Anterior 90° Partial vs Nissen Fundoplication—5?Year Follow-Up of a Single-Centre Randomised Trial

Introduction

Nissen fundoplication can be followed by side effects, and this has driven modifications, including partial fundoplications. We previously reported early outcomes from a randomised trial of Nissen vs anterior 90° partial fundoplication. This paper reports 5-year follow-up outcomes to determine whether anterior 90° fundoplication achieves a satisfactory longer-term outcome.

Methods

From February 1999 to August 2003, 79 patients were randomised to Nissen vs anterior 90° fundoplication. Patients were followed yearly using a standardized clinical questionnaire which included symptom scores to assess heartburn, dysphagia, other post-fundoplication side effects and overall satisfaction with the outcome. Five-year clinical outcomes were analysed.

Results

Seventy-four patients were available for follow-up at 5?years. There were no significant differences for heartburn or satisfaction, although more patients used antisecretory medication after anterior 90° fundoplication (29.7 vs 8.1?%). Dysphagia was greater after Nissen fundoplication when measured by an analogue score for solid food and a composite dysphagia score. Symptoms of bloating were more common following Nissen fundoplication (80.0 vs 32.4?%), and less patients could eat a normal diet (78.4 vs 94.6?%). Re-operation was undertaken in four patients after Nissen fundoplication (dysphagia, three; hiatus hernia, one) vs three after anterior 90° fundoplication (recurrent reflux, three).

Conclusions

At 5?years, anterior 90° partial fundoplication was associated with less side effects, offset by greater use of antisecretory medication. Reflux symptoms and overall satisfaction were similar to Nissen fundoplication. Laparoscopic anterior 90° partial fundoplication is an effective treatment for gastro-esophageal reflux.     

Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication

BACKGROUND: This double-blind, randomized study compared outcomes of laparoscopic Nissen total fundoplication and anterior partial fundoplication carried out by a single surgeon in a private practice. METHODS: All patients with proven gastro-oesophageal reflux disease, regardless of motility, presenting for laparoscopic antireflux surgery were randomized to either Nissen total or anterior partial fundoplication. Primary outcome measures were dysphagia and abolition of reflux. Secondary outcome measures were Visick scores, bloating, patient satisfaction and reoperation rate. RESULTS: Complete follow-up was available for 161 (98.8 per cent) of 163 patients (84 Nissen, 79 anterior). There were no differences in mean heartburn scores between groups. Recurrent reflux was observed in ten patients after anterior fundoplication, but none after the Nissen procedure. Dysphagia scores for both liquids and solids were lower after anterior fundoplication. Four patients had persistent troublesome dysphagia after Nissen fundoplication compared with none after anterior fundoplication. There were no differences between groups in postoperative bloating. The overall reoperation rate at 2 years was 7 per cent, all achieved laparoscopically. CONCLUSION: Nissen fundoplication cured reflux in all patients up to 2 years, but 5 per cent required revisional surgery. Recurrent reflux was more common after anterior fundoplication, but dysphagia was rare. Patient satisfaction was excellent in both groups. Revisional laparoscopic surgery was safe and usually successful.     

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication

HYPOTHESIS: Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind, randomized controlled trial. SETTING: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. PARTICIPANTS: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study. INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. RESULTS: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. CONCLUSIONS: At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.     

Single center prospective randomized trial of laparoscopic Nissen versus anterior 90° fundoplication

Although Nissen fundoplication is a very effective treatment for gastroesophageal reflux, it is associated with a small incidence of troublesome postoperative side effects. To prevent this, progressive modification of surgical techniques has led to the development of an anterior 90° fundoplication. We undertook a prospective randomized trial to compare this procedure with Nissen fundoplication to determine whether it would achieve a better clinical outcome. Patients presenting to a single center for primary laparoscopic antireflux surgery were randomized to undergo either an anterior 90° fundoplication (n=40) or a Nissen fundoplication without division of the short gastric vessels (n=39). Clinical questionnaires were used to assess outcome at 1 month, 3–6 months, and 12 months. Both patients and the clinical interviewer were masked as to which procedure was performed. Follow-up with endoscopy, esophageal manometry, and pH monitoring was also undertaken. Operating time was similar for the two procedures (60 minutes for anterior vs. 55 minutes for Nissen fundoplication). Early postoperative complications were more common after Nissen fundoplication (18% vs. 5%). Two patients underwent laparoscopic reoperation for recurrent reflux after anterior 90° fundoplication, and four underwent laparoscopic reoperation after Nissen fundoplication (dysphagia, 3 patients; acute hiatus hernia, 1 patient). One year after surgery, dysphagia and other wind-related side effects were less common after anterior 90° fundoplication. Control of reflux symptoms and satisfaction with the overall outcome was similar for the two procedures. Anterior 90° fundoplication is followed by fewer side effects than Nissen fundoplication. This advantage is offset by a greater likelihood of reflux recurrence. However, this does not diminish patient satisfaction. Financial support for this study was provided from a project grant (no. 157986) from the National Heath and Medical Research Council of Australia (to D.I.W. and G.G.J.).     

