Efficacy of laparoscopic antireflux surgery in patients with Barrett's esophagus

BACKGROUND: Laparoscopic antireflux surgery (LARS) corrects significant physiologic and anatomic abnormalities in patients with gastroesophageal reflux disease (GERD); however, debate exists whether LARS prevents recurrent symptoms and malignant transformation in patients with Barrett's esophagus (BE). This study compared clinical outcomes after LARS in patients with and without BE. METHODS: From 1994 to 2001, 448 patients who underwent LARS were studied. Of these, 68 (15%) had preoperative evidence of BE with low-grade dysplasia in 3 (4%), and 380 (85%) were without BE. Mean postoperative follow-up was more than 30 months in each group. RESULTS: After LARS, there was equivalent reduction in acid reduction medication use and typical GERD symptoms in both groups. Anatomic failures developed in 12% of patients with BE and in 5% of those without BE (P = 0.05). Upper endoscopy with biopsies was obtained in 50 of 68 patients (74%) with BE at 37 +/- 22 months postoperatively. Intestinal metaplasia was no longer present in 7 of 50 (14%) BE patients, and low-grade dysplasia regressed to nondysplastic Barrett's in 2 of 3 patients. New low-grade dysplasia developed in 1 BE patient (2%) at postoperative endoscopic surveillance. No BE patients developed high-grade dysplasia or adenocarcinoma. CONCLUSIONS: After LARS, patients with BE have symptomatic relief and reduction in medication use equivalent to non-BE patients. Regression of intestinal metaplasia and the absence of progression to high-grade dysplasia or adenocarcinoma suggest that LARS is an effective approach for the management of patients with Barrett's esophagus. The higher failure rate of LARS in BE is of concern and mandates ongoing follow-up of these patients.     

Does major depression in patients with gastroesophageal reflux disease affect the outcome of laparoscopic antireflux surgery?

Background: It is known that psychological factors can affect end points of surgical treatment. The current study aimed to evaluate the outcome of laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who experience concomitant major depression in comparison with GERD patients who have no known comorbidity. Methods: Among a sample of more than 550 patients who underwent LARS, a group of 38 GERD patients with concomitant major depression (MD) were included in this study. The patients included 24 women and 14 men, with a mean age of 51 years. A group of 38 control patients (non-MD) matched in terms of age, gender, and esophageal manometry findings was selected from the database for comparison of surgical outcomes between patients with GERD accompanied by concomitant major depression and GERD patients with no known comorbidity. In each group, 23 patients received a Toupet fundoplication and 15 patients underwent a "floppy" Nissen fundoplication. The following factors were evaluated before surgery, 3 months afterward, and 1 year after LARS: symptoms (heartburn, regurgitation, chest pain, bloating, and dysphagia), quality of life (Gastrointestinal Quality of Life Index [GIQLI]), lower esophageal sphincter pressure (LESP), and 24-h pH monitoring (DeMeester score). Results: Before and after surgery, there were no significant differences between the two groups in terms of LESP and DeMeester score. Preoperative GIQLI showed significant differences (p < 0.05) between the two groups (MD group, 71.8 ± 8.6 vs non-MD group, 91.1 ± 9.8), and significant differences (p < 0.01–0.001) between the mean data and that for healthy individuals (122.6 ± 8.5). The GIQLI scores had improved significantly at 3 months and at 1 year after surgery (p < 0.05–0.001) in all the patients (1 year postoperatively: MD group, 99.3 ± 8.6 vs non-MD group, 121.9 ± 9.7). Before surgery, when symptoms were compared between the two groups, significant differences (p < 0.001) were found in the percentage of chest pain (81.6% vs 37.4%) and bloating (92.2% vs 37.4%), showing that these symptoms were more predominant and graded as much more severe among patients with MD. In both groups, all the symptoms but dysphagia showed a significant improvement in severity (p < 0.05–0.0001). A comparison of both groups postoperatively showed that significant differences were still present in chest pain (44.7% vs 2.6%), bloating (68.4% vs 18.4), and dysphagia (50.1% vs 2.6%). A significant difference (p < 0.001) was observed only in patients with major depression and depending on the kind of wrap procedure (Nissen vs Toupet), showing that dysphagia (78.9% vs 21.1%) and chest pain (82.4% vs 17.6%) were much more predominant in patients who underwent "floppy" Nissen fundoplication. Conclusions: Even if they are good surgical candidates from a physiologic point of view, GERD patients with concomitant major depression should be selected carefully. In these patients, LARS can normalize physiologic data, but some patients have demonstrated less symptomatic relief, suffered from postoperative dysphagia, and showed less quality-of-life improvement. Eventually, laparoscopic Toupet fundoplication used with these patients could result in a better subjective outcome.     

