a visual analogue scale, a validated Dakkak score for dysphagia and Visick scores.

RESULTS

Of the initial 163 patients randomized (Nissen 84, anterior 79), 90 (55·2 per cent) completed 12-year follow-up (Nissen 52, anterior 38). There were no differences in heartburn, dysphagia, gas-related symptoms, patient satisfaction or surgical reintervention rate. Use of acid-suppressing drugs was less common after Nissen than after 180° anterior fundoplication: four of 52 (8 per cent) and 11 of 38 (29 per cent) respectively (P = 0·008). The proportion of patients with absent or only mild symptoms was slightly higher after Nissen fundoplication: 45 of 50 (90 per cent) versus 28 of 38 (74 per cent) (P = 0·044).

CONCLUSION

The two surgical procedures provided similar control of heartburn and post-fundoplication symptoms, with similar patient satisfaction and reoperation rates on long-term follow-up.

Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors

Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.

A meta-analysis of long follow-up outcomes of laparoscopic Nissen (total) versus Toupet (270°) fundoplication for gastro-esophageal reflux disease based on randomized controlled trials in adults

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is the most common surgical procedure for the surgical management of gastro-esophageal reflux disease (GERD). Laparoscopic Toupet fundoplication (LTF) has been reported to have a lower prevalence of postoperative complications yet still obtain a similar level of reflux control. We conducted a meta-analysis to confirm the value of LNF and LTF.

METHODS

PubMed, Medline, Embase, Cochrane Library and Springerlink were searched for randomized controlled trials (RCTs) comparing LNF and LTF. Data regarding the benefits and adverse results of two techniques were extracted and compared using a meta-analysis.

RESULTS

Eight eligible RCTs comparing LNF (n = 625) and LTF (n = 567) were identified. There were no significant differences between LNF and LTF with regard to hospitalization duration, perioperative complications, patient satisfaction, postoperative heartburn, regurgitation, postoperative DeMeester scores, or esophagites. A shorter operative time and higher postoperative lower esophageal sphincter pressure were associated with LNF. Prevalence of postoperative dysphagia, gas-bloating, inability to belch, dilatation for dysphagia and reoperation were higher after LNF, but subgroup analyses showed that differences with respect to dysphagia between LNF and LTF disappeared over time. Subgroup analyses did not support "tailored therapy" according to preoperative esophageal motility.

CONCLUSIONS

LNF and LTF have equivalently good control of GERD and result in a similar prevalence of patient satisfaction. Based on current evidence, it is not rational or advisable to abandon LNF when choosing a surgical procedure for GERD.

Advances in the evaluation and management of esophageal disease of systemic sclerosis

Symptoms of heartburn and dysphagia as well as objective findings of abnormal esophageal acid exposure and esophageal dysmotility are common in patients with systemic sclerosis (SSc). Treatments for SSc esophageal disease are generally limited to gastroesophageal reflux disease (GERD) treatment with proton pump inhibitors. Progresses made in esophageal diagnostic testing offer the potential for improved clinical characterization of esophageal disease in SSc that may help direct management decisions. In addition to reviewing GERD management in patients with SSc, present and potential uses of endoscopy, reflux monitoring, manometry, impedance planimetry, and endoscopic ultrasound are discussed.

A Meta-Analysis of Randomized Controlled Trials to Compare Long-Term Outcomes of Nissen and Toupet Fundoplication for Gastroesophageal Reflux Disease

Aim

In recent years, several studies with large sample sizes and recent follow-up data have been published comparing outcomes between laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication. It is now timely to be re-evaluated and synthesized long-term efficacy and adverse events of both total and partial posterior fundoplication.

Materials and Methods

Electronic searches for RCTs comparing the outcome after laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication were performed in the databases of MEDLINE, EMBASE, and the Cochrane Center Register of Controlled Trials. The data of evaluation in positive and adverse results of laparoscopic Nissen fundoplication and laparoscopic Nissen fundoplication were extracted and compared using meta-analysis.

Results

13 RCTs were ultimately identified involving 814 (52.05%) and 750 (47.95%) patients who underwent laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication, respectively. The operative time, perioperative complications, postoperative satisfaction, recurrence, and the rates of medication adoption or re-operation due to recurrence were not significantly different between two groups. The two types of fundoplication both reinforced the anti-reflux barrier and elevated the lower esophageal sphincter pressure. However, rates of adverse results involving dysphasia, gas-bloat syndrome, inability to belch and re-operation due to severe dysphasia were significantly higher after LNF. In the subgroup analysis of wrap length≤2cm, laparoscopic Nissen fundoplication was associated with a significantly higher incidence of postoperative dysphagia. However, in the subgroup wrap length>2cm, the difference was not statistically significant.

