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1.
Background Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure for gastroesophageal
reflux disease. The rate of failure following fundoplication varies from 2% to 30%, and revision is required in many of the
patients who have recurrent or new foregut symptoms. Common causes of failure include hiatal hernia, wrap disruption, slipped
wrap, and misplaced wrap.
Methods This video depicts three different causes of failure of LNF, each demonstrated while perfoming a redo fundoplication. The
first case shows a common cause of failure, a misplaced wrap. Less common causes of failure are seen in the second and third
cases: a retained foreign body and fundus herniation through the retroesophageal space. In the first two cases, following
the dissection of the original wrap, the proper construction of a Nissen fundoplication is shown.
Results The first patient developed recurrent reflux symptoms that can be explained by the misplaced wrap. In case two, the patient’s
dysphagia was a result of a retained foreign body from the initial procedure creating a fibrotic reaction and esophageal stricture.
The final case shows how chronic failure can sometimes have an acute presentation. We see the patient’s gastric fundus has
herniated through the retroesophageal space and it has become incarcerated and volvulized, creating a closed loop obstruction
and acute distention.
Conclusions The surgeon watching this video can appreciate the identification of various causes of LNF failure, the approach to dissection
of the old wraps, and the important steps in the creation of a Nissen fundoplication.
This article contains a supplementary video. 相似文献
2.
Background Laparoscopic Nissen fundoplication is an established treatment for gastroesophageal reflux disease (GERD). Postoperative improvement
in esophageal physiology can be indicative of successful surgery, but the degree to which it correlates with symptom control
remains questionable. We have performed this study to assess the utility of postoperative esophageal physiology studies in
predicting long-term symptomatic outcome.
Methods Between August 1997 and August 2003, 145 patients with symptomatic GERD underwent laparoscopic Nissen fundoplication as part
of a randomized trial. Four months after surgery patients were invited to have postoperative esophageal physiology studies.
In November 2005, a postal questionnaire was sent to all patients in order to assess reflux symptomatology (DeMeester symptom
score).
Results Completed symptom questionnaires were returned by 108 patients (74%) after a median of 5.7 years postoperatively. Linear regression
of manometry data showed a significant correlation between the level of postoperative neosphincter pressure either above or
below the median and long-term scores for heartburn (p = 0.03), dysphagia (p = 0.02), regurgitation (p = 0.01), and total symptom score (p = 0.002). In contrast, there was no evidence of a significant correlation between results of postoperative esophageal pH
studies and symptom scores.
Conclusion Postoperative physiology studies, particularly manometry, may be predictive of long-term symptoms following laparoscopic Nissen
fundoplication.
Presented as an oral abstract on 20 April 2007 at SAGES 2007, Las Vegas, USA 相似文献
3.
Guérin E Bétroune K Closset J Mehdi A Lefèbvre JC Houben JJ Gelin M Vaneukem P El Nakadi I 《Surgical endoscopy》2007,21(11):1985-1990
Background Laparoscopic Toupet fundoplication (TF) is reported to be as effective as Nissen (NF), but to be associated with fewer unfavorable
postoperative side-effects. This study evaluates the one- and three-year clinical outcome of 140 randomized patients after
a laparoscopic NF or TF.
Patients and methods Inclusion criteria included patients over 16 years old with complications of gastro-oesophageal reflux disease (GORD) and persistence or recurrence of symptoms after three months of treatment. Subjects with a previous history of gastric
surgery or repeated fundoplication, brachy-oesophagus or severe abnormal manometry results were excluded. Seventy-seven NF
and 63 TF were performed. The severity of symptoms was assessed before and after the procedure.
Results One hundred and twenty-one of the 140 patients after one year, and 118 after three years, were evaluated and no statistically
significant clinical difference was observed. The level of satisfaction concerning the outcome of the operation remained high
after one or three years regardless of the type of fundoplication performed.
Conclusions Functional complications after NF are not avoided with TF. 相似文献
4.
Background Laparoscopic Nissen fundoplication (LNF) efficiently controls the symptoms of gastroesophageal reflux disease (GERD); however,
other nonspecific gastrointestinal (GI) symptoms have been reported following LNF. The aim of this study was to evaluate the
long-term effects of LNF on nonspecific GI complaints.