Laparoscopic anterior 180 degrees partial fundoplication: five-year results and beyond

HYPOTHESIS: Laparoscopic anterior 180 degrees partial fundoplication provides good long-term relief for symptoms of gastroesophageal reflux disease and is associated with few adverse effects. DESIGN: Prospectively evaluated case series. SETTING: University teaching hospital. PATIENTS: The late clinical outcome was determined for all patients who had undergone a laparoscopic anterior 180 degrees partial fundoplication by us between August 1, 1993, and November 30, 1999. INTERVENTIONS: Long-term (>/=5 years') follow-up after laparoscopic anterior 180 degrees partial fundoplication was obtained using a structured questionnaire. MAIN OUTCOME MEASURES: Overall satisfaction and the symptoms of heartburn and dysphagia were assessed using analog scales, and the presence or absence of other adverse outcomes was also determined. RESULTS: One hundred seventeen procedures were performed. The outcome at 5 to 11 years' (mean, 6.4 years') follow-up was determined for 113 patients (97%). Twelve patients (11%) died of unrelated causes during follow-up, and 1 patient underwent esophagectomy. Further surgery was undertaken in 12 patients (11%): 8 for recurrent reflux, 3 for a symptomatic hiatal hernia, and 1 for dysphagia. For 100 patients with clinical outcome data at late follow-up, gastroesophageal reflux symptoms were significantly improved following surgery and were well controlled in 80 patients. The incidence and severity of dysphagia were reduced after surgery. Normal belching was preserved in 91 patients, and almost all patients were able to eat normally. The overall outcome of surgery was rated as satisfactory, with 95 patients reporting that they considered their original decision to undergo surgery correct. CONCLUSIONS: Laparoscopic anterior 180 degrees partial fundoplication is an effective procedure for the surgical treatment of gastroesophageal reflux and is associated with a high rate of patient satisfaction at late follow-up. Compared with Nissen fundoplication, however, it is likely to be associated with a higher risk of recurrent reflux, although this is balanced by a lower rate of adverse effects.     

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??Laparoscopic anterior 180° partial fundoplication versus Nissen fundoplication in elderly patients with gastroesophageal reflux disease??A randomized controlled trial ZHAO Hong-zhi, QIN Ming-fang. Center of Tianjin Minimally Invasive Surgery, Nankai Hospital, Tianjin 300100, China
Corresponding author ??ZHAO Hong-zhi, E-mail??tjzhhzh@sina.com
Abstract Objective To compare two anti-reflux procedures??laparoscopic anterior 180° partial fundoplication and Nissen fundoplication??in elderly patients with gastroesophageal reflux disease (GERD). Methods From July 2008 to June 2012, 78 elderly patients with GERD were admitted in Tianjin Nankai Hospital. All the patients were allocated into two groups randomly. Thirty-nine patients were performed laparoscopic anterior 180° partial fundoplication (anterior 180° group) and the other 39 patients were performed Nissen fundoplication (Nissen group). Perioperative clinical parameters were recorded for comparing efficacy between two groups. Results Laparoscopic surgery was accomplished in all patients. The mean operation time of anterior180° group was significantly less than that of Nissen group (P<0.05). There was no significant difference of the mean duration of postoperative hospital stay between two groups (P>0.05). The symptoms in most patients were adequately relieved after operation. Endoscopy, radiology, esophageal manometry and 24-hour pH monitoring were repeated 1 month after surgery. All the results returned to normal compared with preoperative data. A total of 76 patients got follow-up. One patient was lost. One patient died of heart infarction. During follow-up period of 6-54 months (mean 28.5 months), there was no statistical significance between groups for the recurrence rate and satisfaction rate of operation. There was a lower incidence of dysphagia and epigastric bloating in the anterior 180° group. Conclusion For elderly patients with GERD??laparoscopic anterior 180°partial fundoplication has a good and durable anti-reflux effect compared with laparoscopic Nissen fundoplication. With shorter operation time and lower incidence of postoperative complications (dysphagia and epigastric bloating) compared with Nissen fundoplication, laparoscopic anterior 180°partial fundoplication can be employed as a more appropriate procedure for treatment of GERD in elderly patients.     

