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Velanovich V. Practice-Changing Milestones in Anti-reflux and Hiatal Hernia Surgery: a Single Surgeon Perspective over 27 years and 1200 Operations. J Gastrointest Surg 2021; 25:2757-2769. [PMID: 33532979 DOI: 10.1007/s11605-021-04940-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/18/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND There have been steady innovations in hiatal hernia and anti-reflux surgery. The purpose of this article is to provide a historical perspective on practice-changing innovations in the context a single surgeon experience's over a career. METHODS Patients undergoing anti-reflux surgery or hiatal hernia repair by a single surgeon from 12/1992 to 3/2020 were reviewed. DATA COLLECTED sex, age, hiatal hernia type, operation type, adjuncts used, and additional procedure performed during index operation. Superimposed on this experience are the practice-changing innovations that occurred over this timeframe. RESULTS During the time period, 1200 operations were performed. Distributions: Hernia type: I, 707 (58.9%); II-IV, 325 (27.1%); Recurrent/Failed, 168 (14.0%). Type of operation, including laparoscopic and open: Nissen fundoplication: 889 (74.1%); Toupet fundoplication: 162 (13.5%); Collis-Nissen/Toupet fundoplication: 44 (3.7%); hiatal hernia repair without fundoplication (laparoscopic and open): 38 (3.2%); endoluminal fundoplication: 35 (2.9%); hiatal hernia repair with Heller myotomy/ Dor fundoplication: 10 (0.8%); transthoracic Belsey Mark IV: 2 (0.2%); hiatal hernia repair with magnetic sphincter augmentation: 20 (1.7%). Mesh reinforcement: 185 (15.4%). Additional procedures, 210 (17.5%). During this time, these practice-changing innovations occurred: laparoscopic surgery, 48-h pH monitoring, high-resolution manometry, tailoring of fundoplication, energy sources for tissue division and hemostasis, pyloroplasty for symptomatic gastroparesis, the rise and fall of endoluminal therapies, mesh reinforcement, abandonment of short gastric vessel division, and magnetic sphincter augmentation. CONCLUSIONS Over the last 27 years, a number of practice-changing advances have been made. These have led to changes in technique and operation selection of anti-reflux and hiatal hernia surgery.
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Affiliation(s)
- Vic Velanovich
- Division of General Surgery, The University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.
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2
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Nikolic M, Matic A, Kristo I, Paireder M, Asari R, Osmokrovic B, Semmler G, Schoppmann SF. Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up. Surg Endosc 2021; 36:3019-3027. [PMID: 34159461 PMCID: PMC9001554 DOI: 10.1007/s00464-021-08598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 06/06/2021] [Indexed: 01/19/2023]
Abstract
Background Various technical modifications of Nissen fundoplication (NF) that aim to improve patients’ outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF. Methods 283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed. Results Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively. Conclusion Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF.
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Affiliation(s)
- Milena Nikolic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Aleksa Matic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Matthias Paireder
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Reza Asari
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bogdan Osmokrovic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Semmler
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sebastian F Schoppmann
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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McKinley SK, Dirks RC, Walsh D, Hollands C, Arthur LE, Rodriguez N, Jhang J, Abou-Setta A, Pryor A, Stefanidis D, Slater BJ. Surgical treatment of GERD: systematic review and meta-analysis. Surg Endosc 2021; 35:4095-4123. [PMID: 33651167 DOI: 10.1007/s00464-021-08358-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients. METHODS PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale. RESULTS From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference = - 0.51, 95%CI - 0.63, - 0.40, I2 = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I2 = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I2 = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I2 = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I2 = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67). CONCLUSIONS The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.
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Affiliation(s)
| | - Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Danielle Walsh
- Walsh - Department of Surgery, East Carolina University, Greenville, USA
| | - Celeste Hollands
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Lauren E Arthur
- Walsh - Department of Surgery, East Carolina University, Greenville, USA
| | - Noe Rodriguez
- Department of Surgery, Florida Atlantic University, Boca Raton, USA
| | - Joyce Jhang
- University of Nebraska Medical Center, Omaha, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Aurora Pryor
- Department of Surgery, Stony Brook University, Stony Brook, USA
| | | | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA.
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Renzi A, Di Sarno G, d'Aniello F, Brillantino A, Minieri G, Coretti G, Barbato D, Barone G. Complete Fundus Mobilization Reduces Dysphagia After Nissen Procedure. Surg Innov 2020; 28:272-283. [PMID: 33236675 DOI: 10.1177/1553350620971174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Anti-reflux surgery is an effective treatment for gastroesophageal reflux disease (GERD). Nevertheless, surgery is still indicated with great caution in relation to the risk of complications, and in particular to postoperative dysphagia (PD). Objective. To compare the clinical outcomes, with particular focus on the incidence and severity of PD, of laparoscopic Nissen-Rossetti fundoplication (NRF) and floppy Nissen fundoplication (FNF) with complete fundus mobilization, in the surgical treatment of GERD. Methods. Ninety patients with GERD were enrolled. Forty-four patients (21[47.7%] men, 23[52.2%] women; mean age 42.4 ± 14.3 years) underwent NRF (Group A), and 46 patients (23[50%] men, 23[50%] women; mean age 43.3 ± 15.4 years) received laparoscopic FNF with complete fundus mobilization (Group B). Clinical assessment was performed using a structured questionnaire and SF-36 quality of life (QoL) score. PD was assessed using a validated classification, and an overall outcome was also determined by asking the patient to score it. Results. At 24-month follow-up, 38 (88.3%) patients in Group A vs 39 (86.6%) in Group B reported to be completely satisfied with reflux relief and free of protonic pump inhibitors (PPIs), while 3 (6.9%) in Group A vs 2(4.4%) in Group B reported occasional PPI intake and 2(4.6%) in Group A vs 4(8.8%) in Group B needed regular PPI use. Persistent PD was observed in 8(18.6%) patients in Group A and in 2(4.4%) in Group B (P = .03). No significant differences were found in the QoL score and in the overall outcome perceived by the patients. Conclusion. FNF, with complete fundus mobilization, appears to be associated with a lower rate of postoperative persistent dysphagia.
