Role of fundoplication in patient symptomatology after laparoscopic antireflux surgery

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

BACKGROUND

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

METHODS

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

KEY RESULTS

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

CONCLUSIONS & INFERENCES

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

Randomized Trial of Division Versus Nondivision of Short Gastric Vessels During Nissen Fundoplication: 20-Year Outcomes

OBJECTIVE

To evaluate late outcomes from a randomized trial of division versus no division of short gastric vessels during laparoscopic Nissen fundoplication at up to 20 years follow-up.

BACKGROUND

Nissen fundoplication is an established procedure for the treatment of gastroesophageal reflux disease. Controversy about whether side effects such as dysphagia could be reduced by division of the short gastric vessels led to the establishment of a randomized trial in 1994. Early results showed equivalent reflux control and dysphagia, but more bloating after vessel division.

METHODS

A total of 102 patients underwent a laparoscopic Nissen fundoplication between May 1994 and October 1995, and were randomized to short gastric vessel division (50) versus nondivision (52). Follow-up was obtained yearly to 20 years using a standardized questionnaire administered by a blinded investigator. Clinical outcomes at 20 years or most recent follow-up were determined.

RESULTS

No significant differences for heartburn symptom and satisfaction scores or medication use were found between treatment groups. At 15 to 20 (mean 19.6) years follow-up, significant differences persisted for epigastric bloating: 26% versus 50% for nondivision versus division groups (P = 0.046). Heartburn symptom scores were low and not different for nondivision versus division groups (mean analog scores 1.4 vs 2.1/10, P = 0.152). Overall satisfaction after surgery was high in both groups (mean analog scores 8.1 vs 8.6/10, P = 0.989).

CONCLUSIONS

Although laparoscopic Nissen fundoplication has durable efficacy for heartburn symptom control at up to 20 years follow-up, division of short-gastric vessels failed to confer any reduction in side effects, and was associated with persistent epigastric bloat symptoms at late follow-up in this trial.

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.

Gastrointestinal symptoms and patient satisfaction more than 1 year after laparoscopic Nissen fundoplication

BACKGROUND

Symptoms from poorly controlled gastroesophageal reflux disease (GERD) such as heartburn and regurgitation often resolve after laparoscopic Nissen fundoplication. Unfortunately, new gastrointestinal symptoms such as bloating may occur for some patients. Accurate data regarding the gastrointestinal symptoms experienced by patients who have had a laparoscopic fundoplication may help patients to make more informed decisions about pursuing surgery for their reflux disease.

METHODS

Patients more than 12 months after a laparoscopic Nissen fundoplication were mailed symptom surveys. Before surgery, all the patients had medically refractory esophageal symptoms (heartburn, regurgitation, or both). Surveys included the Gastrointestinal Quality of Life Index (GIQLI) and questions regarding satisfaction, reintervention, and medication use. Responses for individual GIQLI items were evaluated to determine the gastrointestinal symptoms experienced by fundoplication patients and the relationship of these symptoms to patient satisfaction.

RESULTS

Of the 76 patients eligible for inclusion in the survey, 48 returned complete surveys (63%). The mean time since surgery was 28±9 months. No patient experienced frequent regurgitation, and few (10%) reported frequent heartburn at follow-up assessment. No patient required redo fundoplication during the follow-up period. Acid reduction medications were resumed by 25% of the patients, but not all of these patients resumed medications for recurrent GERD symptoms (15% total). After surgery, frequent bloating (21%) and excessive flatus (46%) were often noted. Satisfaction with the results of surgery was high, including 83% of the patients.

CONCLUSIONS

Few patients report frequent regurgitation or heartburn after laparoscopic Nissen fundoplication. Although some patients resume acid reduction medications, many do so for reasons other than recurrent GERD symptoms. Most fundoplication patients are quite satisfied with the symptomatic results of surgery, although frequent functional gastrointestinal symptoms are common.

The laparoscopic Nissen fundoplication--a better operation?

BACKGROUND

Laparoscopic Nissen fundoplication has become the method of choice in antireflux surgery replacing its open counterpart before the long-term results of controlled clinical trials were available. METHODS AND AIM: Review of the literature to highlight the long-term results of laparoscopic Nissen fundoplication.

RESULTS

Long-term symptom relief regarding significant reflux symptoms of heartburn and regurgitation can be achieved by laparoscopic fundoplication in 84% to 97% and patients' overall satisfaction with the result of their laparoscopic fundoplication surgery is high, ranging from 86% to 96%. The long-term results of randomised trials have shown no statistically significant differences in subjective symptomatic outcome between laparoscopic and open Nissen fundoplication. Complaints regarding the scar, incisional hernias and higher incidence of defective wraps were associated with the open approach.