Methods The basis for this study is the prospective follow-up of 515 patients (mean age 46 ± 13 years) who underwent a LNF between
1992 and 1998. A questionnaire was designed to evaluate GERD symptoms (i.e., heartburn, epigastric pain, regurgitation, dysphagia,
and fullness, score 0–60) and nonspecific GI symptoms (i.e., vomiting, diarrhea, constipation, and lack of appetite, score
0–48). Patients were assessed before surgery, at 6 months, 2 years, and 5 years after surgery.
Results Laparoscopic Nissen fundoplication was associated with a significant decrease in both GERD and nonspecific GI symptoms score
at 6 months and up to 5 years, in the whole group (p < 0.001). 360 patients (69.7%) had preoperative nonspecific GI symptoms and experienced a significant reduction in these
symptoms following the surgery and lasting up to 5 years. The other 155 patients (30.3%) had no preoperative GI symptoms (GI
symptoms score of 0). In this group, there was a small but statistically significant increase in GI symptoms score (p < 0.001). It was, however, clinically significant (defined as a score >12) in only 9.9% of the patients.
Conclusions Laparoscopic Nissen fundoplication provides an efficient treatment of GERD up to 5 years, and in a majority of patients, it
is not associated with any significant increase in nonspecific GI complaints. New nonspecific bowel symptoms can develop after
LNF in some patients but are unlikely to be clinically significant.
Presented to the Society of American Gastrointestinal Endoscopic Surgeons, Hollywood, Florida, April 2005 相似文献
5.
Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders 总被引:2,自引:0,他引:2
Background: The outcomes of a laparoscopic esophagomyotomy with posterior partial fundoplication were compared between groups of patients
with primary motility disorders.
Methods: In this study, 47 patients (26 women and 21 men, ages 24 to 77 years; mean, 47 years) with significant dysphagia or chest
pain who failed conservative treatment underwent a laparoscopic esophagomyotomy and posterior partial fundoplication. Preoperative
evaluation revealed four groups of primary motility disorders: achalasia (n= 12), nutcracker esophagus (n= 12), hypertensive lower esophageal sphincter (LES) (n= 16), and diffuse esophageal spasm (n= 7). Statistical analysis was performed by Cramer's V test.
Results: Average follow-up period was 30.3 months. There was no mortality or early morbidity. Late morbidity included dysphagia or
chest pain over 6 weeks in 10 patients (21%), recurrent gastroesophageal reflux disease (GERD) in 3 patients (6%), and recurrent
motility disorder in 2 patients (4%). Overall, 94% of the patients ultimately had complete resolution of dysphagia or chest
pain. There was no significant difference in outcomes between groups.
Conclusion: Early results suggest that laparoscopic esophagomyotomy with posterior partial fundoplication provides safe and effective
relief from dysphagia and chest pain in patients with each of the primary motility disorders.
Received: 18 February 1999/Accepted: 16 December 1999/Online publication: 13 June 2000 相似文献
6.
Kaufman JA Houghland JE Quiroga E Cahill M Pellegrini CA Oelschlager BK 《Surgical endoscopy》2006,20(12):1824-1830
A strong link exists between gastroesophageal reflux disease (GERD) and airway diseases. Surgical therapy has been recommended
as it is more effective than medical therapy in the short term, but there is little data on the effectiveness of surgery long-term.
We analyzed the long-term response of GERD-related airway disease after laparoscopic anti-reflux surgery (LARS).
Methods In 2004, we contacted 128 patients with airway symptoms and GERD who underwent laparoscopic antireflux surgery (LARS) between
12/1993 and 12/2002. At median follow-up of 53 months (19–110 mo) we studied the effects on symptoms, esophageal acid exposure,
and medication use and we analyzed the data to determine predictors of successful resolution of airway symptoms.