Quality of Life Following Laparoscopic Anterior 90° Versus Nissen Fundoplication: Results from a Multicenter Randomized Trial

Background The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90° partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90° fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient’s functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90° partial fundoplication than after Nissen fundoplication. Methods Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90° partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires – the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. Results One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90° anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. Conclusions Patients undergoing laparoscopic anterior 90° partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.     

Outcome of laparoscopic anterior 180-degree partial fundoplication for gastroesophageal reflux disease

Although Nissen fundoplication controls gastroesophageal reflux disease effectively, it is associated with an incidence of side effects. For this reason we have investigated the use of a laparoscopic 180-degree anterior fundoplication as a technique that has the potential to control reflux, but with less associated post-operative dysphagia and fewer gas-related side effects. Good short-term (6-month) outcomes have been previously reported within the context of a randomized trial. This report details the technique we used and describes the outcome of this procedure with longer follow-up in a much larger group of patients. The outcome for patients with gastroesophageal reflux disease who underwent a laparoscopic anterior 180-hemifundoplication was determined. Clinical follow-up was carried out prospectively by an independent scientist who applied a standardized questionnaire yearly following surgery. This questionnaire evaluated symptoms of reflux, postoperative problems including dysphagia, gas bloat, ability to belch, and overall satisfaction with clinical outcome. From July 1995 to May 1999, a total of 107 patients underwent a laparoscopic anterior hemifundoplication. Four patients underwent further surgery for recurrent heartburn, and persistent troublesome dysphagia occurred in one. At 1 year 89% of patients remained free of reflux symptoms, and at 3 years 84% remained symptom free. Of those with symptoms of reflux, approximately half of them had only mild symptoms. The overall incidence and severity of dysphagia for liquids and solids was not altered by partial fundoplication. Epigastric bloating that could not be relieved by belching was uncommon, and only 11 % of the patients at 1 year and 10% at 3 years following surgery were unable to belch normally. Overall satisfaction with the outcome of surgery remained high at 3 years’ follow-up. Laparoscopic anterior partial fundoplication is an effective operation for gastroesophageal reflux, with a low incidence of side effects and a good overall outcome.     

Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication

BACKGROUND: In the operative management of gastro-oesophageal reflux, a balance must be achieved between adequate control of reflux and excessive dysphagia. The ideal technique is not known. A randomized study was performed to determine whether laparoscopic anterior fundoplication is associated with a lower incidence of postoperative dysphagia than laparoscopic Nissen fundoplication, while achieving equivalent control of reflux. METHODS: Patients presenting for laparoscopic antireflux surgery were randomized to undergo either a Nissen fundoplication (n = 53) or an anterior 180 degrees hemifundoplication (n = 54). Patients were blinded to which procedure had been performed, and follow-up was obtained by a blinded independent investigator. Standardized clinical grading systems were used to assess dysphagia, heartburn and patient satisfaction 1, 3 and 6 months after operation. Objective measurement of lower oesophageal sphincter pressure, oesophageal emptying time, distal oesophageal acid exposure and endoscopic healing of oesophagitis was also performed. RESULTS: Operating time was similar for the two procedures (58 min for the Nissen procedure versus 60 min for anterior fundoplication). Resting and residual lower oesophageal sphincter pressures were lower following anterior fundoplication (29 versus 18 mmHg, and 13 versus 6 mmHg), and oesophageal emptying times were faster (92 versus 116 s). Acid exposure times and ability to heal oesophagitis were similar. At 3 months' follow-up clinical outcomes were similar for the two procedures. At 6 months, however, patients who had undergone anterior fundoplication experienced significantly less dysphagia for solid food and were more likely to be satisfied with the clinical outcome. CONCLUSION: Laparoscopic anterior fundoplication achieved equivalent control of reflux, more physiological postoperative manometry parameters, and an improved clinical outcome at 6 months. Continued follow-up remains necessary to confirm the long-term efficacy of the partial fundoplication procedure.     

Long‐term outcomes of revisional surgery following laparoscopic fundoplication

Background:

A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long‐term clinical outcomes.

Methods:

Patients requiring late revisional surgery following laparoscopic fundoplication for gastro‐oesophageal reflux were identified from a prospective database. Long‐term outcomes were determined using a questionnaire evaluating symptom scores for heartburn, dysphagia and satisfaction.

