Objective outcomes 14 years after laparoscopic anterior 180-degree partial versus nissen fundoplication: results from a randomized trial. Ann Surg. 2013;258:233-239. [PMID: 23207247 DOI: 10.1097/sla.0b013e318278960e]

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

Laparoscopic total fundoplication is currently considered the gold standard for the surgical treatment of gastroesophageal reflux disease. Short-term outcomes after laparoscopic total fundoplication are excellent, with fast recovery and minimal perioperative morbidity. The symptom relief and reflux control are achieved in about 80 to 90% of patients 10 years after surgery. However, a small but clinically relevant incidence of postoperative dysphagia and gas-related symptoms is reported. Debate still exists about the best antireflux operation; during the last three decades, the surgical outcome of laparoscopic partial fundoplication (anterior or posterior) were compared to those achieved after a laparoscopic total fundoplication. The laparoscopic partial fundoplication, either anterior (180°) or posterior, should be performed only in patients with gastroesophageal reflux disease secondary to scleroderma and impaired esophageal motility, since the laparoscopic total fundoplication would impair esophageal emptying and cause dysphagia.

UEG and EAES rapid guideline: Update systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on surgical management of GERD

BACKGROUND

There are several options for the surgical management of GERD in adults. Previous guidelines and systematic reviews have compared the effects of total fundoplication versus pooled effects of different techniques of partial fundoplication.

OBJECTIVE

To develop evidence-informed, trustworthy, pertinent recommendations on the use of total, posterior partial and anterior partial fundoplications for the management of GERD in adults.

METHODS

We performed an update systematic review, network meta-analysis, and evidence appraisal using the GRADE and the Confidence in Network Meta-Analysis methodologies. An international, multidisciplinary panel of surgeons, gastroenterologists, and a patient representative reached unanimous consensus through an evidence-to-decision framework to select among multiple interventions, and a Delphi process to formulate the recommendation. The project was developed in an online authoring and publication platform (MAGICapp), and was overseen by an external auditor.

RESULTS

We suggest posterior partial fundoplication over total posterior or anterior 90° fundoplication in adult patients with GERD. We suggest anterior >90° fundoplication as an alternative, although relevant comparative evidence is limited (weak recommendation). The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/j20X4n.

CONCLUSION

This rapid guideline was developed in line with highest methodological standards and provides evidence-informed recommendations on the surgical management of GERD. It provides user-friendly decision aids to inform healthcare professionals' and patients' decision making.

A multicenter prospective audit to investigate the current management of patients undergoing anti-reflux surgery in the UK: Audit & Review of Anti-Reflux Operations & Workup

BACKGROUND

There are a variety of surgical and endoscopic interventions available to treat gastroesophageal reflux disease. There is, however, no consensus on which approach is best.The aim of this national audit is to describe the current variation in the UK clinical practice in relation to anti-reflux surgery (ARS) and to report adherence to available clinical guidelines.

METHODS

This national audit will be conducted at centers across the UK using the secure online web platform ALEA. The study will comprise two parts: a registration questionnaire and a prospective multicenter audit of ARS. All participating centers will be required to complete the registration questionnaire comprising details regarding pre-, peri-, and post-operative care pathways and whether or not these are standardized within each center. Following this, a 12-month multicenter prospective audit will be undertaken to capture data including patient demographics, predominant symptoms, preoperative investigations, surgery indication, intraoperative details, and postoperative outcomes within the first 90 days.Local teams will retain access to their own data to facilitate local quality improvement. The full dataset will be reported at national and international scientific congresses and will contribute to peer-reviewed publications and national quality improvement initiatives.

CONCLUSIONS

This study will identify and explore variation in the processes and outcomes following ARS within the UK using a collaborative cohort methodology. The results generated by this audit will facilitate local and national quality improvement initiatives and generate new possibilities for future research in anti-reflux interventions.

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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,

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION NO

CRD42017074783.