Results Cough, hoarseness, wheezing, sore throat, and dyspnea improved in 65-75% of patients. Heartburn improved in 91 % (105/116)
of patients and regurgitation in 92% (90/98). The response rate for airway symptoms was the same in patients with and without
heartburn. Almost every patient took proton pump inhibitors (PPIs) preoperatively (99%, 127/128) and 61% (n = 78) were taking double or triple dose. Postoperatively, 33% (n = 45) of patients were using daily anti-acid therapy but no one was on double dose. The only factor that predicted a successful
surgical outcome was the presence of abnormal reflux in the pharynx as determined by 24-hour pharyngeal pH monitoring. One
hundred eleven (87%) patients rated their results as excellent (n = 78, 57%) or good (n = 33, 24%).
Conclusion LARS provides an effective and durable barrier to reflux, and in so doing improves GERD-related airway symptoms in ∼70% of
patients and improves typical GERD symptoms in ∼90% of patients. Pharyngeal pH monitoring identifies those patients more likely
to benefit from LARS, but better diagnostic tools are needed to improve the response of airway symptoms to that of typical
esophageal symptoms. 相似文献
7.
D. von Renteln I. Schiefke K. H. Fuchs S. Raczynski M. Philipper W. Breithaupt K. Caca H. Neuhaus 《Surgical endoscopy》2009,23(8):1866-1875
Background
The full-thickness Plicator® (Ethicon Endosurgery, Sommerville, NJ, USA) was developed for endoscopic treatment of gastroesophageal reflux disease (GERD). The goal is to restructure the antireflux barrier by delivering transmural pledgeted sutures through the gastric cardia. To date, studies using this device have involved the placement of a single suture to create the plication. The purpose of this study was to evaluate the 12-month safety and efficacy of this procedure using multiple implants to restructure the gastroesophageal (GE) junction.Methods
A multicenter, prospective, open-label trial was conducted at four tertiary centers. Eligibility criteria included symptomatic GERD [GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire, off of medication], and pathologic reflux (abnormal 24-h pH) requiring daily proton pump inhibitor therapy. Patients with Barrett’s epithelium, esophageal dysmotility, hiatal hernia >3 cm, and esophagitis (grade III or greater) were excluded. All patients underwent endoscopic full-thickness plication with linear placement of at least two transmural pledgeted sutures in the anterior gastric cardia.Results
Forty-one patients were treated. Twelve months post treatment, 74% of patients demonstrated improvement in GERD-HRQL scores by ≥50%, with mean decrease of 17.6 points compared with baseline (7.8 vs. 25.4, p < 0.001). Using an intention-to-treat model, 63% of patients had symptomatic improvements of ≥50%, with mean GERD-HRQL decrease of 15.0 (11.0 vs. 26.0, p < 0.001). The need for daily proton pump inhibitor (PPI) therapy was eliminated in 69% of patients at 12 months on a per-protocol basis, and 59% on an intention-to-treat basis. Adverse events included postprocedure abdominal pain (44%), shoulder pain (24%), and chest pain (17%). No long-term adverse events occurred.Conclusions
Endoscopic full-thickness plication using multiple Plicator implants can be used safely and effectively to improve GERD symptoms and reduce medication use. 相似文献8.
Cecilia Hagedorn M.D. Hans Lönroth M.D. Ph.D. Lars Rydberg M.D. Ph.D. Magnus Ruth M.D. Ph.D. Lars Lundell D. Ph.D. 《Journal of gastrointestinal surgery》2002,6(4):540-545
The efficacy of fundoplication operations in the long-term management of gastroesophageal reflux disease (GERD) has been documented.
However, only a few prospective controlled series support the longterm (>10 years) efficacy of these procedures, and further
data are required to also determine whether the type of fundoplication affects the frequency of postfundoplication complaints.
The aim of this study was to conduct a randomized, controlled clinical trial to assess the long-term symptomatic outcome of
a partial posterior fundoplication as compared to a total fundic wrap. During the years 1983 to 1991, a total of 13 7 patients
with chronic gastroesophageal reflux disease were enrolled in the study; 72 were randomized to semifundoplication (Toupet)
and 65 to total fundoplication (Nissen-Rossetti). A standardized symptom questionnaire was used for follow-up of these patients.