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease

Background It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients.Methods From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 ± 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 ± 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients’ satisfaction with surgery. The data of a complete 5-year follow-up are available.Results There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients’ satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 ± 11.6 points/EGD-negative vs 93.8 ± 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 ± 8.5 for EGD-negative vs 120.9 ± 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 ± 8.5).Conclusion We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.Poster presented at the 11th International Congress of the European Association for Endoscopic Surgery, Glasgow, 2003     

Quality of life,surgical outcome,and patient satisfaction three years after laparoscopic Nissen fundoplication

Quality of life data and patient satisfaction are important issues in estimating the outcome of laparoscopic antireflux surgery (LARS). Long-term of quality of life assessment has not yet received wide attention. The aim of this prospective study was to evaluate surgical outcome, including quality of life and patient satisfaction, after laparoscopic "floppy" Nissen fundoplication up to 3 years after surgery. Between 1994 and 1996, a total of 150 consecutive patients with severe gastroesophageal reflux disease underwent laparoscopic "floppy" Nissen fundoplication. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). The GIQLI questionnaire was given to the patients prior to surgery, and again 3 months, 1 year, and 3 years postoperatively. In addition, 24-hour pH monitoring and esophageal manometry were performed preoperatively and at each follow-up date. Finally, surgical side-effects and patient satisfaction with the surgical outcome were evaluated 3 years after LARS. Postoperatively lower esophageal sphincter pressure improved significantly in all patients, whereas pH values showed normal data in all but 5 patients. Before surgery, all patients had a poor quality of life (GIQLI score, 90.1 ± 8.9 points). Postoperatively, GIQLI improved significantly (p <.01) and remained stable for at least 3 years, with a mean value of 123.7 ± 9.8 points. This is comparable to 122.6 ± 8.5 points of healthy individuals. Ninety-eight percent of the patients rated their satisfaction with surgical treatment as excellent or good and would undergo surgery again if necessary. Nine patients suffered from minimal surgical side-effects, but these did not significantly impair their quality of life. Laparoscopic reoperation was performed in 2 patients 3 months after initial surgery because of severe dysphagia. Both patients were free of symptoms 3 years after surgery. The efficacy and long-term outcome of treatment of gastroesophageal reflux disease with laparoscopic "floppy" Nissen fundoplication can be evaluated by objective testing, but also with subjective judgment of the patient, including quality of life assessment.     

The impact of laparoscopic anti-reflux surgery in patients with Barrett’s esophagus

Background

Barrett’s esophagus (BE) is a major risk factor for esophageal adenocarcinoma. It is believed that BE is caused by chronic gastro-esophageal reflux disease (GERD). Laparoscopic anti-reflux surgery (LARS) restores the competency of the cardia and may thereby change the natural course of BE. We studied the impact of LARS on the histological profile of BE and on the control of GERD.

Methods

We identified all patients with BE who underwent LARS from 1994 to 2007 and contacted them to assess post-operative GERD symptoms via questionnaire. Endoscopy findings, histology, 24 hour pH monitoring, and manometry were also collected using our prospectively maintained database. Histological regression was defined as either loss of dysplasia or disappearance of BE.

Results

Two hundred and fifteen patients met the initial inclusion criteria; in 82 of them histology from post-operative endoscopy was available for review. Endoscopy was performed a median of 8 years (range, 1–16 years) after surgery. Regression of BE occurred in 18 (22 %) patients while in 6 (7 %) BE progressed to dysplasia or cancer. Thirty-six (43 %) patients underwent pre- and post-operative manometry. The median lower esophageal sphincter pressure increased from 9 to 17 mmHg in these patients. Thirty-four (41 %) patients underwent pre- and post-operative pH studies. The median DeMeester score decreased from 54 to 9. Sixty-seven (82 %) of 82 patients completed the post-operative questionnaire; 86 % of these patients reported improvement in heartburn and regurgitation.