Results:

The database search found 109 patients, including 98 (5·6 per cent) of 1751 patients who had primary surgery in the authors' unit. Indications for surgical revision were dysphagia (52 patients), recurrent reflux (36), mechanical symptoms related to paraoesophageal herniation (16) and atypical symptoms (five). The median time to revision was 26 months. Outcome data were available for 104 patients (median follow‐up 66 months) and satisfaction data for 102, 88 of whom were highly satisfied (62·7 per cent) or satisfied (23·5 per cent) with the outcome. Patients who had revision for dysphagia had a higher incidence of poorly controlled heartburn (20 versus 2 per cent; P = 0·004), troublesome dysphagia (16 versus 6 per cent; P = 0·118) and a lower satisfaction score (P = 0·023) than those with recurrent reflux or paraoesophageal herniation.

Conclusion:

Revisional surgery following laparoscopic fundoplication can produce good long‐term results, but revision for dysphagia has less satisfactory outcomes. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication

BACKGROUND: Total fundoplication for gastro-oesophageal reflux disease may be followed by unwanted side-effects. A randomized trial demonstrated that an anterior 180 degrees partial fundoplication achieved effective reflux control and was associated with fewer side-effects in the short term than total fundoplication. This paper reports longer-term (5 year) outcomes from that trial. METHODS: Between December 1995 and June 1997, 107 patients were randomized to undergo either laparoscopic total fundoplication or a laparoscopic anterior 180 degrees fundoplication. After 5 years, 101 of 103 eligible patients (51 total, 50 anterior) were available for follow-up. Each patient was interviewed by a single blinded investigator and a standardized questionnaire was completed. The questionnaire focused on symptoms and overall satisfaction with the results of fundoplication. RESULTS: There were no significant differences between the two groups with regard to control of heartburn or patient satisfaction with the overall outcome. Dysphagia, measured by a visual analogue score for solid food and a composite dysphagia score, was worse at 5 years after total fundoplication. Symptoms of bloating, inability to belch and flatulence were also more common after total fundoplication. Reoperation was required for dysphagia in three patients after total fundoplication and for recurrent reflux in three patients after anterior fundoplication. CONCLUSION: Anterior 180 degrees partial fundoplication was as effective as total fundoplication for managing the symptoms of gastro-oesophageal reflux in the longer term. It was associated with a lower incidence of side-effects, although this was offset by a slightly higher risk of recurrent reflux symptoms.     

Laparoskopische Fundoplicatio nach Nissen und Toupet bei Patienten mit gastroösophagealer Refluxkrankheit und Motilitätsstörung des distalen Ösophagus

INTRODUCTION: A Nissen fundoplication for gastrooesophageal reflux disease may more often lead to persistent dysphagia than a Toupet fundoplication. The aim of this study was to assess the results of laparoscopic Nissen versus Toupet fundoplication in patients with reflux disease and impaired distal esophageal motility. PATIENTS AND METHODS: In 15 patients a laparoscopic Nissen and in 17 a laparoscopic Toupet fundoplication was carried out. Criteria for an impaired motility of the distal esophagus were a mean amplitude of < 30 mm Hg of swallow-induced contractions, or > 33% non-propulsive or non-transmitted contraction waves. Before surgery, heartburn, dysphagia, regurgitation and other symptoms were scored and endoscopic, manometric and 24 hour pH-metric investigations performed. Patients were reinvestigated 3 to 30 (median 15) months after Nissen and 3 to 42 (median 7) months after Toupet fundoplication. RESULTS: After Nissen as well as after Toupet fundoplication heartburn was significantly less frequent, whereas dysphagia and all other symptom-scores remained unchanged. In the 26 patients reinvestigated manometrically, the resting pressure of the lower esophageal sphincter was significantly higher following both operations and the residual sphincter pressure upon swallowing higher only after Nissen fundoplication. The amplitude of swallow-induced contractions and the percentages of non-propulsive and non-transmitted contraction waves were not significantly changed after either operation. In the 23 patients restudied pH-metrically, reflux activity was significantly reduced after both Nissen and Toupet fundoplication. CONCLUSION: In patients with reflux disease and impaired distal esophageal motility, laparoscopic Nissen and Toupet fundoplication both yielded satisfactory results and neither operation led to increased dysphagia.     

Is There a Role for Anything Other Than a Nissen’s Operation?