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Affiliation(s)
- Adolfo Renzi
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | | | | | | | - Gianluca Minieri
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Guido Coretti
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Domenico Barbato
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Gianni Barone
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
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5
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Bjelović M, Harsányi L, Altorjay Á, Kincses Z, Forsell P. Non-active implantable device treating acid reflux with a new dynamic treatment approach: 1-year results : RefluxStop™ device; a new method in acid reflux surgery obtaining CE mark. BMC Surg 2020; 20:159. [PMID: 32689979 PMCID: PMC7370422 DOI: 10.1186/s12893-020-00794-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/09/2020] [Indexed: 01/29/2023] Open
Abstract
Background RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected. Methods In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction. Results There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects. Conclusion The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced. Trial registration ClinicalTrials.gov, NCT02759094. Registered 3 May, 2016,
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Affiliation(s)
- Miloš Bjelović
- Department for Minimally Invasive Upper Digestive Surgery, University Hospital for Digestive Surgery - First Surgical Hospital, Clinical Center of Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia.
| | - László Harsányi
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Áron Altorjay
- Surgical Department, Fejér County Szent György University Teaching Hospital, Székesfehérvár, Hungary
| | - Zsolt Kincses
- General Surgery Department, University of Debrecen Kenézy Gyula Teaching Hospital, Debrecen, Hungary
| | - Peter Forsell
- Inventor of RefluxStop™, Seehof 4b, 6072, Sachseln, Switzerland
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6
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Schietroma M, Colozzi S, Romano L, Pessia B, Giuliani A, Vicentini V, Recchia CL, Carlei F. Short- and long-term results after laparoscopic floppy Nissen fundoplication in elderly versus non-elderly patients. J Minim Access Surg 2020; 16:256-263. [PMID: 31031314 PMCID: PMC7440002 DOI: 10.4103/jmas.jmas_269_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Laparoscopic anti-reflux surgery could be of benefit in a subset of elderly patients with gastroesophageal reflux disease. However, there are few reports that have evaluated the long-term results. This study examined the effects of age on the short- and long-term (for at least 5 years) outcomes after laparoscopic Nissen fundoplication (LNF). Patients and Methods: Patients were divided into four groups as follows: young (18–49); adult (50–69); and elderly (70–84), and very elderly (85–91). The database (recorded prospectively) included operating duration, conversion, intra- and early post-operative complication and late outcomes. Mean follow-up was 14.5 years (range 5–24 years). Results: Five hundred and sixty-nine patients met the inclusion criteria: young n = 219 (38.4%); adult n = 248 (43.5%); elderly n = 91 (16.0%) and very elderly n = 11 (1.9%). Hiatal hernia (type I and III) was significantly less frequent in young and adult patients (P < 0.0001). The operation was significantly longer in elderly and very elderly patients (P < 0.001); the use of drains (P < 0.001) and grafts (P < 0.0001) for hiatal hernia repair was less in young and adult patients. The hospital stay, conversion (5.4%), intra-operative and early post-operative complications were not influenced by age. Dysphagia was evenly distributed among the groups. Forty-eight (8.4%) patients had recurrence: 15 in the young group (6.8%), 18 in the adult group (7.2%), 11 in the elderly group (12%) and 4 in the very elderly group (36.3%) (P < 0.0001). Conclusions: Age does not influence short- and long-term outcomes following LNF. Control of reflux in the elderly is worse than adult patients. Therefore, ageing is a relative contraindication to LNF.
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Affiliation(s)
| | - Sara Colozzi
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | - Lucia Romano
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | - Beatrice Pessia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
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Bramhall SR, Mourad MM. Wrap choice during fundoplication. World J Gastroenterol 2019; 25:6876-6879. [PMID: 31908391 PMCID: PMC6938727 DOI: 10.3748/wjg.v25.i48.6876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/03/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Gastro-oesphageal reflux disease is an increasing health burden. The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication. The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications. These complications include "gas bloat" and dysphagia and can occur relatively frequently. Various modifications have been described to the original operation and some of these have been described. In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use. This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique. The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms. The advantages and disadvantages of an anterior wrap are discussed. The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.
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Affiliation(s)
- Simon R Bramhall
- Department of Surgery, The County Hospital, Hereford HR1 2ER, United Kingdom
| | - Moustafa M Mourad
- Department of Surgery, Worcester Royal Infirmary, Worcester WR5 1DD, United Kingdom
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Pérez Lara FJ, Hernández Gonzalez JM, Doblas Fernández J, Corrales Valero E, Oehling de Los Reyes H. Prospective Study of Lactose Intolerance as a Potential Cause of Gas Bloat Syndrome in Patients Treated Surgically for Gastroesophageal Reflux. Surg Innov 2019; 27:160-164. [PMID: 31854238 DOI: 10.1177/1553350619891351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction. The high incidence of lactose intolerance leads us to consider that many of our patients could suffer from this alteration. Therefore, as its main sign (even when asymptomatic) is increased intestinal gas, patients recovering from a Nissen fundoplication have a significant probability of suffering from gas bloat syndrome. Materials and Methods. This prospective study was conducted from November 2012 to January 2017, we included all the patients who had been treated by the Nissen technique for gastroesophageal reflux disease with gas bloat syndrome detected during follow-up and tested positive for lactose intolerance. The study participants were then prescribed a lactose-poor diet to be followed for 3 months. The patients were asked to complete quality of life and symptomatology questionnaires before and after diet. The pre- and post-diet results were then compared. Results. The pre- and post-diet results showed statistically significant improvements in both questionnaires. Conclusion. Lactose intolerance may account for the symptoms presented by a significant number of patients with gas bloat syndrome following antireflux surgery; these patients could benefit from consuming a lactose-free diet, which we expect to alleviate or, in some cases, eliminate the above symptoms.
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Campanello M, Westin E, Unosson J, Lindskog S. Quality of life and gastric acid‐suppression medication 20 years after laparoscopic fundoplication. ANZ J Surg 2019; 90:76-80. [DOI: 10.1111/ans.15471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Magnus Campanello
- Department of SurgeryHalland Hospital Varberg Region Halland Sweden
- Department of SurgeryInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg Gothenburg Sweden
| | - Erik Westin
- Department of SurgeryHalland Hospital Varberg Region Halland Sweden
- Department of SurgeryInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg Gothenburg Sweden
| | - Jon Unosson
- Department of General SurgeryUppsala University Hospital Uppsala Sweden
| | - Stefan Lindskog
- Department of SurgeryHalland Hospital Varberg Region Halland Sweden
- Department of SurgeryInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg Gothenburg Sweden
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10
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Randomized Trial of Division Versus Nondivision of Short Gastric Vessels During Nissen Fundoplication: 20-Year Outcomes. Ann Surg 2019; 268:228-232. [PMID: 29303805 DOI: 10.1097/sla.0000000000002648] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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11
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Csendes A, Orellana O, Cuneo N, Martínez G, Figueroa M. Long-term (15-year) objective evaluation of 150 patients after laparoscopic Nissen fundoplication. Surgery 2019; 166:886-894. [PMID: 31227185 DOI: 10.1016/j.surg.2019.04.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/01/2019] [Accepted: 04/23/2019] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Laparoscopic Nissen fundoplication is the preferred operative treatment for patients with gastroesophageal reflux disease. The most recent published results only refer to clinical evaluations and few discuss objective measurements. Our purpose was to determine the late results of laparoscopic Nissen fundoplication, performing clinical, endoscopic, histologic, and functional studies. MATERIAL AND METHODS A total of 179 patients were included in a prospective study. All had gastroesophageal reflux disease symptoms of at least 5-year duration, daily dependence on proton pump inhibitors, and a type I hiatal hernia less than 5 cm. Exclusion criteria included Barrett's esophagus, hiatal hernia >5 cm, failed antireflux surgery, and obesity (body mass index >30). We performed a radiologic study, 3 or more endoscopic procedures with biopsy samples of the antrum and esophagogastric junction, esophageal manometry, and 24-hour pH monitoring. RESULTS We found that 4 patients (2.2%) died 3-4 years after operation from nonoperatiove reasons. A total of 25 patients (14%) were lost to follow-up, and 150 patients (83.8%) submitted to late objective evaluations (15 years). Visick I-II symptoms were observed in 79.3% and III-IV (failures) in 20.7%. Endoscopy showed a normal positioning of the esophagogastric junction in the Visick I-II patients and a type III cardia or hiatal hernia with erosive esophagitis in Visick III-IV patients. Short-segment Barrett's esophagus developed in 5.3% of patients. Lower esophageal sphincter pressure remained increased over the preoperative value in all groups. The 24-hour pH monitoring also was decreased over the preoperative value in Visick I-II patients but showed no significant change in Visick III-IV patients. Carditis at the esophagogastric junction regressed to fundic mucosa in 50% of Visick I-II patients. CONCLUSION Laparoscopic Nissen fundoplication produces control of symptoms in 80% of patients late (up to 15 years) after surgeries corroborated by endoscopic, histologic examinations, and functional studies. It is essential to perform these objective evaluations to demonstrate the "antireflux effect" after laparoscopic Nissen fundoplication.