Conclusion

Laparoscopic Toupet fundoplication might be the better surgery approach for gastroesophageal reflux disease with a lower rate of postoperative adverse results and equal effectiveness as Laparoscopic Nissen fundoplication.

Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment

Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.

Effect of laparoscopic antireflux surgery on esophageal motility

BACKGROUND/AIMS

The effect of laparoscopic antireflux surgery on esophageal motility is incompletely understood, and any indication for this procedure in patients with motility disorder is disputed in literature. We evaluated the influence of laparoscopic Nissen fundoplication on impaired esophageal motility.

METHODS

In this pathological manometric study, we divided the patients into two groups preoperatively: the hypomotility group (mean amplitude of esophageal contraction wave <40 mm Hg; HYPO group, n = 11) and the normal group (mean amplitude of esophageal contraction wave >40 mm Hg; NORM group, n = 43). The amplitudes of esophageal contraction waves 3 and 8 cm above the lower esophageal sphincter and the percentage of peristaltic contraction waves of the tubular esophagus were analyzed pre- and postoperatively.

RESULTS

In total, 54 patients with GERD underwent esophageal manometry before and 6 months after Nissen fundoplication. The length and pressure of the lower esophageal sphincter were increased in both groups postoperatively (p < 0.01). Patients in the HYPO group (n = 11) showed a statistically significant increase of mean amplitude of esophageal contraction (32.8 vs. 57.3 mm Hg; p < 0.01), while no change was found in the NORM group (n = 43). A total of 72% of patients with preoperative motility disorder showed normal postoperative manometry.

CONCLUSION

Nissen fundoplication normalizes esophageal motility, especially in patients with preoperative hypomotility. Patients with impaired esophageal motility should not per se be excluded from antireflux surgery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A clinical comparison of laparoscopic Nissen and Toupet fundoplication for gastroesophageal reflux disease

AIM

To compare the advantages and disadvantages of laparoscopic Nissen and Toupet fundoplication in the treatment of gastroesophageal reflux disease (GERD) and their indications.

PATIENTS AND METHODS

From June 2001 to December 2011, 383 patients with GERD were randomized into two groups according to the last number in their hospitalization number. Overall, 215 patients underwent laparoscopic Nissen fundoplication, and 168 underwent laparoscopic Toupet fundoplication.

RESULTS

No conversions to laparotomy or deaths were observed, and the symptoms disappeared completely postoperatively in both groups. Average follow-up was 5.6 years. No recurrence of symptoms was observed in the Nissen group. Eighteen patients experienced recurrence of symptoms in the Toupet group and were administered acid-suppressing drugs. Esophageal manometry and acid reflux testing were performed 4 months postoperatively, with normal results in both groups. The cure rate of esophageal inflammation was 88.4% in the Nissen group and 67.7% in the Toupet group. Four days postoperatively, the incidences of dysphagia and abdominal distension were significantly higher in the Nissen group compared with the Toupet group (28.4% and 16.7%, respectively); the difference between the two groups significantly decreased 1 year postoperatively (1.5% and 0.8%, respectively).

CONCLUSIONS

In the short term, the incidence of dysphagia was significantly lower after Toupet fundoplication, but the difference decreased significantly with extension of the postoperative recovery period. For patients with moderate to severe GERD, the laparoscopic Nissen fundoplication may be optimal; for elderly patients or for patients with significantly reduced esophageal peristalsis detected in preoperative examinations, the laparoscopic Toupet fundoplication should be considered.

Influence of wrap length on the effectiveness of Nissen and Toupet fundoplications: 5-year results of prospective, randomized study

BACKGROUND

Long-term results in antireflux surgery may depend on fundoplication type and wrap length. We compared the outcome of two different wrap lengths among the patients undergoing partial or total fundoplications. This study is the next part of a prospective 5-year follow-up assessment.

METHODS

A total of 153 patients were randomized to Nissen or Toupet 1.5- or 3-cm wrap laparoscopic fundoplication. The primary endpoint--treatment failure rate was defined as a recurrent GERD or persistent dysphagia. Intensity of heartburn, dysphagia, gas-bloating, presence of esophagitis were assessed as a secondary outcome at 1-year and 5-year follow-up.