CONCLUSION

At long-term follow-up the laparoscopic Nissen fundoplication has a similar long-term subjective symptomatic outcome as the open procedure but laparoscopic Nissen fundoplication is associated with a significantly lower incidence of incisional hernias and defective fundic wraps at endoscopy, defining laparoscopic Nissen fundoplication as the procedure of choice in surgical management of gastro-oesophageal reflux disease.

Prevalence of symptoms and use of medication for gastroesophageal reflux in an Australian community

INTRODUCTION

Gastroesophageal reflux disease is common in Western societies, although the prevalence of reflux symptoms in the community is not well described. In this study we determined the prevalence of symptoms of gastroesophageal reflux and other "esophageal" symptoms, and the consumption of medication for reflux in an Australian community.

PATIENTS AND METHODS

A population sample designed to accurately reflect the characteristics of the population aged 15 years or older in the State of South Australia was studied. Demographic data; symptoms specific to reflux, dysphagia, and abdominal bloating; and the consumption of antireflux medication were determined in a face-to-face interview. The frequency and severity of heartburn and dysphagia were assessed with analog scales.

RESULTS

A total of 2,973 people (age range: 15-95 years) were interviewed between September and December 2006. Approximately half experienced the symptom of heartburn; 21.2% experienced heartburn at least once a month, and 12.4% described frequent symptoms of heartburn (at least a few times each week). Of those with heartburn, 25.0% graded it as moderate or severe, 10.9% reported some dysphagia for solid foods, and 6.9% reported dysphagia for liquids. 3.7% described dysphagia for solids at least once a month. Abdominal bloating was reported by 48.2%. 16.9% were taking medications for reflux symptoms (10.1% proton pump inhibitors, 1.2% H2-receptor antagonists, 2.1% simple antacids, 3.4% alternative medications). Heartburn was more common in individuals who consumed medication. There were significant associations between heartburn and bloating, and between heartburn and dysphagia.

CONCLUSIONS

Symptoms of gastroesophageal reflux and the use of medications to treat such symptoms are very common in the community of South Australia. Nearly 1 in 7 people over the age of 15 consume medication for the treatment of symptoms of reflux.

Association between persistent symptoms and long-term quality of life after laparoscopic total fundoplication

BACKGROUND

We investigated which factors are significantly associated with long-term quality of life after laparoscopic total fundoplication in the treatment of gastroesophageal reflux disease.

METHODS

Patients (n = 144) were given a standardized frequency-intensity symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

RESULTS

At follow-up evaluation (n = 102), patients had a significant reduction in their symptoms score and no deterioration in quality of life. A significant association with postoperative dysphagia for solids and/or liquids was found in the physical component summary score of the Short-Form 36 administered to patients postoperatively (P = .003).

CONCLUSIONS

In this study, laparoscopic total fundoplication was a safe and effective surgical treatment for gastroesophageal reflux disease, generally offering an improved long-term quality of life, with the exception of a minority of patients (6 of 102 patients; 5.8%) who experienced persistent severe dysphagia.

Reflux Laryngitis: A Feasible Indication for Laparoscopic Antireflux Surgery?

Laparoscopic fundoplication is a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are still contradictions regarding supraesophageal symptoms as an indication for surgery. The aim of this study was to determine the subjective symptomatic outcome and objective laryngeal findings after antireflux surgery in patients with pH monitoring proven reflux laryngitis. Between 1998 and 2002, 40 patients with reflux laryngitis underwent laparoscopic Nissen fundoplication. Patients were referred to surgery and followed-up by a specialist in otorhinolaryngology. Subjective symptoms were collected by a structured questionnaire at a median follow-up of 42 months. The objective laryngeal findings improved from the preoperative situation; at 12 months after surgery, the otorhinolaryngeal status was improved in 92.3% (n=24) of the patients. However, only 38.5% (n=10) of these patients evaluated an improvement in their voice quality. Of all, 62.5% (n=25) of the patients reported no or only mild cough or voice hoarseness symptoms postoperatively, 22.5% (n=9) had moderate symptoms, and 15.0% (n=6) suffered from difficult supraesophageal symptoms. Ninety-five percent of the patients regarded the result of their surgery excellent, good, or satisfactory. Of all, 82.5% (n=33) of the patients would still choose surgery, 7.5% (n=3) would abstain from surgery, and 10% (n=4) of the patients were hesitant about their choice. For patients suffering from supraesophageal symptoms of gastro-esophageal reflux disease with objective evidence of pharyngeal acid exposure, laparoscopic Nissen fundoplication provides a good and alternative adding to current treatment.

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.