Conclusions

LARS was associated with both physiologic and symptomatic control of GERD in patients with BE. LARS resulted in regression of BE in 22 % of patients and progression in 7 %. Thus, continued surveillance of Barrett’s is needed after LARS.     

Quality of life one year after laparoscopic fundoplication is close to that of a control group: prospective study]

AIM OF THE STUDY: Prospective evaluation of the quality of life of patients after laparoscopic fundoplication for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: The quality of life of 30 consecutive patients who underwent laparoscopic fundoplication was evaluated using the GIQLI (gastrointestinal quality of life index) questionnaire, which included 36 items in five different areas: digestive symptoms, physical condition, emotional reaction, social integration and medical treatment. Seventeen men and 13 women (mean age: 50.2 +/- 17 years (32-68) were included with a follow-up of at least 1 year and with complete data available. The quality of life was evaluated before surgery, and at 1 month, 3 months, 6 months and 1 year after surgery with a 100% follow-up. Thirty healthy volunteers representing an identical population (with respect to age, sex, BMI, profession, smoking, etc.) anonymously filled in the same questionnaire. The pre- and postoperative GIQLI scores of patients operated for GERD were compared with the GIQLI score of the control group. RESULTS: Preoperatively, the GIQLI score (87 +/- 9.5) was much lower than that of the control group (123.4 +/- 13.6) (p < 0.001). This score significantly improved 3 months and 1 year after surgery and was comparable to that of the healthy population (115.3 +/- 9.6 vs 123.4 +/- 13.6 [ns]). Improvements were reported mainly with respect to digestive symptoms and physical condition. Social integration was slightly modified. CONCLUSION: The quality of life of patients after laparoscopic antireflux surgery was greatly improved and was close to the level expected in an healthy population. However, the study demonstrated the possible presence of postoperative functional digestive disorders, although these symptoms were not considered as being uncomfortable, since the level of satisfaction was 96.6% (n = 29).     

Symptomatic outcomes of laparoscopic antireflux surgery in patients eligible for endoluminal therapies

Background: This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who would be eligible for endoluminal therapies (ET) with those in patients who would be excluded from ET. Methods: From 1995 to the present, 459 patients who underwent LARS were analyzed prospectively. Of these, 117 patients (25%) without preoperative dysphagia, stricture, esophagitis worse than grade 2 or hiatal hernia larger than 2 cm were considered potential candidates for ET (group 1). By these criteria, 342 patients (75%) were not eligible for ET (group 2). Medication use and GERD symptoms were evaluated and compared between the two groups. Results: Perioperative outcomes including duration of operation, morbidity, length of hospital stay and return to work were similar in the two groups. Although LARS significantly reduced medication use and GERD symptoms in both groups during a mean follow-up period longer than 2 years, there were no outcome differences between groups 1 and 2. The reported improvement in esophageal symptoms and overall satisfaction was 90% or more in both groups. Conclusions: The findings show that LARS is an effective treatment option in patients with GERD whether they are candidates for ET or not. In patients with uncomplicated GERD who currently meet inclusion criteria for ET, LARS provides excellent symptom relief and marked reduction in medication use during a mean follow-up period longer than 2 years.     

Quality of life before and after laparoscopic fundoplication

BACKGROUND: Laparoscopic fundoplication is a well-established surgical option for the treatment of gastroesophageal reflux disease. The aim of this study was to assess the surgical outcomes from the patient's point of view by using a validated quality of life instrument. METHODS: Fifty patients have been prospectively included. All patients underwent a standardized 270-degree posterior fundoplication. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36-item-questionnaire. The patients received the questionnaire before surgery, and 3 months and 1 year after surgery. RESULTS: Preoperative score was 95.6+/-21 points. The score increased significantly (P <0.0005) at 3 months (103.6+/-16) and 1 year (111.4+/-22) after surgery. This improvement concerned the four domains of the questionnaire (symptoms, social functioning, physical status, and emotions). The score in patients at 1 year remained, however, significantly lower than that in healthy persons (126+/-18). CONCLUSIONS: GIQLI is a sensitive tool to assess surgical outcomes after fundoplication. The quality of life after surgery did not reach the level of healthy population, not because of failure of surgery to treat GERD but probably because of functional dyspepsia that was present prior to surgery and did not change after fundoplication.     