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Affiliation(s)
- Attila Csendes
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile.
| | - Omar Orellana
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
| | - Nicole Cuneo
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
| | - Gustavo Martínez
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
| | - Manuel Figueroa
- Department of Surgery, University Hospital, University of Chile, Santiago, Chile
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12
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Persistent dysphagia is a rare problem after laparoscopic Nissen fundoplication. Surg Endosc 2018; 33:1196-1205. [PMID: 30171395 PMCID: PMC6430753 DOI: 10.1007/s00464-018-6396-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 08/20/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although around 30% of patients with gastroesophageal reflux disease (GERD) are insufficiently treated with medical therapy, only 1% opt for surgical therapy. One of the reasons behind this multifactorial phenomenon is the described adverse effect of long-term dysphagia or gastric bloating syndrome after surgical treatment. Aim of this study was to evaluate the most common side effects associated with anti-reflux surgery, as well as long-term outcomes in a large cohort of highly surgically standardized patients after laparoscopic Nissen fundoplication (LNF). METHODS Out of a prospective patients' database including all patients that underwent anti-reflux surgery between 01/2003 and 01/2017 at our institution, 350 consecutive patients after highly standardized LNF were included in this study. A standardized interview was performed by one physician assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD-Health-Related-Quality-of-Life (GERD-HRQL), Alimentary Satisfaction (AS), and patients' overall satisfaction. RESULTS After a median follow-up of 4 years, persistent dysphagia (PD) after LNF was observed in 8 (2%) patients, while postoperative gas-bloat syndrome in 45 (12.7%) cases. Endoscopic dilatation was needed in 7 (2%) patients due to dysphagia, and 19 (5%) patients underwent revision surgery due to recurrence of GERD. The postoperative GERD-HRQL total score was significantly reduced (2 (IQR 0-4.3) vs. 19 (IQR 17-32); p < 0.000) and the median AS was 9/10. Heartburn relief was achieved in 83% of patients. Eighty-three percent of patients were free of PPI intake after follow-up, whereas 13% and 4% of the patients reported daily and irregular PPI use, respectively. CONCLUSION LNF is a safe and effective surgical procedure with low postoperative morbidity rates and efficient GERD-related symptom relief. PD does not represent a relevant clinical issue when LNF is performed in a surgical standardized way. These results should be the benchmark to which long-term outcomes of new surgical anti-reflux procedures are compared.
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Richter JE, Kumar A, Lipka S, Miladinovic B, Velanovich V. Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis. Gastroenterology 2018; 154:1298-1308.e7. [PMID: 29305934 DOI: 10.1053/j.gastro.2017.12.021] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The effects of transoral incisionless fundoplication (TIF) and laparoscopic Nissen fundoplication (LNF) have been compared with those of proton pump inhibitors (PPIs) or a sham procedure in patients with gastroesophageal reflux disease (GERD), but there has been no direct comparison of TIF vs LNF. We performed a systematic review and network meta-analysis of randomized controlled trials to compare the relative efficacies of TIF vs LNF in patients with GERD. METHODS We searched publication databases and conference abstracts through May 10, 2017 for randomized controlled trials that compared the efficacy of TIF or LNF with that of a sham procedure or PPIs in patients with GERD. We performed a network meta-analysis using Bayesian methods under random-effects multiple treatment comparisons. We assessed ranking probability by surface under the cumulative ranking curve. RESULTS Our search identified 7 trials comprising 1128 patients. Surface under the cumulative ranking curve ranking indicated TIF had highest probability of increasing patients' health-related quality of life (0.96), followed by LNF (0.66), a sham procedure (0.35), and PPIs (0.042). LNF had the highest probability of increasing percent time at pH <4 (0.99), followed by PPIs (0.64), TIF (0.32), and the sham procedure (0.05). LNF also had the highest probability of increasing LES pressure (0.78), followed by TIF (0.72) and PPIs (0.01). Patients who underwent the sham procedure had the highest probability for persistent esophagitis (0.74), followed by those receiving TIF (0.69), LNF (0.38), and PPIs (0.19). Meta-regression showed a shorter follow-up time as a significant confounder for the outcome of health-related quality of life in studies of TIF. CONCLUSIONS In a systematic review and network meta-analysis of trials of patients with GERD, we found LNF to have the greatest ability to improve physiologic parameters of GERD, including increased LES pressure and decreased percent time pH <4. Although TIF produced the largest increase in health-related quality of life, this could be due to the shorter follow-up time of patients treated with TIF vs LNF or PPIs. TIF is a minimally invasive endoscopic procedure, yet based on evaluation of benefits vs risks, we do not recommend it as a long-term alternative to PPI or LNF treatment of GERD.
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Affiliation(s)
- Joel E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Morsani College of Medicine, Tampa, Florida.
| | - Ambuj Kumar
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Seth Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Branko Miladinovic
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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Gronnier C, Degrandi O, Collet D. Management of failure after surgery for gastro-esophageal reflux disease. J Visc Surg 2018; 155:127-139. [PMID: 29567339 DOI: 10.1016/j.jviscsurg.2018.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.
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Affiliation(s)
- C Gronnier
- Unité de chirurgie oeso-gastric et endocrinienne, service de chirurgie digestive, centre Magellan, centre hospitalier universitaire de Bordeaux, avenue de Magellan, 33600 Pessac, France; Faculté de médecine de Bordeaux, 33000 Bordeaux, France
| | - O Degrandi
- Unité de chirurgie oeso-gastric et endocrinienne, service de chirurgie digestive, centre Magellan, centre hospitalier universitaire de Bordeaux, avenue de Magellan, 33600 Pessac, France; Faculté de médecine de Bordeaux, 33000 Bordeaux, France
| | - D Collet
- Unité de chirurgie oeso-gastric et endocrinienne, service de chirurgie digestive, centre Magellan, centre hospitalier universitaire de Bordeaux, avenue de Magellan, 33600 Pessac, France; Faculté de médecine de Bordeaux, 33000 Bordeaux, France.
