Mechanisms responsible for recurrent gastroesophageal reflux in neurologically impaired children who underwent laparoscopic Nissen fundoplication

Background: In this study, we attempted to define the lower esophageal sphincter (LES) motor events associated with the occurrence of gastroesophageal reflux (GER) in neurologically impaired children in whom of GER disease recurred after laparoscopic Nissen fundoplication (LNF). Methods: Of 45 neurologically impaired children who had previously undergone LNF, six children in whom recurrence of GER disease was documented by 24-h esophageal pH monitoring were studied. Concurrent esophageal manometry and pH monitoring were conducted for 1 h both before and after the administration of apple juice (10 ml/kg). Results: A total of 89 reflux episodes were recorded in the course of the study. Of these, 51 episodes (57%) were associated with transient LES relaxation. In the remainder, reflux occurred across a contracted LES in 21 episodes (24%) and during absent basal LES tone in 15 episodes (17%). In four of six patients, transient LES relaxation was responsible for more than half of the reflux episodes. Conclusion: Transient LES relaxation is the predominant mechanism of reflux in neurologically impaired children with recurrent GER after LNF.     

Laparoscopic Nissen fundoplication versus 90° and 180° fundoplication for gastroesophageal reflux disease

European Surgery - Laparoscopic Nissen fundoplication (LNF) is standard care for surgical treatment of gastroesophageal reflux disease (GERD) in adults. The main disadvantage is the compression of...     

Gastroesophageal disease and nausea: does fundoplication help or hurt?

HYPOTHESIS: Nausea associated with gastroesophageal reflux disease is cured by laparoscopic Nissen fundoplication (LNF). DESIGN: Prospective cohort study of unselected patients who underwent LNF from January 1, 1995, through March 31, 1999. Patients were followed up by a physician for 6 to 36 months. SETTING: A large community teaching hospital. PATIENTS: One hundred consecutive patients with gastroesophageal reflux disease who underwent LNF; all patients were followed up. Patients were grouped according to the presence (group A, n = 33) or absence (group B, n = 67) of preoperative nausea. Interventions were LNF, esophageal manometry, 24-hour pH monitoring, and nuclear gastric emptying studies. MAIN OUTCOME MEASURES: Resolution of symptoms after LNF. RESULTS: Nausea was the most common atypical symptom of gastroesophageal reflux disease, occurring in 33 patients (33%). There were no differences in esophageal manometry or 24-hour pH results between groups. There was a female preponderance in group A (55% vs 33%; P = .003). Patients in group A had a higher prevalence of preoperative dysphagia (P = .02). Patients with persistent postoperative nausea had a higher prevalence of cough (P = .003) and dysphagia (P = .009). The LNF was more effective in reducing heartburn (95% reduction) and regurgitation (95% reduction) than cough and dysphagia (60% reduction). There was a 79% reduction in the number of patients with nausea (33 to 7; P<.001). CONCLUSION: Laparoscopic Nissen fundoplication is effective in eliminating nausea associated with gastroesophageal reflux disease and is not contraindicated in these patients.     

腹腔镜Nissen胃底折叠术治疗胃食管反流病

目的 探讨腹腔镜Nissen胃底折叠术治疗胃食管反流病的效果.方法 对近2年来收治的109例胃食管反流病实施腹腔镜Nissen胃底折叠术患者的临床资料进行回顾性分析.结果 108例成功完成手术.1例因难以控制的脾上极胃短血管出血而中转开腹.手术用时30-245(平均68.1)min,术中出血5～450(平均30.0)mL;术后住院天数2～8(平均4.2)天.术后102例获3～27个月的随访,7例失访.随访患者中99例(97.1%)反酸、烧心等消化道症状基本消失,2例(2.0%)明显缓解,1例(0.9%)无效.术后2例出现较严重的吞咽困难,1例严重上腹胀气,2例腹泻,1例出现术后食管裂孔疝.结论 腹腔镜Nissen胃底折叠术是治疗胃食管反流病的一种微创、安全、有效的治疗方法.     

