Impact of Nissen fundoplication on laryngopharyngeal reflux symptoms

The reliability of Nissen fundoplication for the successful treatment of laryngopharyngeal reflux (LPR) symptoms remains in question. The purpose of this study was to assess the effect that antireflux surgery has on a variety of LPR symptoms as well as the patient's perceived success of surgical intervention. A retrospective review of all antireflux surgeries between 1998 and 2008 provided a patient base for a survey in which patients ranked pre- and postoperative LPR symptoms in addition to patient satisfaction with the outcome. Of the 611 patients identified and sent the evaluation forms, 244 responses (40%) were obtained. The percentage of patients with symptom improvement after surgery were: heartburn (90.1%), regurgitation (92.6%), voice fatigue (75.2%), chronic cough (76.3%), choking episodes (83.1%), sore throat (82.9%), lump in throat (77.4%), repetitive throat clearing (72.8%), and adult-onset asthma (59.6%). Twenty per cent with repetitive throat clearing and 30 per cent with adult-onset asthma had no improvement in symptoms. Eighty-one per cent considered surgery to be a success. Comparison of those who claimed the operation was successful with those who claimed it was not revealed no difference in demographics, primary diagnosis, procedure type, or reflux symptom index score. There was a statistically significant difference in patient-perceived outcome according to the length of time since surgery. More than 88 per cent in the "not successful" group had an operation greater than 4 years prior as compared with only 70 per cent in the "successful" group (P = 0.020). Nissen fundoplication is an effective treatment for most LPR symptoms, although patients with adult-onset asthma and repetitive throat clearing appear to benefit least from surgical intervention.     

Laparoscopic Nissen fundoplication improves quality of life in patients with atypical symptoms of gastroesophageal reflux

Laparoscopic Nissen fundoplication has been shown to improve overall quality of life (QOL) in patients with gastroesophageal reflux, but most studies have not addressed patients with atypical symptoms. We investigated the effect of laparoscopic Nissen fundoplication on QOL using the Gastrointestinal Quality of Life Index (GIQLI) survey modified to address both typical (heartburn, regurgitation, dysphagia) and atypical (hoarse voice, chronic cough, adult-onset asthma, vocal cord polyps) symptoms. One-hundred forty-eight patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) at UCLA Medical Center from January 1, 1995 to May 1, 2002. Surveys evaluating pre- and postoperative QOL were administered after surgery: 55 per cent of patients responded (82/148). Forty-eight per cent of all patients (72/148) had atypical symptoms. Perioperative morbidity and mortality were 8.8 per cent and 0.7 per cent, respectively. Mean length of postoperative stay was 2.96 +/- 1.5 days. Mean follow-up for the entire cohort was 18.5 months. Postoperative dysphagia not present before surgery occurred in 4.7 per cent of patients. Eighty per cent of patients were medication-free following surgery. QOL scores for all participants increased significantly from 52.5 +/- 15.3 preoperatively to 72.0 +/- 14.9 postoperatively (P < 0.0001). Patients with atypical symptoms or typical symptoms alone showed significant mean QOL score increases from 48.3 +/- 17.6 preoperatively to 71 +/- 15.7 postoperatively (P < 0.0001) and from 55.7 +/- 12.6 to 72.8 +/- 14.4 (P < 0.0001), respectively. Laparoscopic Nissen fundoplication can effectively improve overall QOL for patients with GERD. Patients with atypical GERD symptoms can experience increases in QOL similar to those with only typical gastrointestinal symptoms.     

Measuring improved quality of life after laparoscopic Nissen fundoplication

BACKGROUND: While the correction of pathologic gastroesophageal reflux by means of laparoscopic Nissen fundoplication (LNF) has been well documented, the psychological profiles of patients with this disease and the impact on their quality of life are less well understood. We obtained a baseline psychological profile and measured the impact of LNF on patients' quality of life with 2 standardized instruments: the psychological general well-being index (PGWB) and the gastrointestinal symptoms rating scale (GSRS). The study included 34 consecutive patients with typical symptoms of gastroesophageal reflux who underwent LNF in 1995 at a tertiary care university medical center. METHODS: Patients filled out PGWB and GSRS surveys preoperatively and at 2 weeks, 2 months, and 12 months postoperatively. Data were collected in a blinded fashion by a study nurse and analyzed after completion of the study. Data are expressed as mean +/- standard deviation. RESULTS: The mean preoperative PGWB score (69.6 +/- 17.3) of study patients with gastroesophageal reflux disease was lower than that expected for a healthy population. This was primarily attributable to low scores in the general health domain of the questionnaire, although LNF patients also had low scores in the vitality and positive well-being domains of the PGWB scale. LNF improved the PGWB score to a normal level (78.7 +/- 19.3) (P = .05 vs the preoperative PGWB score) at 12 months post surgery. The GSRS also showed improvement from 34.7 +/- 7.8 to 28.1 +/- 10 (P = .008). The improvement in GSRS was attributed to improvement in the heartburn (7.12 +/- 2.4 to 2.72 +/- 1.2, P < .001) and abdominal pain (6.58 +/- 2.5 to 4.92 +/- 1.6, P = .006) domains of the scale. LNF had no impact on the diarrhea, indigestion, and obstipation domains of the GSRS. CONCLUSIONS: Patients with gastroesophageal reflux disease who are candidates for LNF have low psychological and general well-being scores that are restored to normal levels by successful LNF. When compared with baseline measurements, LNF effectively relieved heartburn and did not cause significant new gastrointestinal complaints.     