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Tog C, Liu DS, Lim HK, Stiven P, Thompson SK, Watson DI, Aly A. Risk factors for delayed gastric emptying following laparoscopic repair of very large hiatus hernias. BJS Open 2017; 1:75-83. [PMID: 29951609 PMCID: PMC5989959 DOI: 10.1002/bjs5.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 06/28/2017] [Indexed: 01/20/2023] Open
Abstract
Background Delayed gastric emptying can complicate surgery for hiatus hernia. The aim of this study was to quantify its incidence following laparoscopic repair of very large hiatus hernias, identify key risk factors for its occurrence and determine its impact on clinical outcomes. Methods Data collected from a randomized trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (more than 50 per cent of stomach in chest) were analysed retrospectively. Delayed gastric emptying was defined as endoscopic evidence of solid food in the stomach after fasting for 6 h at 6 months after surgery. Results Delayed gastric emptying occurred in 19 of 102 patients (18·6 per cent). In univariable analysis, type 2 paraoesophageal hernia (relative risk (RR) 3·15, 95 per cent c.i. 1·41 to 7·06), concurrent anterior and posterior hiatal repair (RR 2·66, 1·14 to 6·18), hernia sac excision (RR 4·85, 1·65 to 14·24), 270°/360° fundoplication (RR 3·64, 1·72 to 7·68), division of short gastric vessels (RR 6·82, 2·12 to 21·90) and revisional surgery (RR 3·69, 1·73 to 7·87) correlated with delayed gastric emptying. In multivariable analysis, division of short gastric vessels (RR 6·27, 1·85 to 21·26) and revisional surgery (RR 6·19, 1·32 to 28·96) were independently associated with delayed gastric emptying. Delayed gastric emptying correlated with adverse gastrointestinal symptomatology, including higher rates of bloating, nausea, vomiting and anorexia, as well as reduced patient satisfaction with the operation and recovery. Conclusion Delayed gastric emptying following large hiatus hernia repair is common and associated with adverse symptoms and reduced patient satisfaction. Division of short gastric vessels and revisional surgery were independently associated with its occurrence.
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Affiliation(s)
- C Tog
- Department of Surgery Austin Hospital Heidelberg Victoria Australia
| | - D S Liu
- Department of Surgery Austin Hospital Heidelberg Victoria Australia.,Division of Cancer Surgery Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | - H K Lim
- Department of Surgery Austin Hospital Heidelberg Victoria Australia
| | - P Stiven
- Department of Surgery Austin Hospital Heidelberg Victoria Australia
| | - S K Thompson
- University of Adelaide Discipline of Surgery Royal Adelaide Hospital Adelaide South Australia Australia
| | - D I Watson
- Flinders University Department of Surgery Flinders Medical Centre Bedford Park South Australia Australia
| | - A Aly
- Department of Surgery Austin Hospital Heidelberg Victoria Australia
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Schietroma M, Piccione F, Clementi M, Cecilia EM, Sista F, Pessia B, Carlei F, Guadagni S, Amicucci G. Short- and Long-Term, 11-22 Years, Results after Laparoscopic Nissen Fundoplication in Obese versus Nonobese Patients. J Obes 2017; 2017:7589408. [PMID: 28584666 PMCID: PMC5444001 DOI: 10.1155/2017/7589408] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/10/2017] [Accepted: 04/23/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Some studies suggest that obesity is associated with a poor outcome after Laparoscopic Nissen Fundoplication (LNF), whereas others have not replicated these findings. The effect of body mass index (BMI) on the short- and long-term results of LNF is investigated. METHODS Inclusion criteria were only patients who undergone a LNF with at least 11-year follow-up data available, patients with preoperative weight and height data available for calculation of BMI (Kg/m2), and patients with a BMI up to a maximum of 34.9. RESULTS 201 patients met the inclusion criteria: 43 (21.4%) had a normal BMI, 89 (44.2%) were overweight, and 69 (34.4%) were obese. The operation was significantly longer in obese patients; the use of drains and graft was less in the normal BMI group (p < 0.0001). The hospital stay, conversion (6,4%), and intraoperative and early postoperative complications were not influenced by BMI. CONCLUSIONS BMI does not influence short-term outcomes following LNF, but long-term control of reflux in obese patients is worse than in normal weight subjects.
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Affiliation(s)
| | - Federica Piccione
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
- *Federica Piccione:
| | - Marco Clementi
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | | | - Federico Sista
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | - Beatrice Pessia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
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Radiofrequency energy delivery to the lower esophageal sphincter improves gastroesophageal reflux patient-reported outcomes in failed laparoscopic Nissen fundoplication cohort. Surg Endosc 2016; 31:2854-2862. [DOI: 10.1007/s00464-016-5296-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/14/2016] [Indexed: 12/26/2022]
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18
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Could a poor outcome of gastro-oesophageal reflux surgery be related to lactase deficiency? Esophagus 2016. [DOI: 10.1007/s10388-015-0512-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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19
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Koetje JH, Nieuwenhuijs VB, Irvine T, Mayne GC, Watson DI. Measuring Outcomes of Laparoscopic Anti-reflux Surgery: Quality of Life Versus Symptom Scores? World J Surg 2016; 40:1137-44. [DOI: 10.1007/s00268-015-3394-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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BONADIMAN A, TEIXEIRA ACP, GOLDENBERG A, FARAH JFDM. DYSPHAGIA AFTER LAPAROSCOPIC TOTAL FUNDOPLICATION: anterior or posterior gastric wall fundoplication? ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:113-7. [DOI: 10.1590/s0004-28032014000200008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 03/06/2014] [Indexed: 01/27/2023]
Abstract
ContextThe occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease.ObjectivesCompare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF).MethodsAnalysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF – n = 160) and Group 2 (Nissen LTF – n = 129).ResultsThe overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF.ConclusionsThe overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.
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Affiliation(s)
- Adorísio BONADIMAN
- Instituto de Assistência Médica ao Servidor Público - HSPE-IAMSPE, Brasil
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21
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Kellokumpu I, Voutilainen M, Haglund C, Färkkilä M, Roberts PJ, Kautiainen H. Quality of life following laparoscopic Nissen fundoplication: Assessing short-term and long-term outcomes. World J Gastroenterol 2013; 19:3810-3818. [PMID: 23840119 PMCID: PMC3699043 DOI: 10.3748/wjg.v19.i24.3810] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/22/2013] [Accepted: 04/10/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the quality of life following laparoscopic Nissen fundoplication by assessing short-term and long-term outcomes.
METHODS: From 1992 to 2005, 249 patients underwent laparoscopic Nissen fundoplication. Short-term outcome data including symptom response, side effects of surgery, endoscopy, and patient’s perception of overall success were collected prospectively. Long-term outcomes were investigated retrospectively in patients with a median follow-up of 10 years by assessment of reflux symptoms, side effects of surgery, durability of antireflux surgery, need for additional treatment, patient’s perception of success, and quality of life. Antireflux surgery was considered a failure based on the following criteria: moderate to severe heartburn or regurgitation; moderate to severe dysphagia reported in combination with heartburn or regurgitation; regular proton pump inhibitor medication use; endoscopic evidence of erosive esophagitis Savary-Miller grade 1-4; pathological 24-h pH monitoring; or necessity to undergo an additional surgery. The main outcome measures were short- and long-term cure rates and quality of life, with patient satisfaction as a secondary outcome measure.