RESULTS

At 5-year follow-up, data were collected from 129 (85 %) patients. At 1-year follow-up, 17 (11 %) treatment failures were detected. At the end of the fifth year, the numbers reached 23 (15 %). The failures were more common in the 1.5-cm Toupet (25 %) and the 3-cm Nissen group (18.2 %). The significant difference in failure rates was found between 1.5-cm and 3-cm Toupet groups (P < 0.05). Dysphagia remained low during the follow-up in all of the groups. The prevalence of higher scores of heartburn after 5 years was detected in Nissen 1.5-cm group (20.8 %). The lowest scores were observed in Toupet 3-cm group. Bloating symptoms were more prevalent among Nissen and Toupet 3-cm group patients at 5-year follow-up. At the end of the fifth year, the prevalence of esophagitis was lower in Nissen 1.5-cm (19.3 %) and Toupet 3-cm (13.3 %) groups. The highest prevalence of esophagitis-32.4 %-was found in Toupet 1.5-cm group.

CONCLUSIONS

Nissen and Toupet fundoplication achieved sufficient control of reflux with success rate of 85 % at 5-year follow-up. There were no significant differences in the postoperative dysphagia, esophagitis, and bloating rates. However, the distribution of treatment failures leads us to conclude that 1.5-cm wrap length is insufficient in cases of posterior partial fundoplication.

Twenty years of laparoscopic fundoplication for GERD

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

Impact of ineffective oesophageal motility and wrap type on dysphagia after laparoscopic fundoplication

BACKGROUND

Laparoscopic 360° fundoplication is the most common operation for gastro-oesophageal reflux disease, but is associated with postoperative dysphagia in some patients. Patients with ineffective oesophageal motility may have a higher risk of developing postoperative dysphagia, but this remains unclear.

METHODS

From 1991 to 2010, 2040 patients underwent primary laparoscopic fundoplication for gastro-oesophageal reflux disease and met the study inclusion criteria; 343 had a 90°, 498 a 180° and 1199 a 360° fundoplication. Primary peristalsis and distal contraction amplitude during oesophageal manometry were determined for 1354 patients. Postoperative dysphagia scores (range 0-45) were recorded at 3 and 12 months, then annually. Oesophageal dilatations and/or reoperations for dysphagia were recorded.

RESULTS

Preoperative oesophageal motility did not influence postoperative dysphagia scores, the need for dilatation and/or reoperation up to 6 years. Three-month dysphagia scores were lower after 90° and 180° compared with 360° fundoplication (mean(s.e.m.) 8·0(0·6) and 9·8(0·5) respectively versus 11·9(0·4); P < 0·001 and P = 0·003), but these differences diminished after 6 years of follow-up. The incidence of dilatation and reoperation for dysphagia was lower after 90° (2·6 and 0·6 per cent respectively) and 180° (4·4 and 1·0 per cent) fundoplications than with a 360° wrap (9·8 and 6·8 per cent; both P < 0·001 versus 90° and 180° groups).

CONCLUSION

Tailoring the degree of fundoplication according to preoperative oesophageal motility by standard manometric parameters has no long-term impact on postoperative dysphagia. There is, however, a proportionate increase in short-term dysphagia scores with increasing degree of wrap, and a corresponding proportionate increase in dilatations and reoperations for dysphagia. These differences in dysphagia scores diminish with time.

Predictors of objectively identified recurrent reflux after primary Nissen fundoplication

Background

Laparoscopic Nissen fundoplication is the most frequently performed operation for gastro-oesophageal reflux disease (GORD). Studies on predictors of subjective outcome of fundoplication have yielded inconsistent results. This study identified predictors of objective reflux control after Nissen fundoplication.

Methods

This was a retrospective analysis of prospectively collected data from patients who underwent Nissen fundoplication for proton pump inhibitor-refractory GORD with pathological acid exposure in a single centre between 1997 and 2005. The predictive value of demographics, endoscopic hiatal hernia size, oesophagitis, lower oesophageal sphincter pressure, distal oesophageal contraction amplitude, percentage of peristaltic contractions and acid exposure was determined. Endpoints were recurrent pathological acid exposure on 24-h pH monitoring at 6 months and surgical reintervention for recurrent GORD up to 6 years.