Quality of life before and after laparoscopic Nissen fundoplication

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder in the Western world. The acute disease can usually be managed by medical therapy. To prevent relapse, many patients require lifelong medication. In these patients, laparoscopic antireflux surgery offers a good alternative. The aim of this study was to evaluate the postoperative results and compare pre- and postoperative quality of life after laparoscopic Nissen fundoplication. METHODS: Clinical investigations, including esophageal manometry, pH monitoring, and endoscopy, and a previously validated Quality of Life Index, were performed before and a median of 41 month after antireflux surgery in 75 patients. RESULTS: After laparoscopic Nissen fundoplication, the percentage of total time with pH <4 decreased from 10.4% to 3.2% on 24-h pH monitoring. The mean pressure of the lower esophageal sphincter improved from 8.1 to 12.3 mmHg. Esophagitis healed in 63 of 66 patients in whom it was present prior to surgery. The overall Quality of Life Index improved significantly from 86 +/- 16 to 116 +/- 16. CONCLUSION: Laparoscopic fundoplication provides effective and durable relief of reflux in patients with GERD. The Quality of Life Index showed significant improvement after surgery.     

Analysis and surgical treatment of persistent dysphagia after Nissen fundoplication

BACKGROUND: After Nissen fundoplication, troublesome dysphagia develops in 5-10 per cent of patients. The mechanism of dysphagia has not been fully resolved, in spite of a number of studies focusing on oesophageal motility and lower oesophageal sphincter (LOS) dynamics. Tightness and length of the wrap have had considerable attention, without giving a fully satisfactory explanation of the pathophysiological mechanism. METHODS: Eighteen patients with persistent dysphagia after Nissen fundoplication needing reoperation were studied. Eighteen patients, matched for age and sex, without dysphagia after Nissen fundoplication were used as controls. Reoperation consisted of conversion of a 360 degrees into a 270 degrees wrap. Barium swallow, endoscopy, oesophageal manometry and 24-h pH monitoring were performed before and after (re)operation. RESULTS: Peristaltic amplitude, velocity and duration of contraction were not significantly influenced by operation. In 16 of 18 patients with dysphagia, LOS relaxation was incomplete and the residual relaxation pressure was significantly higher than that in the group without dysphagia (P < 0.01). No correlation was found between LOS pressure and peristaltic amplitude, nor between LOS pressure and ramp pressure in the distal oesophagus. After reoperation, basal LOS pressure decreased significantly (P < 0.01) and LOS relaxation was complete in all but three patients; residual relaxation pressure decreased (P < 0.01) and was significantly lower than that after uncomplicated Nissen fundoplication. In the latter group, LOS pressure, residual relaxation pressure and ramp pressure increased significantly after operation (P < 0.01). CONCLUSION: A return to complete LOS relaxation and a decrease in residual relaxation pressure play an important role in resolving dysphagia.     

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.     

Robotic Nissen fundoplication: alternative surgical technique for the treatment of gastroesophageal reflux disease.

The first robotic Nissen fundoplication using the da Vinci robotic surgical system was performed on a 56-year-old woman with a 20-year history of severe gastroesophageal reflux disease refractory to medical management. The recovery was uneventful, and follow-up continues.     