RESULTS: Conversion from laparoscopy to open surgery was necessary in 2.4% of patients. Mortality was zero and the 30-d morbidity was 7.6% (95%CI: 4.7%-11.7%). The median postoperative hospital stay was 2 d [interquartile range (IQR) 2-3 d]. Two hundred and forty-seven patients were interviewed for short-term analysis following endoscopy. Gastroesophageal reflux disease was cured in 98.4% (95%CI: 95.9%-99.6%) of patients three months after surgery. New-onset dysphagia was encountered postoperatively in 13 patients (6.7%); 95% reported that the outcome was better after antireflux surgery than with preoperative medical treatment. One hundred and thirty-nine patients with a median follow-up of 10.2 years (IQR 7.2-11.6 years) were available for a long-term evaluation. Cumulative long-term cure rates were 87.7% (81.0%-92.2%) at 5 years and 72.9% (64.0%-79.9%) at 10 years. Gastrointestinal symptom rating scores and RAND-36 quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. Of the patients available for long-term follow-up, 83% rated their operation a success.
CONCLUSION: For the long-term, our results indicate decreasing effectiveness of laparoscopic antireflux surgery, although most of the patients seem to have an overall quality of life similar to that of the general population.
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22
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Beenen E, Fogarty P, Roberts RH. Predicting patient dissatisfaction following laparoscopic Nissen fundoplication: an analysis of symptoms. Surg Endosc 2012; 27:1579-86. [DOI: 10.1007/s00464-012-2630-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 09/25/2012] [Indexed: 01/04/2023]
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Engström C, Cai W, Irvine T, Devitt PG, Thompson SK, Game PA, Bessell JR, Jamieson GG, Watson DI. Twenty years of experience with laparoscopic antireflux surgery. Br J Surg 2012; 99:1415-21. [PMID: 22961522 DOI: 10.1002/bjs.8870] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND There are few reports of large patient cohorts with long-term follow-up after laparoscopic antireflux surgery. This study was undertaken to evaluate changes in surgical practice and outcomes for laparoscopic antireflux surgery over a 20-year period. METHODS A standardized questionnaire, prospectively applied annually, was used to determine outcome for all patients undergoing laparoscopic fundoplication in two centres since commencing this procedure in 1991. Visual analogue scales ranging from 0 to 10 were used to assess symptoms of heartburn, dysphagia and satisfaction with overall outcome. Data were analysed to determine outcome across 20 years. RESULTS From 1991 to 2010, 2261 consecutive patients underwent laparoscopic fundoplication at the authors' institutions. Follow-up ranged from 1 to 19 (mean 7.6) years. Conversion to open surgery occurred in 73 operations (3.2 per cent). Revisional surgery was performed in 216 patients (9.6 per cent), within 12 months of the original operation in 116. There was a shift from Nissen to partial fundoplication across 20 years, and a recent decline in operations for reflux, offset by an increase in surgery for large hiatus hernia. Dysphagia and satisfaction scores were stable, and heartburn scores rose slightly across 15 years of follow-up. Heartburn scores were slightly higher and reoperation for reflux was more common after anterior partial fundoplication (P = 0.005), whereas dysphagia scores were lower and reoperation for dysphagia was less common (P < 0.001). At 10 years, satisfaction with outcome was similar for all fundoplication types. CONCLUSION Laparoscopic Nissen and partial fundoplications proved to be durable and achieved good long-term outcomes. At earlier follow-up, dysphagia was less common but reflux more common after anterior partial fundoplication, although differences had largely disappeared by 10 years.
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Affiliation(s)
- C Engström
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Mickevičius A, Endzinas Ž, Kiudelis M, Jonaitis L, Kupčinskas L, Pundzius J, Maleckas A. Influence of wrap length on the effectiveness of Nissen and Toupet fundoplications: 5-year results of prospective, randomized study. Surg Endosc 2012; 27:986-91. [PMID: 23052526 DOI: 10.1007/s00464-012-2550-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 08/21/2012] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Antanas Mickevičius
- Surgery Department, Lithuanian University of Health Sciences, Eiveniu 2, Kaunas, Lithuania.
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Le K, Griner D, Hope WW, Tackett D. Splenic torsion requiring splenectomy six years following laparoscopic Nissen fundoplication. JSLS 2012; 16:184-8. [PMID: 22906354 PMCID: PMC3407447 DOI: 10.4293/108680812x13291597716861] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Laparoscopic Nissen fundoplication has become a mainstay in the surgical treatment of gastroesophageal reflux disease, as it has proved to be a durable, well-tolerated procedure. Despite the safety and efficacy associated with this procedure, surgeons performing this advanced laparoscopic surgery should be well versed in the potential intraoperative and postoperative complications. METHODS A case is presented of a rare complication of splenic torsion following laparoscopic Nissen fundoplication. Diagnostic evaluations and intraoperative findings are discussed. RESULTS We present an otherwise healthy 41-year-old woman who underwent a laparoscopic Nissen fundoplication 6 years earlier at another medical center and presented with worsening chronic left upper quadrant abdominal pain. She was diagnosed with torsion of the splenic vascular pedicle, resulting in heterogenicity of perfusion with associated hematoma requiring open splenectomy. CONCLUSION Surgeons should be aware of splenic torsion as a potential, albeit rare, complication related to laparoscopic Nissen fundoplication.
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Affiliation(s)
- Khoi Le
- South East Area Health Education Center, Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC, USA
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Outcome following management of dysphagia after laparoscopic anti-reflux surgery. World J Surg 2012; 36:838-43. [PMID: 22302282 DOI: 10.1007/s00268-011-1416-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Some patients develop troublesome dysphagia after laparoscopic antireflux surgery, and a proportion require further intervention. The management of this problem was evaluated. METHODS Patients who underwent intervention for dysphagia after laparoscopic fundoplication were identified from a database. Outcomes were prospectively determined from a standardized questionnaire that evaluated symptoms scores for dysphagia for solids and liquids, as well as patient satisfaction with the overall outcome. Outcomes 1 year after reintervention, and at the most recent follow-up were evaluated. RESULTS From 1994 to 2009, 121 (6.6%) of 1,821 patients who underwent laparoscopic fundoplication for gastroesophageal reflux also underwent endoscopic or surgical reintervention for dysphagia. Of these 121 patients, 56 underwent endoscopic dilatation, and 24 were satisfied with the outcome of dilatation; 18 progressed to surgery, and dysphagia persisted in 14 of them. Overall, 83 patients underwent revisional surgery, and 47 (62.7%) were satisfied with the outcome. Compared to patients who did not undergo any intervention for dysphagia, patients who underwent reintervention had lower satisfaction scores and higher dysphagia scores. CONCLUSIONS Approximately two thirds of patients with troublesome post-fundoplication dysphagia have a satisfactory outcome following either endoscopic dilatation or revisional surgery. However, approximately one third continue to be troubled by symptoms, despite further intervention.