A total of 110 patients completed a median follow-up of 11.5 years; 54 had a total wrap and 56 underwent a partial posterior
fundoplication. During this period, seven patients required reoperation (Nissen-Rossetti in 5 and Toupet in 2), 11 patients
died, and nine patients were lost to follow-up or did not comply with the follow-up program. Control of heartburn (no symptoms
or mild, intermittent symptoms) was achieved in 88% and 92% in the total and partial fundoplication groups, respectively,
and the corresponding figures for control of acid regurgitation were 90% and 94%. We observed no difference in dysphagia scoring
between the two groups, although odynophagia was somewhat more frequently reported in those undergoing a total fundoplication.
On the other hand, a significant difference was observed in the prevalence of rectal flatus and postprandial fullness, which
were recorded significantly more often in those undergoing a total fundoplication (P < 0.001 and P < 0.03, respectively).
Posterior partial fundoplication seems to maintain the same high level of reflux control as total fundoplication. Earlier
observations demonstrating the advantages of a partial fundoplication, which included fewer complaints associated with gas-bloat,
continue to be valid after more than 10 years of follow-up.
prasented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23,
2001 (poster presentation). 相似文献
9.
Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis 总被引:3,自引:0,他引:3
Background: Partial fundoplication has traditionally been indicated for patients with gastroesophageal reflux disease (GERD)
who have defective peristalsis (DP). Because partial fundoplication had been reported to be a less effective means of controlling
acid reflux than total fundoplication, in 1997 we stopped performing partial fundoplication for patients with DP and switched
to a floppy total fundoplication. This study analyzes the results of our new strategy and compares it to our former approach.
Methods: We performed a partial fundoplication in 39 patients with DP (distal amplitude >40% of swallows) between 1994 and
1997 and a total fundoplication in 57 patients between 1997 and 2000. Symptoms scores derived from a standard questionnaire
with a scale of 0–4 manometry, and 24-h pH monitoring were completed preoperatively in 86 patients and postoperatively in
40 patients. Results: Heartburn scores improved in both groups (preoperative, 2.8; postoperative, 0.65; p<0.05). Dysphagia
was 1.1 preoperatively and 0.62 postoperatively (p=NS) in the partial fundoplication group and 1.2 preoperatively and 0.3
postoperatively (p<0.05) in the total fundoplication group. Furthermore, none of the patients in the total fundoplication
group developed new dysphagia and none required dilatation. Distal esophageal acid exposure normalized in both groups after
operative treatment (median DeMeester score:72.3 vs 11.3, p<0.05, For partial fundoplication; 57.1 vs 6.3, p<0.05, For total
fundoplication). Distal esophageal amplitudes averaged 27.8 mmHg preoperatively and 35.6 mmHg (p = NS) in the partial fundoplication
group, they averaged 28.2 mmHg preoperatively vs 49.0 mmHg postoperatively (p<0.005) in the total fundoplication group. Two
patients with a previous partial fundoplication required a conversion to a total fundoplication. No postoperative dilation
was required in either group. Conclusions: Our study shows that both a partial and a total fundoplication are effective in
controlling the symptoms of GERD in patients with defective peristalsis. Dysphagia improves significantly after total fundoplication
but not after partial fundoplication. Although both operations brought acid reflux to within normal limits, the effect was
more pronounced with total fundoplication. Total, but not partial, fundoplication produced a significant increase in amplitude
of esophageal peristalsis, which may explain the subjective improvement during deglution. Therefore, fundoplication should
be the treatment of choice in patients with GERD and defective peristalsis. 相似文献
10.
Aim To assess the performance of a paediatric cohort having a FRECA PEG (FP) placed at the time of laparoscopic fundoplication.
Methods This is retrospective study of a single surgeon’s experience of laparoscopic fundoplications over a decade. Patient details
were retrieved form a Microsoft Excel database and demographic, operative, and performance measures analysed.
Results Of a series of 67 laparoscopic fundoplications, 20 with neurological compromise underwent FP placement at the time of surgery.
Mean age was 3.37 years with a male to female ratio of 1.1:1. A size 9 French FRECA was placed in patients less than 10 kg
(12) with larger patients (8) having a size 15 device. A Watson anterior wrap was performed in 16 cases with the rest having
a Nissen fundoplication. Seven of these cases had pre-existing FPs which were taken down before replacement post fundoplication.