Long-term follow-up of two randomized trials comparing laparoscopic Nissen 360° with anterior 90° partial fundoplication

BACKGROUND

The side-effects of Nissen fundoplication have led to modifications, including partial fundoplications such as an anterior 90° wrap. Five-year follow-up of two randomized trials suggested fewer side-effects following anterior 90° partial fundoplication, but better reflux control after Nissen fundoplication. However, longer-term outcomes have not been reported. This study combined data from previous trials to determine 10-year outcomes.

METHODS

From 1999 to 2003, 191 patients were enrolled in two randomized trials comparing anterior 90° partial versus Nissen fundoplication. Trial protocols were similar, and data were combined to determine long-term clinical outcomes. Patients completed annual questionnaires assessing dysphagia, heartburn, medications, satisfaction and other symptoms. Visual analogue scales (0-10), a composite dysphagia score (0-45) and yes/no responses were used.

RESULTS

Of the 191 patients, 152 (79·6 per cent) were available for 10-year follow-up. After anterior 90° fundoplication, patients reported less dysphagia to solids (score 2·03 versus 3·18 for the Nissen procedure; P = 0·037). Heartburn scores were lower after Nissen fundoplication (1·90 versus 2·83 for anterior 90° fundoplication; P = 0·035) and fewer patients required proton pump inhibitors (PPIs) (22 versus 39 per cent respectively; P = 0·035). Satisfaction scores were similar for both anterior 90° and Nissen groups (7·45 versus 7·36 respectively; P = 0·566), and the majority considered their original decision for surgery to be correct (86 versus 84 per cent; P = 0·818).

CONCLUSION

After 10 years, both procedures achieved similar success as measured by global satisfaction measures. Patients who had a Nissen fundoplication reported more dysphagia, whereas more heartburn and PPI consumption were reported after anterior 90° fundoplication. Registration numbers: ACTRN12607000298415 and ACTRN12607000304437 (http://www.anzctr.org.au/).

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

Laparoscopic Nissen fundoplication is the preferred operative treatment for patients with gastroesophageal reflux disease. The most recent published results only refer to clinical evaluations and few discuss objective measurements. Our purpose was to determine the late results of laparoscopic Nissen fundoplication, performing clinical, endoscopic, histologic, and functional studies.

MATERIAL AND METHODS

A total of 179 patients were included in a prospective study. All had gastroesophageal reflux disease symptoms of at least 5-year duration, daily dependence on proton pump inhibitors, and a type I hiatal hernia less than 5 cm. Exclusion criteria included Barrett's esophagus, hiatal hernia >5 cm, failed antireflux surgery, and obesity (body mass index >30). We performed a radiologic study, 3 or more endoscopic procedures with biopsy samples of the antrum and esophagogastric junction, esophageal manometry, and 24-hour pH monitoring.

RESULTS

We found that 4 patients (2.2%) died 3-4 years after operation from nonoperatiove reasons. A total of 25 patients (14%) were lost to follow-up, and 150 patients (83.8%) submitted to late objective evaluations (15 years). Visick I-II symptoms were observed in 79.3% and III-IV (failures) in 20.7%. Endoscopy showed a normal positioning of the esophagogastric junction in the Visick I-II patients and a type III cardia or hiatal hernia with erosive esophagitis in Visick III-IV patients. Short-segment Barrett's esophagus developed in 5.3% of patients. Lower esophageal sphincter pressure remained increased over the preoperative value in all groups. The 24-hour pH monitoring also was decreased over the preoperative value in Visick I-II patients but showed no significant change in Visick III-IV patients. Carditis at the esophagogastric junction regressed to fundic mucosa in 50% of Visick I-II patients.

CONCLUSION

Laparoscopic Nissen fundoplication produces control of symptoms in 80% of patients late (up to 15 years) after surgeries corroborated by endoscopic, histologic examinations, and functional studies. It is essential to perform these objective evaluations to demonstrate the "antireflux effect" after laparoscopic Nissen fundoplication.

Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high-volume center

INTRODUCTION

Published data regarding robot-assisted hiatal hernia repair are mainly limited to small cohorts. This study aimed to provide information on the morbidity and mortality of robot-assisted complex hiatal hernia repair and redo anti-reflux surgery in a high-volume center.