Background

The Nissen fundoplication is the most frequently applied antireflux operation worldwide. The aim of this review was to compare laparoscopic Nissen with partial fundoplication.

Methods

Nine randomized trials comparing several types of wraps were analyzed, four for the comparison Nissen vs. Toupet and five for the comparison Toupet or Nissen vs. anterior fundoplication. Similar comparisons in nonrandomized studies were also included.

Results

Dysphagia rates and reflux recurrence were not related to preoperative esophageal persistalsis independent of the selected procedure. Overall, Nissen fundoplication revealed slightly better reflux control, but was associated with more side effects, such as early dysphagia and gas bloat. Advantages of an anterior approach were only reported by one group. A significantly higher reflux recurrence rate for anterior fundoplication was observed in all other comparisons.

Conclusion

Tailoring antireflux surgery according to esophageal motility is not indicated. At present, the relevant factor for selection of a Nissen or Toupet fundoplication is personal experience. Anterior fundoplication offers less effective long-term reflux control.

     

Laparoscopic repair of gastroesophageal reflux disease

Summary This report describes our preliminary experience with two surgical laparoscopic fundoplication procedures, the Nissen technique and the Toupet operation, in which the fundal wrap is reduced from 360° to 180–200°. Fourteen patients with symptomatic gastroesophageal reflux disease who were refractory to pharmacologic and medical therapy underwent a laparoscopic Nissen fundoplication; in an additional 14 patients, we performed a laparoscopic Toupet partial fundoplication. Our laparoscopic approach to the two procedures does not differ significantly from the traditional open methods and the effectiveness of the laparoscopic fundoplication procedures appears similar to that of the same conventional techniques. Oral feedings can be resumed on the first postoperative day and patients typically are discharged on the second day after surgery. Operative time for performing the Toupet procedure averaged just approximately 1.6 h and was shorter than that for the Nissen fundoplication, due to the use of a stapler to secure the fundal wrap. Confirming earlier observations, the laparoscopic Toupet 180–200° fundoplication was associated with a lower incidence of postoperative digestive complications, such as dysphagia, than was the laparoscopic Nissen operation. The laparoscopic fundoplication approach offers the advantages of clear visualization, adequate dissection and precise repair, along with the benefits associated with endoscopic surgery: diminished postoperative pain and discomfort, reduced hospitalization, and quicker return to normal activities. Our experience indicates that the Toupet fundoplication may be preferable to the Nissen technique for many patients requiring surgical treatment of their reflux disease.     

A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair.

HYPOTHESIS: The technique used for repair of the esophageal hiatus during laparoscopic Nissen fundoplication can influence the likelihood of postoperative dysphagia. DESIGN: A prospective double-blind randomized control trial. SETTING: A university teaching hospital. PARTICIPANTS: A total of 102 patients with proven gastroesophageal reflux disease, undergoing a laparoscopic Nissen fundoplication were randomized to undergo fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Patients were excluded for the following reasons: they had esophageal motility disorders, required a concurrent abdominal procedure, had undergone previous antireflux surgery, or had very large hiatus hernias. INTERVENTIONS: Laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, patient satisfaction, and other symptoms 1, 3, and 6 months following surgery, using multiple standardized clinical grading systems. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, distal esophageal acid exposure, and endoscopic assessment of postoperative anatomy and esophageal mucosa. RESULTS: Symptoms of postoperative dysphagia, relief of heartburn, and overall satisfaction 6 months after surgery were not influenced by the hiatal repair technique. However, to achieve a similar incidence of dysphagia, more patients who initially underwent posterior hiatal repair required a second surgical procedure (6 vs 0 patients). The hiatal repair technique did not affect the likelihood of early postoperative paraesophageal herniation. CONCLUSION: Anterior suturing of the hiatus appears to be at least as good in the short-term as posterior suturing as a method of narrowing the hiatus during laparoscopic Nissen fundoplication.     

Revisional laparoscopic antireflux surgery after unsuccessful endoscopic fundoplication

Background

Transoral incisionless fundoplication (TIF), a novel endoscopic procedure for treating gastroesophageal reflux disease (GERD), currently is under evaluation. In case of treatment failure, subsequent revisional laparoscopic antireflux surgery (rLARS) may be required. This study aimed to evaluate the feasibility, safety, and outcomes of revisional antireflux surgery after previous endoscopic fundoplication.

Methods

Chronic GERD patients who underwent rLARS after a previous TIF procedure were included in the study. Pre- and postoperative assessment included GERD-related quality-of-life scores, proton pump inhibitor (PPI) usage, 24-h pH-metry, upper gastrointestinal endoscopy, and registration of adverse events.