Feeding was resumed the next morning except in three with delayed gastric emptying. Other complications (3) were seen but
were not PEG related. The median stay for the series was 4 days (SD 3) and patients were followed up for a mean of 684 days.
Over this period four patients relapsed and resumed medical treatment. A single mortality occurred in a syndromic 3-year-old
a year later from problems unrelated to surgery.
FPs were changed to a button device under general anaesthetic 3–24 months following placement.
Conclusion FP placement at the time of laparoscopic fundoplication does not appear to compromise the outcome of surgery. Neither the
size of patient nor the type of wrap is an impediment to its placement and the device can be used shortly after surgery in
the majority allowing for an early discharge. Complications are infrequent; however, change to a button device within 2 years
of initial placement requires general anaesthetic. 相似文献
11.
Winslow ER Clouse RE Desai KM Frisella P Gunsberger T Soper NJ Klingensmith ME 《Surgical endoscopy》2003,17(5):738-745
Background: The clinical outcomes of laparoscopic antireflux surgery (LARS) in patients with the spectrum of nonspecific spastic esophageal motor disorders (NSSDs) are not known. Methods: From a prospective database of patients undergoing LARS between 1997 and 2000, those with preoperative manometry at our institution and follow-up at 6 months were identified. Results: Of the 121 patients, 35 had NSSDs. There were no differences in symptoms between groups preoperatively, but in the immediate postoperative period NSSD patients had more symptoms than nonspastic patients. At 18-month mean follow-up, NSSD patients reported significantly more heartburn (22% vs 7%), waterbrash (14% vs 4%), and medication usage (17% vs 5%) than nonspastic patients (p < 0.05 for each). Despite this difference, nearly all patients reported subjective improvement postoperatively, and the degree of improvement was similar between groups. Conclusions: Patients with NSSDs are more likely to have esophageal symptoms following LARS than subjects without these abnormalities. However, these patients still experience significant improvement in preoperative symptoms.
Presented at the 8th World Congress Society of American Gastrointestinal Endoscopic Surgeons (SAGES). New York, NY, USA, March 2002 相似文献
12.
Papasavas PK Keenan RJ Yeaney WW Caushaj PF Gagné DJ Landreneau RJ 《Surgical endoscopy》2003,17(8):1200-1205
Background: Recent reports have suggested that antireflux surgery should not be advised with the expectation of elimination of medical treatment. We reviewed our results with laparoscopic fundoplication as a means of eliminating the symptoms of gastroesophageal reflux disease (GERD), improving quality of life, and freeing patients from chronic medical treatment for GERD. Methods: A total of 297 patients who underwent laparoscopic fundoplication (Nissen, n = 252; Toupet, n = 45) were followed for an average of 31.4 months. Preoperative evaluation included endoscopy, barium esophagram, esophageal manometry, and 24-h pH analysis. A preoperative and postoperative visual analogue scoring scale (0–10 severity) was used to evaluate symptoms of heartburn, regurgitation, and dysphagia. A GERD score (2–32) as described by Jamieson was also utilized. The need for GERD medications before and after surgery was assessed. Results: At 2-year follow-up, the average symptom scores decreased significantly in comparison to the preoperative values: heartburn from 8.4 to 1.7, regurgitation from 7.2 to 0.7, and dysphagia from 3.7 to 1.0. The Jamieson GERD score also decreased from 25.7 preoperatively to 4.1 postoperatively. Only 10% of patients were on proton pump inhibitors (PPI) at 2 years after surgery for typical GERD symptoms. A similar percentage of patients (8.7%) were on PPI treatment for questionable reasons, such as Barretts esophagus, sensitive stomach, and irritable bowel syndrome. Seventeen patients (5.7%) required repeat fundoplication for heartburn (n = 9), dysphagia (n = 5), and gas/bloating (n = 3). Conclusions: Laparoscopic fundoplication can successfully eliminate GERD symptoms and improve quality of life. Significant reduction in the need for chronic GERD medical treatment 2 years after antireflux surgery can be anticipated.
Presented at the combined meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the 8th World Congress of Endoscopic Surgery, New York, NY, USA, 13–16 March 2002 相似文献