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Khatri K, Sajid MS, Brodrick R, Baig MK, Sayegh M, Singh KK. Laparoscopic Nissen fundoplication with or without short gastric vessel division: a meta-analysis. Surg Endosc 2011; 26:970-8. [PMID: 22042586 DOI: 10.1007/s00464-011-1979-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 09/26/2011] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The aim of this work is to systematically analyse the prospective randomised controlled trials on laparoscopic Nissen fundoplication (LNF) with and without short gastric vessel division (SGVD) for management of gastro-oesophageal reflux disease (GORD). METHODS After an extensive literature search, all previous trials on laparoscopic Nissen fundoplication with and without SGVD for management of GORD were assessed. Those meeting study quality criteria were analysed to generate summative data expressed by standardised mean difference (SMD) and risk ratio (RR). RESULTS Five randomised controlled trials on 388 patients qualified for the meta-analysis. There were 194 patients in the no-SGVD group and 194 patients in the SGVD group. No-SGVD was associated with shorter operative time and length of stay. In both fixed- and random-effects models, there were no statistically significant differences in laparoscopic to open conversion rate or complications between the two groups. Three trials presented data on 1-year follow-up, with 118 patients in the no-SGVD group and 112 patients in the SGVD group. There was no statistically significant difference in heartburn, dysphagia, regurgitation or gas bloat syndrome between these two groups. Two trials presented data on 10-year follow-up, with 84 patients in the no-SGVD group and 86 patients in the SGVD group. There was no significant difference in heartburn, dysphagia, regurgitation or gas bloat syndrome between these two groups either. There was no heterogeneity between trials. CONCLUSIONS Based on this review, SGVD in LNF is associated with longer operative time and hospital stay. However, there is no difference in terms of functional outcomes for 1- and 10-year follow-up. Routine use of SGVD may therefore not be necessary in LNF.
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Affiliation(s)
- Kamran Khatri
- Department of Surgery, Worthing Hospital, Washington Suite, North Wing, Worthing, West Sussex, BN11 2DH, UK.
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Abstract
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.
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Affiliation(s)
- Bernard Dallemagne
- Department of Digestive and Endocrine Surgery, and Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD), University Hospital of Strasbourg, IRCAD-EITS, 1 Place de l'Hôpital, 67091, Strasbourg, France.
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Engström C, Jamieson GG, Devitt PG, Watson DI. Meta-analysis of two randomized controlled trials to identify long-term symptoms after division of the short gastric vessels during Nissen fundoplication. Br J Surg 2011; 98:1063-7. [PMID: 21618497 DOI: 10.1002/bjs.7563] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2011] [Indexed: 01/27/2023]
Abstract
BACKGROUND Randomized trials suggest that division of the short gastric vessels during Nissen fundoplication is unnecessary. Some trials report an increased risk of gas bloat symptoms following division of the short gastric vessels. In this study long-term follow-up data from the two largest randomized clinical trials of division versus no division of the short gastric vessels during laparoscopic Nissen fundoplication were combined to determine whether there were differences in late outcome. METHODS Patients with gastro-oesophageal reflux disease who underwent primary laparoscopic antireflux surgery and were included in two previously reported randomized trials were studied. Of 99 patients enrolled in the Swedish study and 102 in the Australian study, the short gastric vessels were divided in 104 and left intact in 97. Data sets were combined and late clinical outcomes analysed. RESULTS At 10-12 years' follow-up (mean 11.5 years) clinical data were obtained from 170 patients (86 with vessels divided, 84 undivided). Statistical analysis of the combined data set showed no significant differences in symptoms of heartburn or dysphagia, ability to belch or vomit, and use of antisecretory medications. Division of the short gastric vessels was associated with a higher rate of bloating symptoms (72 versus 48 per cent; P = 0.002). CONCLUSION Division of the short gastric vessels is followed by a slightly poorer clinical outcome at late follow-up after Nissen fundoplication. Surgeons should avoid dividing these vessels when undertaking a laparoscopic Nissen fundoplication.
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Affiliation(s)
- C Engström
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden.
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Markar SR, Karthikesalingam AP, Wagner OJ, Jackson D, Hewes JC, Vyas S, Hashemi M. Systematic review and meta-analysis of laparoscopic Nissen fundoplication with or without division of the short gastric vessels. Br J Surg 2011; 98:1056-62. [PMID: 21560121 DOI: 10.1002/bjs.7519] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this meta-analysis was to provide a pooled analysis of individual trials comparing clinical outcome following laparoscopic Nissen fundoplication with or without division of the short gastric vessels (SGVs). METHODS Primary outcome measures were the requirement for reoperation, and the presence of postoperative gastro-oesophageal reflux and postoperative dysphagia. Secondary outcome measures were duration of operation, length of hospital stay, postoperative complications (within 30 days of surgery), postoperative gas bloat syndrome, lower oesophageal sphincter resting pressure and DeMeester score. Pooled odds ratios were calculated for categorical outcomes, and weighted mean differences for secondary continuous outcomes, using random-effects models for meta-analysis. RESULTS Five randomized trials were included in the analysis. There was no statistically significant effect on the requirement for reoperation, or presence of postoperative dysphagia or reflux. SGV division was associated with a longer duration of operation and a reduced postoperative lower oesophageal sphincter pressure. There was no statistically significant difference in length of hospital stay, postoperative complications, postoperative gas bloat syndrome or DeMeester score. CONCLUSION This meta-analysis has demonstrated that clinical outcome following laparoscopic Nissen fundoplication appears to be similar regardless of whether the short gastric vessels are divided. However, it is not possible to exclude many potentially important clinical differences and further studies are needed.
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Affiliation(s)
- S R Markar
- Department of General Surgery, University College London Hospitals NHS Foundation Trust, London, UK
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Davis CS, Baldea A, Johns JR, Joehl RJ, Fisichella PM. The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease. JSLS 2011; 14:332-41. [PMID: 21333184 PMCID: PMC3041027 DOI: 10.4293/108680810x12924466007007] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND For nearly 2 decades, the laparoscopic correction of gastroesophageal reflux disease (GERD) has demonstrated its utility. However, the surgical technique has evolved over time, with mixed long-term results. We briefly review the evolution of antireflux surgery for the treatment of GERD, provide an update specific to the long-term efficacy of laparoscopic antireflux surgery (LARS), and analyze the factors predictive of a desirable outcome. MATERIALS AND METHODS PubMed and Medline database searches were performed to identify articles regarding the laparoscopic treatment of GERD. Emphasis was placed on randomized control trials (RCTs) and reports with follow-up >1 year. Specific parameters addressed included operative technique, resolution of symptoms, complications, quality of life, division of short gastric vessels (SGVs), mesh repair, and approximation of the crura. Those studies specifically addressing follow-up of <1 year, the pediatric or elderly population, redo fundoplication, and repair of paraesophageal hernia and short esophagus were excluded. RESULTS LARS has varied in technical approach through the years. Not until recently have more long-term, objective studies become available to allow for evidenced-based appraisals. Our review of the literature found no long-term difference in the rates of heartburn, gas-bloat, antacid use, or patient satisfaction between laparoscopic Nissen and Toupet fundoplication. In addition, several studies have shown that more patients had an abnormal pH profile following laparoscopic partial as opposed to total fundoplication. Conversely, dysphagia was more common following laparoscopic total versus partial fundoplication in 50% of RCTs at 12-month follow-up, though this resolved over time, being present in only 20% with follow-up >24 months. We confirmed that preoperative factors, such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Last, no trial disfavored division of the short gastric vessels (SGVs), closure of the crura, or mesh repair for hiatal defects. CONCLUSION LARS has significantly evolved over time. The laparoscopic total fundoplication appears to provide more durable long-term results than the partial approach, as long as the technical elements of the operation are respected. Division of the SGVs, closure of the crura, and the use of mesh for large hiatal defects positively impacts long-term outcome. Hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting are potential predictors of failure in LARS.