MATERIALS AND METHODS

All patients that underwent robot-assisted hiatal hernia repair, redo hiatal hernia repair, and anti-reflux surgery between 2011 and 2017 at the Meander Medical Centre, Amersfoort, the Netherlands were evaluated. Primary endpoints were 30-day morbidity and mortality. Major complications were defined as Clavien-Dindo ≥ IIIb.

RESULTS

Primary surgery 211 primary surgeries were performed by two surgeons. The median age was 67 (IQR 58-73) years. 84.4% of patients had a type III or IV hernia (10.9% Type I; 1.4% Type II; 45.5% Type III; 38.9% Type IV, 1.4% no herniation). In 3.3% of procedures, conversion was required. 17.1% of patients experienced complications. The incidence of major complications was 5.2%. Ten patients (4.7%) were readmitted within 30 days. Symptomatic early recurrence occurred in two patients (0.9%). The 30-day mortality was 0.9%. Redo surgery 151 redo procedures were performed by two surgeons. The median age was 60 (IQR 51-68) years. In 2.0%, the procedure was converted. The overall incidence of complications was 10.6%, while the incidence of major complications was 2.6%. Three patients (2.0%) were readmitted within 30 days. One patient (0.7%) experienced symptomatic early recurrence. No patients died in the 30-day postoperative period.

CONCLUSIONS

This study provides valuable information on robot-assisted laparoscopic repair of primary or recurrent hiatal hernia and anti-reflux surgery for both patient and surgeon. Serious morbidity of 5.2% in primary surgery and 2.6% in redo surgery, in this large series with a high surgeon caseload, has to be outweighed by the gain in quality of life or relief of serious medical implications of hiatal hernia when counseling for surgical intervention.

Comparison of the outcome of laparoscopic procedures for GERD

A total laparoscopic fundoplication has become the procedure of choice for the surgical treatment of gastroesophageal reflux disease in patients with normal esophageal motility, with reduced postoperative pain, faster recovery and similar long-term outcomes compared to conventional open total fundoplication. Most controversial surgical aspects are the division of the short gastric vessels and the insertion of a bougie to calibrate the wrap. The anterior 180° and the posterior partial fundoplications lead to similar control of heartburn when compared to total fundoplication with lower risk of dysphagia. However, when performed, 24-h pH monitoring shows pathologic reflux more frequently after partial than total fundoplication. Disappointing results are achieved by anterior 90° partial fundoplication. More recently, a magnetic sphincter augmentation with the LINX Reflux Management System (Torax Medical) and the lower esophageal sphincter Electrical Stimulation (EndoStim) have been developed, seeking for a durable and effective minimally invasive alternative to laparoscopic fundoplication for the treatment of reflux. Both devices seem to be promising, with very low postoperative complications and good short-term functional outcomes. Large randomized controlled trials comparing them with laparoscopic fundoplication over a long period of follow-up are needed to verify their indications and outcomes.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

A Novel, Dynamic Statistical Model for Predicting Patient Satisfaction with Fundoplication Based on Pre-Operative Symptom Patterns

BACKGROUND

Fundoplication provides excellent control of gastro-oesophageal reflux disease (GORD), but there remain a number of unsatisfied patients who have proven difficult to identify pre-operatively. We hypothesised that pre-operative symptom patterns can predict of the risk of post-operative dissatisfaction.

METHODS

Pre-operative symptoms and post-operative satisfaction were measured using standardised questionnaires along with routine investigations. These data were used to calculate our novel pre-operative risk of dissatisfaction (PROD) score. Potential pre-operative prognostic markers were tested against the post-operative satisfaction data, including the objective investigations and the PROD score. The prognostic utility of the PROD score and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline was tested using receiver operating characteristic analysis to determine the area under the curve (AUC).

RESULTS

An association was found between our PROD score and each of the satisfaction measures (n = 225, p < 0.001) which is likely to be of prognostic utility (AUC = 0.67-0.79). No such association was found between the routine investigations and post-operative satisfaction. The PROD score was found to be of greater prognostic utility than the SAGES guideline (n = 166, p < 0.001).