Nissen fundoplication in the management of gastroesophageal reflux occurring after repair of esophageal atresia

BACKGROUND/PURPOSE: Gastroesophageal reflux is a major cause of complications after esophageal atresia repair. The suitability of the Nissen fundoplication in these patients is still disputed. Therefore, the authors evaluated the results of their prospective treatment protocol in those patients who underwent a Nissen fundoplication. METHODS: From 1984 to 1996, 125 patients underwent anastomosis for esophageal atresia. A Nissen fundoplication was later performed in 29 patients. The prospective protocol included x-ray after 10 days, 6 weeks, 12 weeks, 6 months, and 12 months. Forty-eight-hour pH measurements were performed between 6 and 12 weeks. Mean postfundoplication follow-up was at least 5 years (range, 2 to 13 years). RESULTS: Two of the 29 patients died after the Nissen fundoplication from unrelated causes. A third patient was excluded from the study group. Nineteen of the remaining 26 patients showed severe stricture. pH-metry succeeded in 18 patients, showing pathological reflux in 17. In 24 patients the fundoplication was performed between 1 and 24 months (median, 4 months), in the other 2 patients much later. In 4 of the 26 patients(15%) the Nissen proved to be insufficient and had to be redone. The remaining 22 patients had no short-term or long-term complications. CONCLUSION: The authors' findings in this group of patients, comparing them with the results reported in the literature, indicate that there is no reason to change their prospective treatment protocol nor their policy to perform Nissen fundoplications at an early stage.     

Outcome after radical prostatectomy depends on surgical technique but not approach

Conclusions The results after radical prostatectomy currently are very good but could be better. There is no question that surgical technique is important in decreasing morbidity and improving outcomes. The same principles apply regardless of surgical approach. Ultimately, there may be little difference in the important outcome measures regardless of the approach used. Exploration of innovative approaches and techniques should be encouraged but measured by their effect on outcome rather than assumed improvements or promotional efforts.     

Association between persistent symptoms and long-term quality of life after laparoscopic total fundoplication

Background

We investigated which factors are significantly associated with long-term quality of life after laparoscopic total fundoplication in the treatment of gastroesophageal reflux disease.

Methods

Patients (n = 144) were given a standardized frequency-intensity symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

Results

At follow-up evaluation (n = 102), patients had a significant reduction in their symptoms score and no deterioration in quality of life. A significant association with postoperative dysphagia for solids and/or liquids was found in the physical component summary score of the Short-Form 36 administered to patients postoperatively (P = .003).

Conclusions

In this study, laparoscopic total fundoplication was a safe and effective surgical treatment for gastroesophageal reflux disease, generally offering an improved long-term quality of life, with the exception of a minority of patients (6 of 102 patients; 5.8%) who experienced persistent severe dysphagia.     

Nissen fundoplication and pyloroplasty in the management of gastro-oesophageal reflux in children

A retrospective study was carried out of children undergoing Nissen fundoplication and pyloroplasty for the correction of gastro-oesophageal reflux. Twenty children (thirteen males, seven females) aged 8 months to 12 years underwent surgery over a 10 year period. Forty per cent were mentally retarded. Presentation was failure to thrive in 19 (95 per cent), recurrent vomiting in 18 (90 per cent) and haematemesis in 14 (70 per cent). Four children had Barrett's oesophagus. There were no operative or perioperative mortalities. Follow-up (mean period 3 years, 9 months) revealed no further symptoms of reflux. The 'normal' children gained weight postoperatively whereas the 'retarded' group did not. Adhesion obstruction (10 per cent) was the major late postoperative complication. Regression of Barrett's epithelium was noted endoscopically. 'Gas-bloat' syndrome, a major complication following fundoplication, was not encountered.     

Prospective study of the effect of laparoscopic Nissen fundoplication on reflux mechanisms.

BACKGROUND: Laparoscopic Nissen fundoplication effectively reduces acid reflux and reflux symptoms. Little is known about the effect on reflux mechanisms, especially on transient lower oesophageal sphincter relaxations (TLOSRs). METHODS: Twenty-seven patients were studied prospectively before and after laparoscopic Nissen fundoplication, by simultaneous recording of pH and lower oesophageal sphincter (LOS) characteristics using sleeve manometry. In all of the 27 patients the operation was judged successful, based on major improvement or resolution of reflux symptoms and acid reflux. Vagus nerve integrity was studied indirectly by the secretion of pancreatic polypeptide (PP) in response to insulin-induced hypoglycaemia. RESULTS: After fundoplication basal LOS pressure increased significantly from mean(s.e.m.) 13(1) to 22(1) mmHg (P < 0.001). Laparoscopic Nissen fundoplication significantly decreased the frequency of TLOSR in the fasting period from mean(s.e.m.) 2.5(0.5) to 0.6(0.2) per h, and in the postprandial period from 4.0(0.4) to 1.3(0.3) per h (P < 0.01). The percentage of TLOSRs associated with reflux also decreased significantly from 24(10) to 0(0) per cent in the fasting period and from 42(6) to 12(6) per cent in the postprandial period, before and after fundoplication respectively (P < 0.01). After operation the PP response was abnormal in three patients, pointing to vagus nerve dysfunction. Postoperative TLOSR frequency and LOS pressure were no different between patients with and without vagus nerve dysfunction. CONCLUSION: Laparoscopic Nissen fundoplication significantly increased fasting and postprandial LOS pressure and significantly decreased the rate of TLOSR. This resulted in a significant reduction in oesophageal acid exposure but postprandial LOS characteristics were preserved.     