Results

Of 177 patients, 22 had recurrent pathological acid exposure at 6 months for which 11 had surgery within 6 years. Only low percentage of peristaltic contractions (odds ratio (OR) 0·97, 95 per cent confidence interval 0·95 to 0·99; P = 0·004) and high supine acid exposure (OR 1·03, 1·00 to 1·07; P = 0·025) were independent predictors of recurrent pathological acid exposure. The absolute risk of recurrent exposure was 45·5 per cent in patients with both predictors. High supine acid exposure was also an independent predictor of surgical reintervention (OR 1·05, 1·01 to 1·08; P = 0·006).

Conclusion

Nissen fundoplication should not necessarily be withheld from patients with poor oesophageal peristalsis or excessive supine acid exposure. As about half of patients with both variables experience recurrent pathological acid exposure after primary Nissen fundoplication, surgery should be restricted in this group.

A meta-analysis comparing laparoscopic partial versus Nissen fundoplication

BACKGROUND

For proven gastro-oesophageal reflux disease, partial fundoplication is considered as effective as Nissen, but with fewer side effects. The aim of this meta-analysis was to compare the effect of laparoscopic partial fundoplication (LPF) with laparoscopic Nissen fundoplication (LNF).

METHODS

Extensive medical literature searches of the PubMed, Medline and Embase databases were performed up to April 2010 for all randomized clinical trials that compared LPF versus LNF. The effect variables analysed were the incidence of post-operative dysphagia, heartburn, inability to belch, outcome or satisfaction and Visick score. Meta-analyses were carried out using odds ratios (ORs) with 95% confidence interval.

RESULTS

Thirteen randomized trials were considered suitable for the meta-analysis. A total of 1374 patients underwent LPF or LNF. There was a significant reduction of the incidence of post-operative dysphagia (OR = 0.44, P < 0.0001) and inability to belch (OR = 0.41, P < 0.005) for the LPF compared to that of the LNF group. Compared with LPF, LNF resulted in a significant reduction of the incidence of post-operative heartburn (OR = 1.94, P < 0.01). The outcome or satisfaction of patients and Visick I and II scores were comparable between the two groups.

CONCLUSION

Both LPF and LNF are effective for the treatment of proven gastro-oesophageal reflux disease. LPF enables a decreased post-operative dysphagia and gas-related side effects, while LNF is more successful in controlling reflux symptoms, particularly heartburn, than LPF. A balance should be found between anti-reflux and side effects.

Meta-analysis of laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastro-oesophageal reflux disease based on randomized clinical trials

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is the standard procedure for surgical management of gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) is reported to be as effective as LNF but to be associated with a lower incidence of post-operative dysphagia. This meta-analysis was performed to compare the two techniques with respect to reflux control and associated complications, particularly dysphagia.

METHODS

Pubmed, Medline, Embase and The Cochrane Library were searched. Only randomized controlled trials (RCTs) comparing LNF and LTF were included. Outcomes evaluated were occurrences of heartburn and associated complications (e.g. dysphagia) and degree of patient's satisfaction at early (three to six months) and later (one to three years) post-operative periods.

RESULTS

Of 939 patients in seven RCTs, 478 received LNF and 461 received LTF. For both groups, control of reflux was good and occurrence of heartburn were similar. A lower incidence of post-operative dysphagia for both early and later post-operative periods was observed for the LTF group. Patient's satisfaction following either procedure was similar.

CONCLUSION

LNF and LTF are both safe and effective. LTF is truly associated with a lower occurrence of dysphagia. However, LTF is more likely than LNF to be associated with early surgical complications. On the whole, post-surgical satisfaction ratios for the two groups were comparable.

Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is currently considered the surgical approach of choice for gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) has been said to reduce troublesome dysphagia and gas-related symptoms. A systematic review and meta-analysis of randomized clinical trials (RCTs) was performed to compare LNF and LTF.

METHODS

Four electronic databases (MEDLINE, Embase, Cochrane Library and ISI Web of Knowledge CPCI-S) were searched and the methodological quality of included trials was evaluated. Outcomes included recurrent pathological acid exposure, oesophagitis, dysphagia, dilatation for dysphagia and reoperation rate. Results were pooled in meta-analyses as risk ratios (RRs) and weighted mean differences.