Effect of laparoscopic antireflux operation on esophageal manometry, 24 hours pH-metry and quality of life in gastroesophageal reflux disease

It has been suggested that laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastroesophageal reflux disease (GERD). Twenty-six patients with chronic gastroesophageal reflux disease underwent laparoscopic floppy Nissen fundoplication. 24 hours pH-metry, manometry and Gastrointestinal Quality of Life Index (GIQLI) questionnaire were done preoperatively, six-month and one year after the operation. The six weeks control investigation was limited to 24 pH-metry and GIQLI interview. Adequate reflux control was obtained in all patients, with reduction in acid reflux variables at six weeks, six months as well as at one year after the operation. Preoperative reflux index and DeMeester score was significantly higher than those we found postoperatively at both time period. Preoperative lower esophageal sphincter tone and length was abnormal on average. Both parameters increased significantly at six-month and one year after the operation. GIQLI also showed characteristic changes. Compared to preoperative values we found significantly higher GIQLI at both six-month and one year following surgery. Laparoscopic Nissen fundoplication provides an excellent symptomatic and physiologic outcome in patients with esophageal reflux disease.     

Motor function of the esophagus and the lower esophageal sphincter in children who undergo laparoscopic nissen fundoplication

BACKGROUND/PURPOSE: To define the clinical role of laparoscopic Nissen fundoplication (LNF) in children with gastroesophageal reflux (GER), an appropriate understanding of its functional effects is required. The aim of this study was to investigate the motor function of the esophageal body and the lower esophageal sphincter (LES) with special reference to the effects of caloric nutrients in children undergoing LNF. METHODS: Studies were performed in 12 children with GER (age, 6 months to 13 years) before and a month after LNF. Continuous manometric examination was performed with an infusion system using a sleeve sensor for an hour each before and after the administration of apple juice (AAJ; 10 mL/kg). RESULTS: AAJ increased postoperative basal LES pressure from 15 +/- 7 to 20 +/- 6 mm Hg, whereas it decreased the preoperative values from 13 +/- 5 to 10 +/- 4 mm Hg (P < .05). Significant residual pressure was noted at the nadir of swallow-induced LES relaxation after LNF, which was increased by AAJ from 7 +/- 3 to 11 +/- 4 mm Hg. A child with a high nadir LES pressure showed postoperative dysphagia. Significant changes in the patterns of esophageal contractions were not noted after LNF. CONCLUSIONS: Characteristics of the effect of LNF on the LES were a postprandial increase of basal LES pressure and significant residual LES pressure at the nadir of LES relaxation. The motor function of the esophageal body was not affected by LNF.     

Normal Lower Esophageal Sphincter Pressure and Length Does Not Impact Outcome After Laparoscopic Nissen Fundoplication

Intuitively, a manometrically normal lower esophageal sphincter (LES) will promote dysphagia after laparoscopic Nissen fundoplication. This study was undertaken to compare outcomes after laparoscopic Nissen fundoplication for patients who had normal and manometrically inadequate LES preoperatively. Before fundoplication, the length and resting pressures of LES were determined manometrically in 59 patients with documented gastroesophageal reflux disease (GERD). Twenty-nine patients had a manometrically normal LES, with resting pressures >10 mm Hg and length >2 cm. Thirty patients had resting pressures of ≤10 mm Hg and length of ≤2 cm. Before and after fundoplication, patients graded the frequency and severity of symptoms of GERD utilizing a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). DeMeester scores and symptom scores before and after fundoplication were compared. Before fundoplication, the manometric character of the LES did not impact the elevation of DeMeester scores or the frequency/severity of reflux symptoms. All symptoms improved significantly with fundoplication independent of LES pressure/length. Prefundoplication, manometric character of the LES did not impact the frequency or severity of reflux symptoms after fundoplication. Preoperative manometric character of the LES does not impact the presentation of GERD or the outcome after fundoplication. Symptoms globally and significantly improve after fundoplication, independent of manometric LES character. Normal LES manometry does not impact outcome and, specifically, does not promote dysphagia, after laparoscopic Nissen fundoplication. Presented at the 47th Annual Meeting for the Society of Surgery of the Alimentary Tract, Los Angeles, CA May 20 to 24 2006     