CONCLUSIONS

The PROD score is a novel, easy-to-use test that can predict individual patient satisfaction with fundoplication.

Laparoscopic Nissen (total) versus anterior 180° fundoplication for gastro-esophageal reflux disease: A meta-analysis and systematic review

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has been the gold standard for the surgical management of Gastro-esophageal reflux disease (GERD). Laparoscopic anterior 180° fundoplication (180° LAF) is reported to reduce the incidence of postoperative complications while obtaining similar control of reflux. The present meta-analysis was conducted to confirm the value of the 2 techniques.

METHODS

PubMed, Medline, Embase, Cochrane Library, Springerlink, and China National Knowledge Infrastructure Platform databases were searched for randomized controlled trials (RCTs) comparing LNF and 180° LAF. Data regarding the benefits and adverse results of 2 techniques were extracted and compared using a meta-analysis.

RESULTS

Six eligible RCTs comparing LNF (n = 266) and 180° LAF (n = 265) were identified. There were no significant differences between LNF and 180° LAF with regard to operating time, perioperative complications, length of hospital stay, patient satisfaction, willingness to undergo surgery again, quality of life, postoperative heartburn, proton pump inhibitor (PPI) use, postoperative DeMeester scores, postoperative lower esophageal sphincter (LES) pressure, postoperative gas-bloating, unable to belch, diarrhea, or overall reoperation. LNF was associated with a higher prevalence of postoperative dysphagia compared with 180° LAF, while 180° LAF was followed by more reoperation for recurrent reflux symptoms.

CONCLUSION

LNF and 180° LAF are equally effective in controlling reflux symptoms and obtain a comparable prevalence of patient satisfaction. 180° LAF can reduce the incidence of postoperative dysphagia while this is offset by a higher risk of reoperation for recurrent symptoms. The risk of recurrent symptoms should need to be balanced against the risk of dysphagia when surgeons choose surgical procedures for each individual with GERD.

Laparoscopic Anterior Partial Fundoplication is Comparable With Nissen Fundoplication for Gastroesophageal Reflux Disease

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has been the gold standard for gastroesophageal reflux disease (GERD), but the side effects of dysphagia and bloating have lead to interest in partial fundoplication as an alternative.

AIM

To compare the symptomatic and objective parameters after LNF and laparoscopic anterior partial fundoplication (LAPF) in patients with GERD.

PATIENTS AND METHODS

The study was conducted in the Division of Minimal Access Surgery, Maulana Azad Medical College from June 2008 to October 2016. Patients with GERD with high score on 24-hour pH monitoring were selected for surgery (LAPF) and were compared with our historical control of 25 patients who underwent LNF. The preoperative and postoperative symptom score and objective parameters were analyzed.

RESULTS

Of 50 GERD patients, 20 patients underwent surgery (LAPF) and these were compared with 25 patients who underwent LNF. Demester score, modified Visick grade decreased from 4.12, 3.23 in LNF; 4.35, 3.35 in LAPF to 0, 1 in both groups. There was significant and similar increase in lower esophageal sphincter (LES) length, intra-abdominal LES length, LES pressure. The 24-h pH) decreased from 10.18% and 8.08% to 0.85% and 1.09% in LNF and LAPF, respectively. At 1 year and 5 years of follow-up, symptom scores, manometric analysis, and pH metry evaluation remained to be improved in both the groups.

CONCLUSIONS

LAPF is as effective as LNF for GERD, with less dysphagia.

Randomized clinical trial of 270° posterior versus 180° anterior partial laparoscopic fundoplication for gastro-oesophageal reflux disease

BACKGROUND

Partial fundoplications provide similar reflux control with fewer post-fundoplication symptoms compared with Nissen fundoplication for gastro-oesophageal reflux disease (GORD). The best choice of procedure for partial fundoplication remains unclear. The aim of this study was to compare the outcome of two different types of partial fundoplication for GORD.