Medical or Surgical Management of GERD Patients with Barrett’s Esophagus: The LOTUS Trial 3-Year Experience

Introduction

The long-term management of gastroesophageal reflux in patients with Barrett’s esophagus (BE) is not well supported by an evidence-based consensus. We compare treatment outcome in patients with and without BE submitted to standardized laparoscopic antireflux surgery (LARS) or esomeprazole treatment.

Methods

In the Long-Term Usage of Acid Suppression Versus Antireflux Surgery trial (a European multicenter randomized study), LARS was compared with dose-adjusted esomeprazole (20–40 mg daily). Operative difficulty, complications, symptom outcomes [Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD)], and treatment failure at 3 years and pH testing (after 6 months) are reported.

Results

Of 554 patients with gastroesophageal reflux disease, 60 had BE—28 randomized to esomeprazole and 32 to LARS. Very few BE patients on either treatment strategy (four of 60) experienced treatment failure during the 3-year follow-up. Esophageal pH in BE patients was significantly better controlled after surgical treatment than after esomeprazole (p?=?0.002), although mean GSRS and QOLRAD scores were similar for the two therapies at baseline and at 3 years. Although operative difficulty was slightly greater in patients with BE than those without, there was no difference in postoperative complications or level of symptomatic reflux control.

Conclusion

In a well-controlled surgical environment, the success of LARS is similar in patients with or without BE and matches optimized medical therapy.     

Assessment of quality of life after antireflux surgery

AIM OF THE STUDY: To assess the quality of life (QoL) of patients operated for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: This prospective study included 82 consecutive patients submitted to antireflux surgery between October 1998 and January 1999. A new questionnaire was used to assess their QoL: the Gastrointestinal Quality of Life Index (GIQLI) that includes 36 items concerning 5 dimensions: symptoms, vitality, emotions, social relations and medical treatment. The series consisted of 44 men and 38 women with a mean age of 47 years (range: 18-78). QoL was assessed before and 6 months after surgery; the follow-up rate was 94% (77/82). The pre- and postoperative GIQLI scores of the study group and the GIQLY score of a control group of 110 healthy patients were compared. RESULTS: Before surgery, the GIQLI score (90 +/- 23) was greatly impaired compared to the score (123 +/- 13) observed in the control group (p < 0.001). After surgery, the GIQLI score (110 +/- 23) increased significantly (p < 0.001), but remained statistically lower than the score of the control group (p < 0.001). The postoperative score recorded in the symptoms dimension was lower than the control group score: 55 +/- 11 versus 66 +/- 6 (p < 0.001), while no significant difference was observed in the other 4 dimensions. Univariate statistical analysis revealed that the postoperative GIQLI score (y) was correlated with the preoperative GIQLI score (x) according to the formula: y = 0.43 x + 71 (p < 0.001) and the sex of the patients, as the postoperative GIQLI score was higher in male patients (115 +/- 19) than in female patients (103 +/- 23) (p < 0.02). CONCLUSION: The QoL of the patients was greatly improved after antireflux surgery, but remained lower than that of a control group of healthy subjects. Better patient selection should improve the results. In our series, male patients or patients with a high preoperative GIQLI score were the best candidates for antireflux surgery.     