Randomized clinical trial of standard laparoscopic versus robot-assisted laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease

BACKGROUND: Robotic systems for minimally invasive surgery may be of added value during extensive dissection and suturing in confined spaces, such as laparoscopic Nissen fundoplication (LNF). The purpose of this trial was to compare standard LNF with robot-assisted Nissen fundoplication (RNF). METHODS: Between 2003 and 2005, 50 patients with confirmed refractory gastro-oesophageal reflux disease were assigned to LNF (25) or RNF (25). Patients who had undergone previous antireflux surgery were excluded. Independent assessment of dysphagia, regurgitation, heartburn and general well-being was performed before and 6 months after surgery using questionnaires. Objective outcome was studied 6 months after surgery by oesophageal manometry, 24-h pH monitoring, barium oesophagram series and upper endoscopy. RESULTS: Operating time, blood loss, postoperative pain scores, hospital stay and complication rates did not differ significantly between the two groups. Reoperation rates were the same (one incisional hernia after LNF and one patient with repeat Nissen after RNF because of persistent dysphagia). Postoperative self-rated change in reflux symptoms and quality of life improved equally in both groups. The reduction in oesophageal acid exposure, increase in lower oesophageal sphincter tone and mucosal healing were comparable in both groups at follow-up. CONCLUSION: RNF yielded similar subjective and objective results to LNF in this study. Therefore no additive value of robotic systems for this procedure was detected up to 6 months after surgery.     

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.     

The effect of total and anterior partial fundoplication on antireflux mechanisms of the gastroesophageal junction

BACKGROUND: The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication. METHODS: Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension. RESULTS: Both types of fundoplication resulted in significant increases in LES resting (P <0.001) and postdeglutition relaxation pressure (P <0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04). CONCLUSIONS: Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.     

腹腔镜胃底折叠术治疗胃食管反流病372例

目的 探讨腹腔镜胃底折叠术治疗胃食管反流病(GERD)的可行性和临床应用价值.方法 2005年9月至2010年8月,对372例GERD病人实施腹腔镜胃底折叠术,其中Nissen胃底折叠术146例,Toupet胃底折叠术79例,前180°胃底折叠术147例,记录围手术期相关指标,随访观察治疗效果.结果 372例均完成腹腔镜手术,无中转开腹者.手术时间50～210 min,平均85 min;术中出血40～150 ml,平均86 ml.术后住院3～21天,平均4.3天.术后临床症状均得到缓解,无严重并发症及死亡病例.术后3个月复查胃镜、上消化道造影、食管测压和24 h食管pH检测均恢复正常.350例随访～63个月,平均27.3个月,对手术效果满意率92.57%,19例有进固体食物时轻度梗噎感,6例反酸症状复发,使用抑酸药物可控制,1例食管裂孔疝复发.结论 腹腔镜胃底折叠术治疗中、重度GERD充分体现了微创手术创伤小、恢复快、安全可行、疗效可靠的特点;3种胃底折叠方式根据病人具体情况应用,能够最大限度地保证手术效果、降低操作难度,减少术后并发症.