METHODS

A double-blind RCT was conducted between 2012 and 2015 in two hospitals specializing in antireflux surgery. Patients were randomized to undergo either a laparoscopic 270° posterior fundoplication (Toupet) or a laparoscopic 180° anterior fundoplication. The primary outcome was postoperative dysphagia at 12 months, measured by the Dakkak score. Subjective outcome was analysed at 1, 3, 6 and 12 months after surgery. Objective reflux control was assessed before and 6 months after surgery.

RESULTS

Ninety-four patients were randomized to laparoscopic Toupet or laparoscopic 180° anterior fundoplication (47 in each group). At 12 months, 85 patients (90 per cent) were available for follow-up. Objective scores were available for 76 (81 per cent). Postoperative Dakkak dysphagia score at 12 months was similar in the two groups (mean 5·9 for Toupet versus 6·4 for anterior fundoplication; P = 0·773). Subjective outcome at 12 months demonstrated no significant differences in control of reflux or post-fundoplication symptoms. Overall satisfaction and willingness to undergo surgery did not differ between the groups. Postoperative endoscopy and 24-h pH monitoring showed no significant differences in mean oesophageal acid exposure time or recurrent pathological oesophageal acid exposure.

CONCLUSION

Both types of partial fundoplication provided similar control of GORD at 12 months, with no difference in post-fundoplication symptoms. Registration number: NTR5702 (www.trialregister.nl).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Supragastric belching

PURPOSE OF REVIEW

Supragastric belching has recently gained recognition as a belching disorder of behavioral origin that can be accurately diagnosed on esophageal impedance monitoring. Its contribution to numerous other gastrointestinal disorders is beginning to be appreciated. Improved knowledge of its pathophysiology has enabled identification of therapeutic goals, some of which have been subject to formal study and demonstrated good outcomes. This review sets out to present and discuss new findings related to the improved understanding of the relationship between supragastric belching and other gastrointestinal disorders, as well as fresh concepts in terms of management.

RECENT FINDINGS

Supragastric belching is now shown to be associated with globus, as well as reflux symptoms in proton pump inhibitor nonresponders. Patients with supragastric belching experience higher frequency of belching events if they have concurrent esophageal hypomotility. Gum chewing and sleeve gastrectomy have no impact on supragastric belching. Pediatric studies suggest an overlap with aerophagia that is not observed in adults. Successful treatments trialed recently include psychoeducation and behavioral therapy delivered by a health psychologist with expertise in gastroenterology.

SUMMARY

With the foreseeable increase in recognition and diagnosis of pathological supragastric belching, there is a clear need to better understand its pathophysiology, especially in terms of its emerging importance in relation to other gastrointestinal disorders. Further study is justified to uncover additional therapeutic options for this benign but disabling condition.

Laparoscopic Mesh-augmented Hiatoplasty With Cardiophrenicopexy Versus Laparoscopic Nissen Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Double-center Randomized Controlled Trial

OBJECTIVE

Laparoscopic mesh-augmented hiatoplasty with cardiophrenicopexy (LMAH-C) might represent an alternative treatment of gastroesophageal reflux disease (GERD) and may provide durable reflux control without fundoplication. The expected benefit is the prevention of fundoplication-related side effects. Aim of the present trial was to compare LMAH-C with laparoscopic Nissen fundoplication (LNF) in patients with GERD.

METHODS

In a double-center randomized controlled trial (RCT) patients with proven GERD were eligible and assigned by central randomization to either LMAH-C (n = 46) or LNF (n = 44). The indigestion subscore of the Gastrointestinal Symptom Rating Scale questionnaire (GSRS) indicating gas-related symptoms as possible side effects of LNF was the primary endpoint. Secondary endpoints comprised pH testing and endoscopy and other symptoms measured by the GSRS, dysphagia, and the Gastrointestinal Quality of Life Index. The follow-up period was 36 months.