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Affiliation(s)
- C S Davis
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
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Partial or total fundoplication (with or without division of the short gastric vessels): which is the best laparoscopic choice in GERD surgical treatment? Surg Laparosc Endosc Percutan Tech 2011; 20:371-7. [PMID: 21150412 DOI: 10.1097/sle.0b013e3181fd6990] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) has emerged as one of the most common diseases in the modern civilization.The immense success of laparoscopic surgery as an effective treatment of GERD has established the minimally invasive surgery as the gold standard for this condition with lower morbidity and mortality, shorter hospital stay, faster recovery, and reduced postoperative pain. METHODS Articles were sourced from PubMed and Medline, using the MeSH terms "gastroesophageal reflux disease" and "laparoscopic surgery" and "fundoplication technique." The selection of articles was based on peer review, journal, relevance, and English language. RESULTS AND CONCLUSIONS There are some controversies with regard to the technique. First, whether total or partial fundoplication is the more appropriate treatment for GERD; second, if a total fundoplication (360 degrees) is performed, what is the effect of fundic mobilization and the division of short gastric vessels. In this review article the authors evaluate the most recent articles to establish the parameters for a "gold standard technique" in antireflux surgery.
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Garlos Manterola D. Cómo evaluar e interpretar un artículo de terapia. REVISTA MÉDICA CLÍNICA LAS CONDES 2011. [DOI: 10.1016/s0716-8640(11)70402-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:2647-69. [PMID: 20725747 DOI: 10.1007/s00464-010-1267-8] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Zingg U, Rosella L, Guller U. Population-based trend analysis of laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease. Surg Endosc 2010; 24:3080-5. [PMID: 20464418 DOI: 10.1007/s00464-010-1093-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 04/06/2010] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Nissen and Toupet fundoplications are the most commonly used techniques for surgical treatment of gastroesophageal reflux disease. To date, no population-based trend analysis has been reported examining the choice of procedure and short-term outcomes. This study was designed to analyze trends in the use of Nissen versus Toupet fundoplications, and corresponding short-term outcomes during a 10-year period between 1995 and 2004. METHODS A trend analysis was performed of 873 patients (Toupet: 254 patients, Nissen: 619 patients) prospectively enrolled in the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery. RESULTS The frequency of the performed techniques remained stable during the observation period (p value for trend 0.206). The average postoperative and total length of hospital stay both significantly decreased during the 10-year period from 5.6 to 4.0 days and 6.8 to 4.8 days, respectively (both p values for trend <0.001). The average duration of surgery decreased significantly from 141 minutes to 121 minutes (p value for trend <0.001). There was a trend towards less complications in later years (2000-2004) compared to early years (1995-1999, p = 0.058). Conversion rates were significantly lower in later years compared with early years (p = 0.004). CONCLUSIONS This is the first trend analysis in the literature reporting clinical outcomes of 873 prospectively enrolled patients undergoing Nissen and Toupet fundoplications during a 10-year period. The proportion of laparoscopic Nissen versus Toupet fundoplications remained stable over time, indicating that literature reports of the advantages of one procedure over the other had minimal influence on surgeons' choice of technique. Length of hospital stay, duration of surgery, morbidity, and conversion rate decreased over time, reflecting the learning curve. Clearly, patient outcomes have much improved during the 10-year observation period.
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Affiliation(s)
- U Zingg
- Department of Surgery, University Hospital Basel, 4031, Basel, Switzerland.
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Ten-year outcome of laparoscopic and conventional nissen fundoplication: randomized clinical trial. Ann Surg 2009; 250:698-706. [PMID: 19801931 DOI: 10.1097/sla.0b013e3181bcdaa7] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare 10 years outcome of a multicenter randomized controlled trial on laparoscopic (LNF) and conventional Nissen fundoplication (CNF), with focus on effectiveness and reoperation rate. SUMMARY OF BACKGROUND DATA LNF has replaced CNF as surgical treatment for gastroesophageal reflux disease (GERD). Decisions are based on equal short-term effectiveness and reduced morbidity, but confirmation by long-term level 1 evidence is lacking. METHODS From 1997 to 1999, 177 proton pump inhibitor (PPI)-refractory GERD patients were randomized to undergo LNF or CNF. The 10 years results of surgery on reflux symptoms, general health, PPI use, and reoperation rates, are described. High-resolution manometry, 24-hour pH-impedance monitoring and barium swallow were performed in symptomatic patients only. RESULTS A total of 148 patients (79 LNF, 69 CNF) participated in this 10-year follow-up study. GERD symptoms were relieved in 92.4% and 90.7% (NS) after LNF and CNF, respectively. Severity of heartburn and dysphagia were similar, but slightly more patients had relief of regurgitation after LNF (98.7% vs. 91.0%; P = 0.030). The percentage of patients using PPIs slowly increased with time in both groups to 26.6% for LNF and 22.4% for CNF (NS). General health (74.7% vs. 72.7%; NS) and quality of life (visual analogue scale score: 65.3 vs. 61.4; NS) improved similarly in both groups. The percentage of patients who would have opted for surgery again was similar as well (78.5% vs. 72.7%; NS). Twice as many patients underwent reoperation after CNF compared with LNF (12 [15.2%] vs. 24 [34.8%]; P = 0.006), including a higher number of incisional hernia corrections (2 vs. 9; P = 0.015). Mean interval between operation and reintervention was longer after CNF (22.9 vs. 50.6 months; P = 0.047). Of the patients who were dependent on daily PPI therapy at 10 years (LNF 10, CNF 10), 7 patients (LNF 3, CNF 4) had recurrent GERD on pH-impedance monitoring, 5 of them with some form of anatomic recurrence. A total of 13 of 20 (65.0%) patients did not have recurrent GERD. Fourteen patients had an abnormal high-resolution manometry. CONCLUSIONS CNF carries a higher risk for surgical reintervention compared with LNF, mainly due to incisional hernia corrections. The 10-year effectiveness of LNF and CNF is comparable in terms of improvement of GERD symptoms, PPI use, quality of life, and objective reflux control. Consequently, the long-term results from this trial lend level 1 support to the use of LNF as the surgical procedure of choice for GERD.
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Abstract
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.
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Affiliation(s)
- P Salminen
- Department of Surgery, Turku University Central Hospital, Turku, Finland.
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Abstract
Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.
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Affiliation(s)
- David C Gotley
- Department of Surgery, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, Qld 4102, Australia.
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Shaw JM, Bornman PC, Callanan MD, Beckingham IJ, Metz DC. Long-term outcome of laparoscopic Nissen and laparoscopic Toupet fundoplication for gastroesophageal reflux disease: a prospective, randomized trial. Surg Endosc 2009; 24:924-32. [PMID: 19789920 DOI: 10.1007/s00464-009-0700-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 08/10/2009] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- John M Shaw
- Department of Surgery, J45 OMB, Health Sciences Faculty, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Watson DI, Lally CJ. Prevalence of symptoms and use of medication for gastroesophageal reflux in an Australian community. World J Surg 2009; 33:88-94. [PMID: 18949510 DOI: 10.1007/s00268-008-9780-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- David I Watson
- Department of Surgery, Flinders University, Room 3D211, Flinders Medical Centre, Bedford Park, SA, 5042, Australia.