RESULTS

Seven eligible RCTs comparing LNF (n = 404) with LTF (n = 388) were identified. LNF was associated with a significantly higher prevalence of postoperative dysphagia (RR 1.61 (95 per cent confidence interval 1.06 to 2.44); P = 0.02) and dilatation for dysphagia (RR 2.45 (1.06 to 5.68); P = 0.04). There were more surgical reinterventions after LNF (RR 2.19 (1.09 to 4.40); P = 0.03), but no differences regarding recurrent pathological acid exposure (RR 1.26 (0.82 to 1.95); P = 0.29), oesophagitis (RR 1.20 (0.78 to 1.85); P = 0.40), subjective reflux recurrence, patient satisfaction, operating time or in-hospital complications. Inability to belch (RR 2.04 (1.19 to 3.49); P = 0.009) and gas bloating (RR 1.58 (1.21 to 2.05); P < 0.001) were more prevalent after LNF.

CONCLUSION

LTF reduces postoperative dysphagia and dilatation for dysphagia compared with LNF. Reoperation rate and prevalence of gas-related symptoms were lower after LTF, with similar reflux control. These results provide level 1a support for the use of LTF as the posterior fundoplication of choice for GORD.

Gastroesophageal reflux and altered motility in lung transplant rejection

BACKGROUND

Lung transplantation has become an effective therapeutic option for selected patients with end stage lung disease. Long-term survival is limited by chronic rejection manifest as bronchiolitis obliterans syndrome (BOS). The aspiration of gastric contents has been implicated as a causative or additive factor leading to BOS. Gastroesophageal reflux (GER) and altered foregut motility are common both before and after lung transplantation. Further, the normal defense mechanisms against reflux are impaired in the allograft. Recent studies using biomarkers of aspiration have added to previous association studies to provide a growing body of evidence supporting the link between rejection and GER. Further, the addition of high-resolution manometry (HRM) and impedance technology to characterize bolus transit and the presence and extent of reflux regardless of pH might better identify at-risk patients. Although additional prospective studies are needed, fundoplication appears useful in the prevention or treatment of post-transplant BOS.

PURPOSE

This review will highlight the existing literature on the relationship of gastroesophageal reflux and altered motility to lung transplant rejection, particularly BOS. The article will conclude with a discussion of the evaluation and management of patients undergoing lung transplantation at our center.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease.

METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis.

RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients’ satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.

CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Long-term outcome of laparoscopic Nissen and laparoscopic Toupet fundoplication for gastroesophageal reflux disease: a prospective, randomized trial

BACKGROUND

A prospective, randomized trial was performed to evaluate the long-term outcome and patient satisfaction of laparoscopic complete 360 degrees fundoplication compared with partial posterior 270 degrees fundoplication. Partial fundoplication is purported to have fewer side effects with a higher failure rate in controlling gastroesophageal reflux disease (GERD), while complete fundoplication is thought to result in more dysphagia and gas-related symptoms.

METHODS

Patients were randomized to either laparoscopic Nissen (LN) or laparoscopic Toupet (LT) fundoplication. Esophageal manometry, 24-h pH studies, a detailed questionnaire, and a visual analog symptom (VAS) score were completed before and after surgery. A final global outcome questionnaire was performed. Failure was defined as recurrent GERD requiring revision surgery, maintenance proton pump inhibitor (PPI) therapy, or surgery for postoperative dysphagia.

RESULTS

One hundred patients were randomized to LN (50) or LT (50). There were no differences between LN and LT with respect to postoperative symptoms and physiological variables except a higher wrap pressure in the LN group (15.2 vs. 12.0 mmHg). Dysmotility improved in 8/14 (57%) and 6/11 (54%) patients in the LN group and the LT group, respectively, after surgery. There was no correlation between dysmotility and dysphagia both pre- and post surgery in the two groups. Recurrent symptoms of GERD occurred in 8/47 (17.0%) and 8/48 (16.6%) in the LN group and the LT group, respectively. Outcome of patients with dysmotility was similar to those with normal motility in both groups. At final follow-up (59.76 + or - 24.23 months), in the LN group, 33/37 (89.1%) would recommend surgery to others, 32/37 (86.4%) would have repeat surgery, and 34/37 (91.8%) felt they were better off than before surgery. The corresponding numbers for the LT group (follow-up = 55.18 + or - 25.97 months) were 35/36 (97.2%), 30/36 (83.3%), and 33/36 (91.6%).

CONCLUSION

LN and LT are equally effective in restoring the lower esophageal sphincter function and provide similar long-term control of GERD with no difference in dysphagia. Esophageal dysmotility had no influence on the outcome of either operation.

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

METHODS

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

RESULTS

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

CONCLUSIONS

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.

The use of medication after laparoscopic antireflux surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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