Laparoscopic fundoplication

BACKGROUND: The effectiveness of laparoscopic Nissen fundoplication (LNF) was assessed in patients with chronic gastroesophageal reflux disease (GERD) using pH study and different quality-of-life indexes. We correlated both types of data and hypothesised that improvement in quality of life following LNF does not necessarily correlate with improvement in pH values. METHODS: Seventy patients presenting with typical symptoms of GERD (14 with Barrett's esophagus) underwent LNF between May 1997 and December 2000. All patients were evaluated both prior to and 3 months after surgery using 24-h pH study, endoscopy, and a validated quality-of-life questionnaire. RESULTS: Following LNF, reflux was reduced to normal in all but six patients. Howevers despite persistent reflux, the Gastrointestinal Quality of Life Index (GQLI), of these six patients improved postoperatively from 79.5 +/- 12.2 to 111.7 +/- 8.3. These results correlate with those of patients who had normal postoperative pH studies-namely, 88.5 +/- 19.3 to 112 +/- 16.7. There was no difference in quality-of-life improvement between patients with Barrett's esophagus and those without it. CONCLUSION: There is only a weak correlation between quality-of-life assessment and pH study. Because the patient's quality of life is likely to improve following LNF, an objective means parameter of assessing the effectiveness of antireflux surgery, such as pH study or endoscopy, is recommended.     

Initial experience with the stretta procedure for the treatment of gastroesophageal reflux disease

BACKGROUND: The Stretta device (Curon Medical, Sunnyvale, CA) is a balloon-tipped four-needle catheter that delivers radiofrequency (RF) energy to the smooth muscle of the gastroesophageal junction. It can be used for the endoscopic treatment of gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: Data prospectively collected on the first 25 consecutive patients undergoing the Stretta procedure at Vanderbilt University Medical Center between August 2000 and March 2001 are reported. Patient evaluation included esophageal manometry, ambulatory 24-hour pH testing, a standard GERD-specific quality-of-life survey (QOLRAD), a general quality-of-life survey (SF12), and endoscopy. Stretta surgery was performed following a standardized protocol. Thermocouple-controlled RF energy was delivered to the lower esophageal sphincter (LES) after endoscopic location of the z-line. Patients were followed up 3 months after endoscopic treatment. Results are presented as mean +/- SEM. RESULTS: Prior to treatment, patients had a mean DeMeester score of 31.0+/-11.4, an LES pressure of 24+/-2 mm Hg, and normal esophageal peristalsis. Of the 25 outpatient procedures, 19 were done under conscious sedation and 6 under general anesthesia. There was a small learning curve (76+/-8 min for the first three procedures; 50+/-2 min for the subsequent 22). The mild to moderate pain during the first 24 postoperative hours was controlled with over-the-counter medication. Two complications were noted: one patient presented with ulcerative esophagitis and gastroparesis 10 days after the Stretta treatment, and one patient developed pancreatitis on postoperative day 27, which was probably unrelated to the Stretta procedure. Eight of the thirteen patients (62%) available for 3-month follow-up were off all antisecretory medication. The other five patients were still taking medications but had been able to reduce the amount considerably. The average daily dose of proton pump inhibitors was 43.0+/-5.0 mg/preoperatively and 6.4+/-2.2 mg/3 months postoperatively (P < 0.001). Other classes of GERD treatment such as metoclopramide had been completely abandoned. In all patients, QOLRAD scores improved (3.5+/-0.4 to 5.5+/-0.5; P < 0.001) as did SF12 physical (23.7+/-3.0 to 31.0+/-3.4; P < 0.008) and mental (40.5+/-2.9 to 47.7+/-3.2, P < 0.017) scores. All patients would undergo a Stretta procedure again except one 78-year-old man with progressive Alzheimer's disease. CONCLUSION: The Stretta procedure is a promising new modality in the management of GERD. It can be safely performed in one short session with gastroesophageal endoscopy under conscious sedation in an outpatient setting. It improves GERD symptoms and quality-of-life scores in patients at 3 months and eliminates or significantly reduces the need for antisecretory drugs.     

Assessment of long-term quality of life after laparoscopic and open surgery for Crohn''s disease