Results

Revisional laparoscopic Nissen fundoplication was feasible for all 15 patients included in the study without conversions to open surgery. Acid exposure of the distal esophagus improved significantly after rLARS, and esophagitis, PPI usage, and hiatal hernia decreased. Quality of life did not improve significantly after rLARS, and 33 % of the patients experienced dysphagia.

Conclusion

Revisional laparoscopic Nissen fundoplication was feasible and safe after unsuccessful endoscopic fundoplication, resulting in objective reflux control at the cost of a relatively high rate of dysphagia.     

Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease

BACKGROUND: The aim of this study was to compare laparoscopic and open Nissen fundoplication for gastro-oesophageal reflux disease in a randomized clinical trial. METHODS: Ninety-nine patients were randomized to either laparoscopic (52) or open (47) Nissen fundoplication. Patients with oesophageal dysmotility, those requiring a concurrent abdominal procedure and those who had undergone previous antireflux surgery were excluded. Independent assessment of dysphagia, heartburn and patients' satisfaction 1, 3, 6 and 12 months after surgery was performed using multiple standardized clinical grading systems. Objective measurement of oesophageal acid exposure and lower oesophageal sphincter pressure before and after surgery, and endoscopic assessment of postoperative anatomy, were performed. RESULTS: Operating time was longer in the laparoscopic group (median 82 versus 46 min). Postoperative pain, analgesic requirement, time to solid food intake, hospital stay and recovery time were reduced in the laparoscopic group. Perioperative outcomes, postoperative dysphagia, relief of heartburn and overall satisfaction were equally good at all follow-up intervals. Reduction in oesophageal acid exposure, increase in lower oesophageal sphincter tone and improvement in endoscopic appearances were the same for the two groups. CONCLUSION: The laparoscopic approach to Nissen fundoplication improved early postoperative recovery, with an equally good outcome up to 12 months.     

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

Background  

A prospective, randomized trial was performed to evaluate the long-term outcome and patient satisfaction of laparoscopic complete 360° fundoplication compared with partial posterior 270° 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.     

Reflux Symptoms and Side Effects Among Patients with Gastroesophageal Reflux Disease at Baseline, During Treatment with PPIs, and After Nissen Fundoplication

Background

There are no prospective studies available on the behavior of extraesophageal and esophageal symptoms and treatment-related side effects in patients without effective antireflux medication, receiving the most effective antireflux medication, and after laparoscopic fundoplication.

Methods

Extraesophageal and esophageal reflux symptoms and treatment-related side effects were assessed in 60 patients while they were on no effective antireflux medication (three-week washout period), after three month of treatment with double-dose esomeprazole, and 3 months after laparoscopic Nissen fundoplication. Esophageal and extraesophageal reflux symptoms, rectal flatulence, and bloating were analyzed with the visual analog scale. In addition, dysphagia, rectal flatulence, and bloating were recorded as none, mild, moderate, or severe.

Results

Both extraesophageal and esophageal reflux symptoms decreased after treatment with esomeprazole and were further reduced after fundoplication. Dysphagia and flatulence did not increase from baseline after surgery. Bloating decreased both after treatment with esomeprazole and after fundoplication. In contrast, dysphagia and increased flatus were found more often after surgery than during treatment with esomeprazole. Dysphagia and rectal flatulence were less common during treatment with esomeprazole than at baseline or after surgery.

Conclusions

Both extraesophageal and esophageal reflux symptoms decreased after treatment with esomeprazole and were reduced further after fundoplication. Any treatment-related side effect was not increased after surgery when compared to baseline. However, compared to esomeprazole there was more dysphagia and flatulence after fundoplication.     

Laparoscopic conversion from Nissen to partial fundoplication for refractory dysphagia

Laparoscopic Nissen fundoplication is effective for treating gastroesophageal reflux and is usually well tolerated. Some patients, however, experience postoperative dysphagia refractory to conservative measures. We report our experience and operative technique for laparoscopic conversion of previous laparoscopic Nissen fundoplication to partial fundoplication to relieve dysphagia. We retrospectively reviewed the medical records of 6 patients with refractory dysphagia after laparoscopic Nissen fundoplication who underwent laparoscopic conversion to partial fundoplication using a laparoscopic linear stapler. There were no perioperative deaths and no fundoplication-related complications. In short-term follow-up, all patients reported improvement of dysphagia symptoms.