Abstract：

Objective To investigate the feasibility and clinical value of laparoscopic surgery in treating patients with gastroesophageal reflux disease. Methods From September 2001 to August 2009, 372 patients with gastroesophageal reflux disease undertwent laparoscopic fundoplication, including 146 cases of Nissen fundoplication, 79 Toupet fundoplication, and 147 anterior 180 degrees partial fundoplication. Para-operative clinical parameters were recorded. All patients were routinely followed up. Clinical outcomes were collected and analyzed. Results Laparoscopic surgery was successfully performed in all patients, and no conversions were required. The operating time was 50 -210 minutes (mean, 85 minutes), the operative blood loss was 40 - 150 ml( mean, 86 ml) ,the postoperative hospital stay was 3 - 21 days( mean, 4.3 days ). The symptoms in most cases were adequately relieved after operation. There were no severe postoperative morbidity and mortality. Endoscopy, radiology, esophageal manometry and 24-hour pH monitoring were repeated 3 months after surgery. After the follow-up period of 3 -63 months ( mean, 27.3 months), the satisfaction rate of operation was 92.57%. 19 cases had mild dysphagia when eating solid food. Symptoms recurrence of acid reflux occurred in 6 cases, which were controlled by antacid medications. Hiatal hernia recurrence occurred in 1 case. Conclusions Laparoscopic operation should be the method of choice to treat the moderate to severe gastroesophageal reflux disease, with the advantages of minimized trauma,quick recovery, safety,feasibility and reliable effect. According to individual condition of patients, appropriate fundoplication procedure should be employed carefully to ensure results of operations, reduce operating difficulties and the rate of postoperative complications.     

Laparoscopic Nissen fundoplication: two-year comprehensive follow-up of a technique of minimal paraesophageal dissection.

OBJECTIVE: To provide a comprehensive follow-up of 381 patients after laparoscopic Nissen fundoplication (LNF) using a technique of minimal paraesophageal dissection. METHODS: Patients underwent a 24-hour pH recording, esophageal manometry, and symptom score assessment for six symptoms of gastroesophageal reflux disease preoperatively. To date, 260 patients have undergone repeat studies at 6 months and 108 patients at 2 years. RESULTS: LNF was associated with a significant (p < 0.0001) increase in the lower esophageal sphincter (LES) pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours and symptom score 6 and 24 months after surgery when compared to preoperative values. Twelve patients (3%) have experienced recurrence of reflux symptoms, 8 presenting in the first 6 months and 4 by the second year after surgery, but only 1 has required repeat surgery. The incidence of clinical dysphagia was found to be 1.3% of the patient group. CONCLUSIONS: LNF remains an effective antireflux procedure at 2 years. Most recurrences occur early, and there is no significant deterioration in the high-pressure zone at the LES, the percentage reflux in 24 hours, or symptom control between 6 months and 2 years after surgery, suggesting that the long-term results should be satisfactory.     

Meta-analysis of laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastro-oesophageal reflux disease based on randomized clinical trials

Background: Laparoscopic Nissen fundoplication (LNF) is the standard procedure for surgical management of gastro‐oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) is reported to be as effective as LNF but to be associated with a lower incidence of post‐operative dysphagia. This meta‐analysis was performed to compare the two techniques with respect to reflux control and associated complications, particularly dysphagia. Methods: Pubmed, Medline, Embase and The Cochrane Library were searched. Only randomized controlled trials (RCTs) comparing LNF and LTF were included. Outcomes evaluated were occurrences of heartburn and associated complications (e.g. dysphagia) and degree of patient's satisfaction at early (three to six months) and later (one to three years) post‐operative periods. Results: Of 939 patients in seven RCTs, 478 received LNF and 461 received LTF. For both groups, control of reflux was good and occurrence of heartburn were similar. A lower incidence of post‐operative dysphagia for both early and later post‐operative periods was observed for the LTF group. Patient's satisfaction following either procedure was similar. Conclusion: LNF and LTF are both safe and effective. LTF is truly associated with a lower occurrence of dysphagia. However, LTF is more likely than LNF to be associated with early surgical complications. On the whole, post‐surgical satisfaction ratios for the two groups were comparable.     

Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease (GERD)

Background: A prospective study was conducted to evaluate the physiologic and clinical consequences of laparoscopic Nissen fundoplication (LNF), using strict indications for surgery. Methods: From 1992 to 1997, 50 patients underwent LNF. Indications for operative treatment were either failure of conservative treatment or foresight to see long-term use of strong acid suppressive therapy. Patients were evaluated by barium esophagogastric study (BES), esophagoscopy, 24-h pH monitoring (pHM), stationary esophageal manometry, gastric-emptying studies (GES), pancreatic polypeptide stimulation test (PPT) and clinical evaluation using questionnaires. Results: Perioperative complications necessitated conversion to laparatomy in two cases, and there was no mortality. Severe dysphagia resulted in reoperation in two patients. The average maximum lower esophageal sphincter pressure (MLESP) increased from 6.1 mmHg to 12.7 mmHg. Endoscopy showed improved grading of the esophagitis, and the total percentage of pH less than 4 during 24 h decreased from a mean of 9.2 to 0.95. Three patients demonstrated impaired PPTs postoperatively; two had (mild) diarrhea. The overall success rate after the operation was 90%. Conclusions: The results of LNF in a limited number of patients with severe and/or resistant gastroesophageal reflux disease (GERD) receiving continuous medical treatment with proton pump inhibitors (PPIs) on a maintenance base are comparable with LNF results in centers with a more liberal policy concerning indications for LNF surgery. Received: 15 September 1997/Accepted: 12 October 1997     

Comparison of laparoscopic and open Nissen fundoplication 2 years after operationrid=""

BACKGROUND: Laparoscopic operation has replaced the conventional open procedure in the treatment of gastroesophageal reflux disease (GERD) in spite of the fact that long-term results based on controlled clinical trials have been lacking. The objective of this study was to compare outcome, quality of life, and patient satisfaction after laparoscopic and open Nissen fundoplication in a community hospital setting with a 2-year follow-up. METHODS: Forty-two patients with GERD were randomized to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Outcome evaluation included reflux symptoms, gastrointestinal quality of life (GIQLI), and upper GI endoscopy. RESULTS: Esophagitis was cured among all patients in the LNF group and in 90% of the ONF group. There were two patients (10%) in both groups who had medicine-dependent recurrent reflux together with significant worsening in the GIQLI scores. One patient in the LNF group has been reoperated due to a suture granuloma in the left epigastric port. Two patients in the LNF group needed esophageal dilatation due to persistent dysphagia. GIQLI scores (scale, 0-144) were equally normalized in both groups. Overall, 90% in the LNF and 100% in the ONF group were either satisfied or very satisfied with the operation. There was only one patient (LNF) who would not choose to have the operation again. CONCLUSIONS: Laparoscopic and open Nissen fundoplication seem to be equally effective methods for improving reflux symptoms and quality of life, resulting in a high rate of satisfaction among patients with an intermediate follow-up period of 2 years.     

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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.     

Impact of laparoscopic nissen fundoplication with prosthetic hiatal closure on esophageal body motility: Results of a prospective randomized trial

HYPOTHESIS: Prosthetic crural closure does not adversely influence esophageal body motility. In most patients, postoperative increased dysphagia resolves spontaneously during the first months after surgery. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatal closure and those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: Forty consecutive patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease. INTERVENTIONS: A 360 degrees Nissen fundoplication with simple sutured crura (n = 20; nonmesh group) vs the same procedure with posterior 1 x 3-cm polypropylene onlay mesh prosthesis (n = 20; mesh group). MAIN OUTCOME MEASURES: Recurrences; postoperative dysphagia rate; localization, length, and pressure of the lower esophageal sphincter (LES); results of 24-hour pH monitoring; esophageal body motility; peristalsis; and esophageal amplitude of contraction and interrupted waves. RESULTS: Preoperatively, both groups had pathological LES pressure and DeMeester scores. These values improved significantly (P < .01) after surgery and remained stable at 1 year after surgery. Patients in the nonmesh group had a significantly lower LES pressure 1 year after surgery compared with those in the mesh group. There were no significant differences in postoperative mean LES length (4.1 vs 3.8 cm), LES relaxation (93.4% vs 92.4%), and intra-abdominal LES length (2.1 vs 2.1 cm). Patients in the mesh group had fewer simultaneous waves and interrupted waves 1 year after surgery, but the difference between groups was not significant. There were no significant differences in interrupted waves and amplitude of contraction between groups 1 year after surgery. CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic crural closure does not impair postoperative esophageal body motility compared with laparoscopic Nissen fundoplication with simple suture hiatal closure, although it is associated with a higher rate of short-term dysphagia.     

Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study

BACKGROUND: Postoperative intrathoracic wrap migration is the most frequent morphological complication after laparoscopic antireflux surgery. Previous authors have studied the use of prosthetic materials for hiatal closure to prevent recurrence of hiatal hernia and/or postoperative intrathoracic wrap herniation. HYPOTHESIS: Patients with prosthetic hiatal closure have a higher rate of short-term dysphagia but a significantly lower rate of postoperative intrathoracic wrap herniation at follow-up. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatoplasty with those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: One hundred consecutive patients undergoing laparoscopic Nissen fundoplication for gastroesophageal reflux disease and hiatal hernia repair. INTERVENTION: Laparoscopic Nissen fundoplication with simple sutured crural closure (n = 50 [group 1]) vs laparoscopic Nissen fundoplication with simple sutured cruroplasty and onlay of a polypropylene mesh (n = 50 [group 2]). MAIN OUTCOME MEASURES: Recurrences; complications; results of esophageal manometry, 24-hour pH monitoring, esophagogastroduodenoscopy, and barium swallow test; and symptomatic outcome. RESULTS: Patients in both groups had similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring. At the 3-month and 1-year follow-ups, functional outcome variables (lower esophageal sphincter pressure and DeMeester score) improved significantly compared with the preoperative values. A higher postoperative dysphagia rate could be evaluated in group 2. An intrathoracic wrap migration occurred in 13 patients (26%) in group 1 vs 4 (8%) in group 2 (P<.001). CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic cruroplasty is an effective procedure to reduce the incidence of postoperative hiatal hernia recurrence and intrathoracic wrap herniation.     

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. Methods A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. Results In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 ± 5.2 mmHg (range, 6.0–30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% ± 8.3% (range, 70–100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett’s progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1–46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. Conclusion The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360° fundoplication should not be contraindicated for patients with severe esophageal dysmotility.     

Impact of laparoscopic Nissen’s fundoplication on response of disease specific symptoms and quality of life

The aim of this study is to establish responsiveness of gastroesophageal reflux disease (GERD) symptom score, quality of life SF-36 score in GERD with relation to oesophageal manometry and upper gastrointestinal endoscopy following laparoscopic Nissen’s fundoplication (LNF). Interventional prospective study was done enrolling 77 patients of GERD who respond to proton pump inhibitor (PPI) and have undergone LNF, strict diagnostic criteria were followed with GERD score, upper gastrointestinal endoscopy, oesophageal manometry, and endoscopically negative patients have further undergone 24-h pH study. Follow-up was done at 12 and 24 months by GERD score, SF-36 score, endoscopy, oesophageal manometry. GERD score shows significant difference in pre-operative and post-operative score with P value <0.001 except dysphagia. Post-LNF improvement in GERD score is consistent with improvement in lower oesophageal sphincter (LES) pressure at 12 months. All dimensions in quality of life SF-36 show significant difference in pre-operative and post-operative score at 12 months with P value <0.001. Results are consistent at 24 months. Oesophagitis was decreased from 40.2 to 11.6 % as well as it showed down grading on endoscopy in post-operative period. Out of three patients of complete disruption of wrap, two patients underwent redo surgery and showed improvement. In properly diagnosed PPI respondent patients by GERD score, LNF has got improvement in GERD score, quality of life in all dimensions of SF-36 score in relation to improvement with LES pressure and oesophagitis.