OBJECTIVE: Surgery for Crohn's disease (CD) is associated with a high recurrence rate and quality of life (QOL) in these patients is controversial. The aim of this study was to assess QOL in patients after laparoscopic and open surgery for CD by two different validated instruments, a generic nonspecific score and a specific gastrointestinal QOL index. PATIENTS AND METHODS: Patients with CD who underwent elective laparoscopic or open ileocaecal resection with primary anastomosis between 1992 and 2000 were followed for recurrence and surgery-related complications. QOL was assessed by the SF-36 Health Survey containing a mental (MCS) and a physical (PCS) component summary score and by the Gastrointestinal Quality of Life Index (GIQLI) developed by Eypasch. RESULTS: Thirty-seven patients with a mean age of 48.8 +/- 18.4 years including 23 females and 14 males were evaluated at a mean follow-up of 42.6 +/-25.8 months (minimum of 8 months). Twenty-one (57%) patients underwent laparoscopic resection and 16 (43%) open surgery. Both groups were well matched for age, gender, ASA class and body mass index. Fourteen (38%) patients developed recurrent disease and 3 (8%) had postoperative incisional hernias. Overall, QOL scores were 103 +/- 26.8 for the GIQLI, 47.2 +/- 11.8 for the PCS, and 49.2 +/- 11.5 for the MCS. The GIQLI correlated well with the SF36, correlation coefficient = 0.68 for GIQLI vs PCS (95% CI, 0.41,0.95) and 0.67 for GIQLI vs MCS (95%CI, 0.39, 0.95), respectively. When compared to the general US population, mean GIQLI scores (-13.8, P = 0.002) and mean PCS scores (-4.7, P = 0.001) were significantly lower in these patients than in healthy individuals. In a multivariate analysis of impact factors on QOL, recurrence within the follow-up period was the single significant determinant reducing the PCS (-35.1, P = 0.026) and the GIQLI (-36.1, P = 0.018). CONCLUSION: QOL is significantly reduced in patients with CD at long-term follow-up after both laparoscopic and open surgery. Recurrence is the only factor adversely affecting QOL of CD patients in remission irrespective of the operative technique applied.     

Clinical and pathologic response of Barrett's esophagus to laparoscopic antireflux surgery

BACKGROUND DATA: Patients with Barrett's esophagus (BE) are frequently offered laparoscopic antireflux surgery (LARS) to treat symptoms. The effectiveness of this operation with regards to symptoms and to the evolution of the columnar-lined epithelium remains controversial. METHODS: We analyzed the course of 106 consecutive patients with BE who underwent LARS between 1994 and 2000, representing 14% of all LARS (754) performed in our institution during that period. All 106 patients agreed to clinical follow-up in 2002 at 40 months (median; range, 12-95 months). Fifty-three patients (50%) agreed to functional evaluation (manometry and 24-hour pH monitoring); 90 patients (85%) to thorough endoscopy, with appropriate biopsies and histologic evaluation to determine the status of BE. RESULTS: Heartburn improved in 94 (96%) of 98 and resolved in 69 patients (70%) after LARS. Regurgitation improved in 58 (84%) of 69 and dysphagia improved in 27 (82%) of 33. Distal esophageal acid exposure improved in 48 (91%) of 53 patients tested and returned to normal in 39 patients (74%). One patient underwent reoperation 2 days after fundoplication (gastric perforation). Preoperatively, biopsy revealed BE without dysplasia in 91 patients, BE indefinite for dysplasia in 12 patients, and low-grade dysplasia in 3 patients. Fifty-four of the 90 patients with endoscopic follow-up had short-segment BE (<3cm), and 36 had long-segment BE (>3cm) preoperatively. Postoperatively, endoscopy and pathology revealed complete regression of intestinal metaplasia (absence of any sign suggestive of BE) in 30 (55%) of 54 patients with short-segment BE but in 0 of 36 of those with long-segment BE. Among patients with complete regression, 89% of those tested with pH monitoring had normal esophageal acid exposure. This was observed in 69% of those who failed to have complete regression. One patient developed adenocarcinoma within 10 months of LARS. CONCLUSIONS: In patients with BE, LARS provides excellent control of symptoms and esophageal acid exposure. Moreover, intestinal metaplasia regressed in the majority of patients who had short-segment BE and normal pH monitoring following LARS, a fact that was, heretofore, not appreciated. LARS should be recommended to patients with BE to quell symptoms and to prevent the development of cancer.     

Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective?