RESULTS

Indigestion subscore (LMAH-C 2.9 ± 1.5 vs LNF 3.7 ± 1.6; P = 0.031) but not dysphagia (2.8 ± 1.9 vs 2.3 ± 1.7; P = 0.302) and quality of life (106.9 ± 25.5 vs 105.8 ± 24.9; P = 0.838) differed between the groups at 36 months postoperatively. Although the reflux subscore improved in both groups, it was worse in LMAH-C patients (2.5 ± 1.6 vs 1.6 ± 1.0; P = 0.004) corresponding to a treatment failure of 77.3% in LMAH-C patients and of 34.1% in LNF patients (P < 0.001).

CONCLUSIONS

LNF is more effective in the treatment of GERD than LMAH-C. Procedure-related side effects seem to exist but do not affect the quality of life. Laparoscopic fundoplication therefore remains the standard surgical treatment for GERD.

Laparoscopic anterior versus posterior fundoplication for gastro-esophageal reflux disease: a meta-analysis and systematic review

OBJECTIVES

Although laparoscopic posterior fundoplication (LPF) i.e., Nissen or Toupet have the proven efficacy for controlling gastro-esophageal reflux surgically, there remain problems with postoperative dysphagia and gas bloat syndrome. To decrease some of these postoperative complications, laparoscopic anterior fundoplication (LAF) was introduced. The aim of this study was to conduct a meta-analysis and systematic review of randomized controlled trials (RCTs) to investigate the merits and drawbacks of LPF versus LAF for the treatment of gastro-esophageal reflux disease (GERD).

DATA SOURCES, STUDY SELECTION, AND REVIEW METHODS

A search of Medline, Embase, Science Citation Index, Current Contents, PubMed, ISI Web of Science, and the Cochrane Database identified all RCTs comparing different types of LPF and LAF published in the English Language between 1990 and 2013. The meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. Data was extracted and analyzed on ten variables which include dysphagia score, heartburn rate, redo operative rate, operative time, overall complications, rate of conversion to open, Visick grading of satisfaction, overall satisfaction, length of hospital stay, and postoperative 24-h pH scores.

DATA SYNTHESIS

Nine trials totaling 840 patients (anterior = 425, posterior = 415) were analyzed. There was a significant reduction in the odds ratio for dysphagia in the LAF group compared to the LPF group. Conversely, significant reduction in the odds ratio for heartburn was observed for LPF compared to LAF. Comparable effects were noted for both groups for other variables which include redo surgery, operating time, overall complications, conversion rate, Visick's grading, patients' satisfaction, length of hospital stay, and postoperative 24-h pH scores.

CONCLUSIONS

Based on this meta-analysis, LPF compared to LAF is associated with significant reduction in heartburn at the expense of higher dysphagia rate on a short- and medium-term basis. We therefore conclude that LPF is a better alternative to LAF for controlling GERD symptoms.

Normal values of esophageal motility after antireflux surgery; a study using high-resolution manometry

BACKGROUND

Fundoplication is an effective therapy for gastroesophageal reflux disease (GERD), but can be complicated by postoperative dysphagia. High-resolution manometry (HRM) can assess esophageal function, but normal values after fundoplication are lacking. Our aim was to obtain normal values for HRM after successful Toupet and Nissen fundoplication.

METHODS

Esophageal HRM was performed 3 months after Toupet or Nissen fundoplication in 40 GERD patients without postoperative dysphagia and with a normal barium esophagogram. Normal values for all measures of the Chicago classification were calculated as 5th and 95th percentile ranges.

KEY RESULTS

The normal values (5th-95th percentiles) for integrated relaxation pressure (IRP) were higher after Nissen (5.1-24.4 mmHg) than after Toupet fundoplication (3.1-15.0 mmHg), and upper limit of normal was significantly higher after Nissen fundoplication than observed in the asymptomatic subjects that were described in the Chicago Classification. Distal contractile integral was significantly higher after Nissen (357-4947 mmHg*s*cm) than after Toupet (68-2177 mmHg*s*cm), and transition zone length was significantly shorter after Nissen (0-4.8 cm) than after Toupet fundoplication (0-12.8 cm).