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Oláh T. [Surgery of oesophagus]. Magy Seb 2009; 62:204-212. [PMID: 19679529 DOI: 10.1556/maseb.62.2009.4.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Tibor Oláh
- Kaposi Mór Oktató Kórház Altalános Sebészeti, Er- és Mellkassebészeti Osztály Siófok
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Jamieson GG. Contributions of Australian Surgeons to the Development of the Laparoscopic Upper Gastrointestinal Surgery Revolution: A Narrative. World J Surg 2009; 33:1581-3. [DOI: 10.1007/s00268-009-0085-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Szor DJ, Herbella FAM, Bonini AL, Moreno DG, Del Grande JC. Gastric fundus tension before and after division of the short gastric vessels in a cadaveric model of fundoplication. Dis Esophagus 2009; 22:539-42. [PMID: 19222530 DOI: 10.1111/j.1442-2050.2009.00945.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Short gastric vessels (SGV) division is a controversial topic in antireflux surgery. Some surgeons do not divide the SGV routinely to perform a fundoplication; however, excessive tension of the gastric fundus (GF) forces this procedure necessary in some cases. This study aims to evaluate in a cadaveric model of Nissen fundoplication: (i) the correlation of GF tension with anatomic parameters; and (ii) the effect of SGV division on GF tension. In total, 23 fresh cadavers (18 men, mean age 62 years) were studied. The abdominal esophagus was dissected, and the GF transposed to a limit of 3 cm to the right border of the esophagus. A dynamometer was attached to the GF and the tension recorded. Cadavers were grouped according to the presence or absence of tension. SGV were divided and GF tension measured again. The presence or absence of initial GF tension was correlated to: (i) number of SGV; (ii) length of the GF; (iii) distance between His angle and the first SGV; and (iv) size of the spleen. The mean GF pressure was 0.5 N +/- 1.0 (0-2.5) before SGV division and 0.1 N +/- 0.3 (0-1.5) after SGV division (P= 0.002). Initial tension was absent in 12 (52.2%) cases. GF tension did not correlate with any of the anatomic parameters. Our results show that: (i) GF tension does not correlate with anatomic parameters; and (ii) SGV division affects GF tension significantly.
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Affiliation(s)
- D J Szor
- Department of Surgery, Sao Paulo Medical School, Federal University of Sao Paulo, Brazil
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Division of the short gastric vessels during laparoscopic Nissen fundoplication: clinical and functional outcome during long-term follow-up in a prospectively randomized trial. Surg Endosc 2008; 23:2208-13. [PMID: 19082662 DOI: 10.1007/s00464-008-0267-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Revised: 10/23/2008] [Accepted: 11/21/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although the first laparoscopic Nissen fundoplication was performed almost two decades ago, division of the short gastric vessels is still controversially discussed. The aim of this prospectively randomized trial was to evaluate the clinical and functional outcome following laparoscopic Nissen fundoplication with division versus saving of the short gastric vessels during short- and long-term follow-up. METHODS Forty-one consecutive patients (30 men, 11 women) with gastroesophageal reflux disease were allocated to undergo Nissen fundoplication without division (group 1, n = 19) or with division (group 2, n = 22) of short gastric vessels. All patients were evaluated prior to and at 6 months as well as 5 years following fundoplication. Tests included endoscopy, barium swallow, 24-h pH monitoring, and esophageal manometry. Gastroesophageal reflux disease (GERD) symptoms were evaluated and a gastrointestinal quality-of-life index was calculated. RESULTS Preoperative symptoms such as heartburn (84/86%), regurgitation (79/86%), pulmonary symptoms (47/45%), dysphagia (11/32%), chest pain (16/9%), and globus sensation (21/27%) were seen in groups 1 and 2, respectively. In group 1 regurgitation and mild dysphagia were seen in 7 and 26% of patients, respectively, at 5 years. In group 2 the rate of dysphagia decreased from 32 to 17% during short-term follow-up, but increased thereafter to 18%. Reflux esophagitis (preoperative rates: group 1, 74%; group 2, 59%) disappeared in all patients after fundoplication. Mean operative time (group 1, 109 min versus group 2, 125 min; p < 0.05) and mean blood loss (group 1, not measurable; group 2, 25 ml; p < 0.05) showed statistically significant differences. DeMeester score improved in group 1 from 26.6 to 2.2 and in group 2 from 24.7 to 2.5 at 5-year follow-up (p = 0.02). Lower esophageal sphincter (LES) resting pressure returned to normal values (group 1, 23.9 mmHg; group 2, 24.6 mmHg; p < 0.007) with regular relaxation. Quality-of-life index was high in both cohorts, without statistically significant differences between the two groups. CONCLUSION Routine division of the short gastric vessels during Nissen fundoplication in the followed patient group yields neither functional nor clinical advantages in short- or long-term follow-up.
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Ross SB, Villadolid D, Paul H, Al-Saadi S, Gonzalez J, Cowgill SM, Rosemurgy A. Laparoscopic Nissen Fundoplication Ameliorates Symptoms of Reflux, Especially for Patients with Very Abnormal DeMeester Scores. Am Surg 2008. [DOI: 10.1177/000313480807400711] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intuitively, more severe acid reflux causes more severe symptoms. This study was undertaken to correlate preoperative DeMeester scores with symptoms before and after laparoscopic Nissen fundoplication. Before fundoplication, all patients with gastroesophageal reflux disease underwent 24 to 48 hour pH testing. Before and after fundoplication, the frequency and severity of reflux symptoms were scored using a Likert scale. Four hundred and eighty-one patients underwent fundoplication and were followed for a mean of 32 months. The preoperative median DeMeester score was 41 (range 14.8 to 361.5). Before fundoplication, DeMeester scores correlated with severity of gastroesophageal reflux disease symptoms (Spearman regression analysis, P < 0.05 for all). Postoperatively, all symptom scores improved (Wilcoxon matched pairs test, P < 0.05 for all). After fundoplication, preoperative DeMeester scores did not correlate with the frequency or severity of symptoms. For patients with excessive acid reflux, reflux severity impacts the frequency and severity of symptoms before fundoplication. Laparoscopic Nissen fundoplication improves the frequency and severity of all reflux symptoms. The severity of preoperative reflux does not impact the frequency or severity of symptoms after fundoplication. Relief of excessive acid reflux, regardless of severity or degree ( i.e., DeMeester scores), ameliorates symptoms of acid reflux thereby encouraging fundoplication, especially for patients with very abnormal DeMeester scores.
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Affiliation(s)
- Sharona B. Ross
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Desiree Villadolid
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Harold Paul
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sam Al-Saadi
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Javier Gonzalez
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sarah M. Cowgill
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Alexander Rosemurgy
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
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Scientific Surgery. Br J Surg 2008. [DOI: 10.1002/bjs.6228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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