Background: The elderly have prevalence rates and clinical features of gastroesophageal reflux disease (GERD) similar to those in younger individuals, but the role of laparoscopic antireflux surgery (LARS) in the elderly has not been clearly established. The purpose of this study was to determine if the results of LARS in the elderly are comparable with those in younger patients. Methods: All patients undergoing LARS for GERD at the Washington University Medical Center were entered prospectively into a computerized database. Between May 1992 and June 1998, 339 patients underwent LARS and were divided into two groups based on age: nonelderly (ages, 18–64 years; n= 303) and elderly (age, ≥65 years; n = 36). Data were expressed as mean ± standard deviation (SD) and statistical analysis was performed. Results: Elderly patients had a higher American Society of Anesthesiology (ASA) score (2.3 ± 1.5) and a longer hospital stay (2.1 ± 0.2 days) than the younger group (ASA, 1.9 ± 0.5; hospital stay, 1.6 ± 0.9 days; p < 0.001). Operation times averaged 154 ± 68 min in the elderly compared with 134 ± 49 min in the nonelderly (p= NS). Grade I complications occurred significantly more frequently in the elderly (13.9%) than in the nonelderly (2.6%), but the incidence of grade II complications was similar between the groups (elderly 2.8% vs nonelderly 2.7%). There were no grade III complications in either group, but there was one death in the nonelderly group. At follow-up ranging to 81 months (median, 27 months), the two groups had similar low incidences of heartburn and dysphagia. Anatomic failures of LARS developed in 19 nonelderly patients (6.2%) compared with 2 elderly patients (5.5%; p= NS). Conclusions: As shown in this study, LARS is safe and effective in elderly patients with GERD. Age older than 65 years should not be a contraindication to laparoscopic antireflux surgery in properly selected patients. Received: 3 March 1999/Accepted: 2 April 1999     

Laparoscopic antireflux surgery for the elderly: A surgical and quality-of-life study

Purpose Laparoscopic antireflux surgery (LARS) has long been introduced as an alternative method for the treatment of gastroesophageal reflux disease (GERD) in young adults. However, the safety of this procedure and the associated improvement in the quality of life for the elderly are rarely discussed. This study compared the results between young and elderly patients who underwent laparoscopic fundoplication for the treatment of GERD. Methods From January 1999 to January 2006, there were 231 adult patients who underwent LARS for GERD at a single institute. Among all patients, 33 patients were older than 70 years old (14.3%, 73.0 ± 1.9, range 70–76), 198 patients were younger than 70 years old (85.7%, 46.6 ± 11.5, range 20–69). The clinical characteristics, operation time, postoperative hospital stay, surgical complications, and quality of life were retrospectively analyzed. Results The mean operation time had no significant difference between the younger group and the elderly group. The mean postoperative hospital stay in the elderly group was slightly longer than the younger group (4.1 ± 2.5 days vs 3.4 ± 1.3 days, P = 0.19). There were no mortalities and no major complications found in each group. No patients required conversion to an open procedure. Four patients had minor complications (three in the elderly group, rate: 9.0%; one in the younger group, rate: 0.5%, P < 0.05). There were two patients in the nonelderly group who had recurrence. A comparison of the preoperative and postoperative Gastro-Intestinal Quality of Life Index (GIQLI) scores showed significant improvements (99.3 ± 19.2 points, and 110.2 ± 20.6 points, respectively, P < 0.05) with no significant difference between the two groups. Conclusion Laparoscopic antireflux surgery thus appears to provide an equivalent degree of safety and symptomatic relief for elderly patients with GERD as that observed in young patients.     

Barrett's esophagus without esophageal stricture does not increase the rate of failure of Nissen fundoplication

OBJECTIVE: To assess whether the presence of Barrett's esophagus (BE) modifies the results of Nissen fundoplication. SUMMARY BACKGROUND DATA: Some authors consider that BE, whether or not there is associated stricture, significantly increases the failure rate of standard antireflux surgery; they recommend using different and more aggressive surgical procedures in all patients with BE. METHODS: One hundred seventy-seven patients with gastroesophageal reflux disease, without esophageal stricture, were included in a retrospective study. Patients were divided into two groups: those with BE (n = 57) and those without BE (n = 120). Nissen fundoplication was performed in all patients by the same surgical team. Clinical, endoscopic, and functional (manometry and 24-hour pH monitoring) results in the two study groups were compared. RESULTS: After a median follow-up of 5 years (range 1-18) in the BE group and 6 years (range 1-18) in the non-BE group, the rate of clinical recurrence was 8% in the BE group and 10% in the non-BE group, with no statistically significant difference. The rate of pH-metric recurrence was the same in both groups (15%). CONCLUSIONS: The presence of BE without esophageal stricture does not increase the rate of failure of Nissen fundoplication.     