Late subjective results and symptomatic outcome after laparoscopic fundoplication

Laparoscopic fundoplication is generally accepted as a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are few reports on the long-term results after this procedure. Between 1996 and 2001, 468 patients underwent laparoscopic Nissen fundoplication of which 464 patients were available for follow-up. The follow-up data were collected both from the hospital records and by a structured questionnaire, which were completed by 441 patients (95%). Eighty-nine percent (n=394) of the patients regarded the result of their surgery excellent, good, or satisfactory at a median follow-up of 51 months. With the benefit of hindsight 83% of the patients would again choose surgical treatment. Eighty-seven percent of the patients had no significant reflux symptoms. Bloating or increased flatulence were the most common side-effects. One hundred thirty-two patients (30%) had started to use antireflux medications postoperatively, but only 51 of them used it daily. Laparoscopic Nissen fundoplication provides a good and effective alternative to a life-long use of antireflux medication.

Surgeons' experience with laparoscopic fundoplication after the early personal experience: does it have an impact on the outcome?

BACKGROUND

The adverse outcomes of laparoscopic fundoplication are more likely during the initial 20 cases performed by each individual surgeon. This study aimed to evaluate the impact of substantial surgical experience versus experience beyond the learning curve on the early and late objective and subjective results.

METHODS

The patients were divided into two groups according to the surgeon. In group 1 (n = 230), all the patients underwent surgery by a surgeon with substantial experience in laparoscopic fundoplication. In group 2 (n = 118), the patients were treated by a total of seven surgeons whose personal experience exceeded the individual learning curve, but was distinctively less than that of the group 1 surgeon.

RESULTS

The conversion rate was 2.2% in group 1 and 4.4% in group 2. The median operating time was 65 min in group 1 and 70 min in group 2 (p = 0.0020). The occurrence of immediate complications was 3.5% in group 1 and 7.6% in group 2 (p = 0.0892). At 6 months after surgery, 7.4% of the patients in group 1 and 16.1% of the patients in group 2 reported that dysphagia disturbed their daily lives (p = 0.0115). The late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in the two groups.

CONCLUSIONS

Substantial experience with the procedure is associated with a shorter operating time and somewhat fewer complications, conversions, and early dysphagia episodes. This supports the provision of expert supervision even after the initial learning phase of 20 individual procedures. The patients' long-term subjective symptomatic outcome was similar in the two groups. Substantial experience does not provide better late results than surgical experience beyond the learning curve.

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial

BACKGROUND

The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication.

METHODS

Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively.

RESULTS

One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores.

CONCLUSIONS

Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.

Laparoscopic fundoplication: a 10-year learning curve

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has become the most common surgical treatment for gastroesophageal reflux disease (GERD). Controversies still exist regarding the operative technique and the durability of the procedure.

METHODS

A retrospective study of 808 patients undergoing 838 LNF for GERD at a tertiary referral center was undertaken. Demographic, perioperative, and follow-up data had been entered onto the unit database.

RESULTS

During a median follow-up period of 60 months (range, 2-120 months), heartburn decreased to 3% of the patients (19/645) and regurgitation to 2% (11/582) (p < 0.01). Respiratory symptoms improved in 69 (85%) of 81 patients (p < 0.01). The incidence of postoperative dysphagia was unaffected by the use of an intraesophageal bougie (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.82-1.64; p = 0.41) or division of the short gastric vessels (OR, 0.84; 95% CI, 0.42-1.07; p = 0.72). In the immediate postoperative period, the incidence of abdominal symptoms increased by 10% (p < 0.01) and dysphagia by 16% (p < 0.01). After 10 postoperative years, only 3% (30/484) were found to have abdominal symptoms, whereas the incidence of dysphagia declined to zero.

CONCLUSION

The findings show that LNF is a safe and effective procedure with long-term durability. Abdominal symptoms and dysphagia are the principal postoperative complaints, which improve with time. Personal preference should dictate the use of a bougie, division of the short gastric vessels, or both.

Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group

BACKGROUND

Laparoscopic fundoplication effectively controls reflux symptoms in patients with gastroesophageal reflux disease (GERD). However, symptom relapse and side effects, including dysphagia and gas bloat, may develop after surgery. The aim of the study was to assess these symptoms in patients who underwent laparoscopic fundoplication, as well as in control subjects and patients with hiatal hernia.

METHODS

A standardized, validated questionnaire on reflux, dysphagia, and gas bloat was filled out by 115 patients with a follow-up of 1 to 7 years after laparoscopic fundoplication, as well as by 105 subjects with an incidentally discovered hiatal hernia and 238 control subjects.

RESULTS

Patients who underwent fundoplication had better reflux scores than patients with hiatal hernia ( P = .0001) and similar scores to control subjects ( P = .11). They also had significantly more dysphagia and gas bloat than patients with hiatal hernia and controls ( P < .005 for all comparisons). Gas bloat and dysphagia were more severe in hiatal hernia patients than in controls ( P < 0.005). After fundoplication, the 25% of the patients with the shortest follow-up (1.5 +/- 0.2 years) and the 25% patients with the longest follow-up (5.8 +/- 0.6 years) had similar reflux, dysphagia, and gas bloat scores ( P = .43, .82, and .85, respectively).