CONCLUSIONS & INFERENCES

HRM metrics for subjects after a Toupet fundoplication are similar to the normal values derived from healthy subjects used for the Chicago classification. However, after Nissen fundoplication a higher esophagogastric junction resting pressure and higher IRP are observed in asymptomatic subjects and this can be considered normal in the postoperative state. In addition, more vigorous contractions and less and smaller peristaltic breaks are normal after Nissen fundoplication.

One- and ten-year outcome of laparoscopic anterior 120° versus total fundoplication: a double-blind, randomized multicenter study

BACKGROUND

Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD) but can cause adverse effects like flatulence and dysphagia. The aim was to compare laparoscopic anterior 120° fundoplication (APF) to total fundoplication (Nissen) concerning flatulence and other adverse effects, in a randomized blinded study.

METHODS

Seventy-two patients were randomized to APF (n = 36) or Nissen (n = 36). Gastroscopy, 24-h pH monitoring and evaluation for symptoms and quality of life using questionnaires (GSRS, PGWB and 7-graded Likert scales) were performed preoperatively, at 1 and 10 years postoperatively. Patients and the researchers were blinded to operative method.

RESULTS

When entering the study, most patients had mild-moderate reflux disease according to the symptom score, the 24-h pH measurements, and frequency and grade of esophagitis. At 1-year (n = 68) flatulence, dysphagia, heartburn and acid regurgitation did not differ between groups. More patients could belch (p = 0.005), and pH monitoring showed a higher time with pH < 4 in the APF group (p = 0.006). At 10 years (n = 61), the APF group reported less dysphagia (p < 0.001), more heartburn (p = 0.019) and more patients could belch (p = 0.012) and vomit (p < 0.001) compared to the Nissen. No difference remained at 10 years in pH monitoring (n = 23) between groups. Symptoms of heartburn and acid regurgitation were less than preoperatively in both groups (p < 0.001). No revisional operations were performed.

CONCLUSIONS

Both procedures offer good long-term control of reflux symptom, with modest post-fundoplication symptoms. Anterior 120° fundoplication results in less dysphagia, better ability to belch and vomit than total fundoplication at 10-year follow-up. The results suggest that APF could be an alternative to Nissen fundoplication in the surgical treatment of mild-moderate GERD.

Optimizing Patient Selection and Outcomes for Surgical Treatment of GERD and Achalasia

OPINION STATEMENT

Gastroesophageal reflux disease is a common disorder in the United States and other western countries. In addition to troublesome symptoms, this condition is associated with impaired quality of life and the potential for disease progression to esophageal adenocarcinoma. Acid suppression medications are extremely effective for the relief of heartburn symptoms, but don't address the physiologic derangements that cause reflux. The goal of an antireflux procedure is to correct these defects and abolish the dietary and lifestyle compromises that accompany medical therapy for gastroesophageal reflux. The Nissen fundoplication has a long and well-established track record and new options such as the LINX magnetic sphincter augmentation device allow correction of reflux with fewer side-effects than a fundoplication in appropriate patients. These options should be considered in patients incompletely satisfied on medical therapy and in those with risk factors for disease progression. The role of these therapies in patients with gastroesophageal reflux disease will be reviewed in this chapter. Achalasia is an uncommon motility disorder of the esophagus that leads to profound dysphagia symptoms and greatly impaired alimentary satisfaction. Pneumatic dilation offers an endoscopic approach to the management of these patients, but often requires repeated dilatations due to the inconsistent disruption of the lower esophageal sphincter with this technique. An alternative is a laparoscopic Heller myotomy, which offers precise division of the muscle of the lower esophageal sphincter, but requires incisions and lifestyle restrictions while healing. A new therapy, per-oral endoscopic myotomy, allows the precise division of the lower esophageal sphincter muscle as in a laparoscopic myotomy, but is done endoscopically with no external incisions. The role of these therapies in patients will be reviewed in this chapter.

GERD procedures: when and what?

BACKGROUND

The topic of "when and what" for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the "when") and on the right antireflux operation to perform once the ideal candidate is identified (the "what").

AIMS

The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.

Laparoscopic fundoplication for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.