Clinical results of laparoscopic fundoplication at ten years after surgery

BACKGROUND: Several studies have demonstrated laparoscopic antireflux surgery (LAS) for the treatment of gastroesophageal reflux disease (GERD) to be efficient at short- and midterm follow-up evaluations. The aim of this study was to evaluate the results for LAS 10 years after surgery. METHODS: The 100 consecutive patients who underwent LAS by a single surgeon in 1993 were entered into a prospective database. Nissen fundoplication was performed for 68 patients, and partial posterior fundoplication (modified Toupet procedure) was performed for 32 patients. Evaluations of the outcome were made 5 and 10 years after surgery. A structured symptom questionnaire and upper gastrointestinal barium series were used at 5 years. The same questionnaire and an added quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI]) were used at 10 years. RESULTS: Seven patients died of unrelated causes during the 10-year period. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms. Three patients were lost to any follow-up study. At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major side effects (flatulence and abdominal distension) were related to "wind" problems. The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors. CONCLUSIONS: Elimination of GERD symptoms improved quality of life and eliminated the need for daily acid suppression in most patients. These results, apparent 5 years after the operation, still were valid at 10 years.     

Lebensqualität und subjektive Beurteilung der Ergebnisqualität 3 Jahre nach laparoskopischer Antirefluxchirurgie

PURPOSE: Evaluation of quality of life data and patient satisfaction to estimate the outcome of laparoscopic antireflux surgery (LARS) is nowadays an important issue, the long-term outcome of this has not yet received much attention. METHODS: In the present study we evaluated the outcome of quality of life data of 70 patients who underwent "floppy" Nissen fundoplication at our institute 3 years after surgery. Quality of life was evaluated with the Gastrointestinal Quality of Life Index (GIQLI). Additionally the subjectivity and objectivity of the quality of the procedure and possible side effects were evaluated with a questionnaire. RESULTS: Three years after laparoscopic Nissen fundoplication, patients gave their quality of life (GIQLI) in an overall score of 123.9 points. This is comparable to 122.6 points in the normal population. There was no difference detectable in the subdimensions of GIQLI. Ninety-eight percent of the patients estimated their satisfaction with the procedure as excellent or good and would undergo surgery again if necessary. Four patients suffered from minimal side effects from the procedure, but had no decrease in their quality of life. None of the patients needed antireflux medications postoperatively. Laparoscopic redo-fundoplication was performed in two patients 3 months after initial surgery because of persisting dysphagia. CONCLUSION: The efficacy and long-term outcome of treatment of gastroesophageal reflux disease with laparoscopic "floppy" Nissen fundoplication can be evaluated by objective testing, but also by subjective judgment of the patient and with an evaluation of quality of life.     

腹腔镜抗反流手术治疗胃食管反流病的总体疗效及手术指征选择

目的:探讨腹腔镜抗反流手术治疗胃食管反流病的疗效及手术指征选择。方法:总结2000年至2013年收治的185例胃食管反流病病人的临床资料和术后近期远期结果(生活质量、病人满意率、抗反流手术相关并发症及复发),分析腹腔镜抗反流手术的安全性和有效性。结果:185例病人均顺利施行腹腔镜抗反流手术(食管裂孔修补+胃底折叠),手术用时50~200 min,术中失血10~100 mL,无中转开腹和手术死亡病例。20例病人发生围手术期并发症,经针对性处理后痊愈;术后并发慢性吞咽困难16例,多为轻、中度;163例GERD病人术后日常生活质量改善明显,手术满意率达88.1%;166例病人术前胃食管反流症状典型,术后152例症状明显改善(91.6%),14例无缓解。随访见8例术后复发,其中2例合并食管裂孔疝复发。结论:腹腔镜手术治疗胃食管反流病安全可行、疗效可靠,但术前应严格把握手术适应证。