CONCLUSION

In patients with severe GERD, laparoscopic fundoplication decreases reflux symptoms to levels found in control subjects. These results appear to be stable over time. However, patients who underwent fundoplication experience more dysphagia and gas bloat than controls and patients with hiatal hernia-symptoms that should be seen as a side effect of the procedure and of GERD itself.

Gastroenterologists' views of symptoms following laparoscopic fundoplication: anecdotally based medicine?

BACKGROUND

Currently gastro-oesophageal reflux disease (GORD) can be managed either medically or surgically. The management decision is often based on the referring doctor's perception of the pros and cons of surgical management versus the medical alternative. A large group of gastroenterologists was surveyed to determine their understanding of the common outcomes of surgical management of GORD.

METHODS

A 15-question survey was sent to all gastroenterologists in Australia who were members of the Gastroenterology Society of Australia. Questions centred on management decisions and postoperative symptoms in fundoplication patients. The findings were compared to current published outcome data.

RESULTS

One hundred and thirty-four gastroenterologists responded anonymously to the survey. More than 75% described fundoplication as a safe and established procedure, and 80% had referred patients who were well controlled on medication for surgical management. The gastroenterologists' perceptions of the problems of postoperative dysphagia and bloating differed from published outcomes.

CONCLUSIONS

Gastroenterologists are often the gatekeepers for the management of patients with GORD. The understanding that this group has about surgical outcomes is important so that patients can make well-informed management decisions. The present study found that gastroenterologists are likely to convey to their patients higher degrees of postoperative dysphagia and bloating following fundoplication than is actually reported. This may deter some patients who would benefit from fundoplication from consulting a surgeon.

Laparoscopic treatment of gastro-oesophageal reflux disease

Laparoscopic antireflux surgery is now well established as a treatment of moderate to severe gastro-oesophageal reflux disease. It is indicated for patients with reflux symptoms who have not responded fully to medical therapy or who do not wish to continue medication for the rest of their lives. The evidence base for the determination of appropriate practice has expanded considerably in recent years with the publication of several important randomized trials. These trials have confirmed the superiority of fundoplication compared to medical therapy for the treatment of these patients. They have also demonstrated that the laparoscopic approach achieves an improved short-term outcome compared to the equivalent open approach. Additional trials suggest that the routine application of partial fundoplication procedures achieves equivalent reflux control and fewer side-effects than total fundoplication. Longer-term outcome studies have also been reported recently, with success rates of approximately 90% claimed at 5-8 years. Hence, laparoscopic fundoplication is now the 'gold standard' for the management of patients with more severe gastro-oesophageal reflux disease. New endoscopic treatments for reflux will need to achieve similar outcomes before they can replace the laparoscopic approach.

Efficacy of an anterior as compared with a posterior laparoscopic partial fundoplication: results of a randomized, controlled clinical trial

OBJECTIVE

The aim of the study was to compare the efficacy and mechanical consequences of 2 partial fundoplications performed laparoscopically under the framework of a randomized, controlled clinical trial.

SUMMARY BACKGROUND DATA

Although laparoscopic total fundoplication procedures have proven their effectiveness in the control of gastroesophageal reflux, problems remain with the functional consequences after a supra-competent gastric cardia high-pressure zone. Partial fundoplications have been found to be associated with fewer mechanical side effects.

PATIENTS AND METHODS

During a 2-year period, 95 patients with gastroesophageal reflux disease were enrolled into a randomized, controlled single-institution clinical trial comparing a partial posterior (Toupét, n = 48) fundoplication and an anterior partial wrap (Watson, n = 47). All patients were assessed postoperatively at predefined time points, and the 12-month follow-up data are presented in terms of clinical results and 24-hour pH monitoring variables.

RESULTS

Both patient groups were strictly comparable at the time of randomization. All operations were completed laparoscopically, and no serious complications were encountered. During the first postoperative year, a difference regarding the control of reflux symptoms was observed in favor of the posterior fundoplication. Esophageal acid exposure (% time pH <4) was substantially reduced by both operations but to a significantly lower level after a Toupét compared with the Watson partial fundoplication (1.0 +/- 0.3 vs. 5.6 +/- 1.1 mean +/- SEM; p < 0.001). Postfundoplication symptoms were infrequently recorded with no difference between the groups.

CONCLUSIONS

When performing a laparoscopic partial fundoplication, the posterior modification (Toupét) offers advantages in terms of better reflux control compared with an anterior type (Watson).

Surgical and endoscopic treatment of gastroesophageal reflux disease

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.