Dysphagia and quality of life after laparoscopic Nissen fundoplication in patients with and without prostetic reinforcement of the hiatal crura

BACKGROUND: Recurrent hiatal hernia with or without intrathoracic wrap migration ("slipping Nissen") is one of the most common complications after laparoscopic Nissen fundoplication (LNF). Therefore, we decided to reinforce the hiatal crura using a prosthetic mesh prosthesis in an attempt to reduce recurrent hiatal hernia. METHODS: The current nonrandomized study compares the surgical outcome, including quality of life data [Gastrointestinal Quality of Life Index (GIQLI)] and subjective degree of dysphagia, in a total of 200 patients with (n = 100) or without (n = 100) mesh prosthesis for a follow-up for at least 1 year. RESULTS: There are no significant differences between groups in postoperative DeMeester score or lower esophageal sphincter pressure. In the group without mesh prosthesis, in 6 cases laparoscopic redo surgery was necessary due to severe and persistent dysphagia (n = 2) or a slipping Nissen (n = 4). Additionally, in 5 patients we found recurrent hiatal hernia, but patients have been without symptoms for at least 1 year. In the group with mesh prosthesis, laparoscopic refund application was performed in only 1 patient due to a slipping Nissen. In this group, recurrent hiatal hernia was not found in endoscopy. After laparoscopic antireflux surgery, GIQLI showed an equal improvement in both groups with an outcome comparable to that for healthy individuals. Postoperative dysphagia was significantly higher in the group with mesh prothesis within the 3 first months after surgery. One year after surgery no differences could be found. CONCLUSIONS: Our findings suggest that LNF with reinforcement of the hiatal crura reduces the risk of recurrent hiatal hernia with or without wrap migration. In addition, LNF with mesh prosthesis improves patient's quality of life significantly to the same level as that in patients without mesh prosthesis. Postoperative dysphagia is higher in the early period after surgery, but this is only temporary. Long-term results of a randomized trial must be obtained before a general standardization can be discussed.     

Quality of life and predictors of long-term outcome in patients undergoing open Nissen fundoplication for chronic gastroesophageal reflux

BACKGROUND: Long-term outcome of antireflux operations as well as pre- and postoperative parameters able to predict their clinical results are still controversial. The aim of the present study was to evaluate long-term quality of life of patients undergoing open fundoplication for chronic GERD and to investigate pre- and early postoperative functional parameters possibly related to persistence or recurrence of symptoms. METHODS: A cohort of 25 patients who underwent open Nissen fundoplications was reviewed for an evaluation of long-term residual symptoms and quality of life at an average follow-up of more than 10 years. Clinical evaluation was performed by using a symptom-specific score (DeMeester's score), 3 health-related quality of life scores, a GERD-specific (GERD-HRQL score) score, and 2 generic scores (SF-36) evaluating physical and psychological well-being. Subjective satisfaction grade of the patients was also investigated. In addition, a univariate analysis is provided, according to the long-term presence or absence of residual symptoms (120.6-month follow-up), taking into account pre- and postoperative (6-month follow-up) data of endoscopy, 24-hour pH monitoring, stationary manometry, and gastric-emptying test. RESULTS: Persistence or recurrence of GERD-specific symptoms (heartburn and regurgitation) were reported by 8 patients (32%); 2 patients (8%) were reoperated on for persistent dysphagia, whereas 17 patients (68%) were asymptomatic. GERD-HRQL and SF-36 scores displayed significant postoperative improvement, which continued in long-term follow-up. Twenty patients (80%) had repeat fundoplication. Among tested parameters, only postoperative mean supine esophageal clearance and gastric emptying half-time, although on average improved significantly after the antireflux procedure, differed significantly in long-term asymptomatic and symptomatic subgroups. In long-term asymptomatic patients, postoperative (6 month) mean supine esophageal clearance was 0.8 +/- 0.3 minutes (P = .011) and 2.4 +/- 0.2 minutes in symptomatic patients. Postoperative (6 month) mean gastric emptying half-time of long-term asymptomatic patients was 93.3 +/- 8.9 minutes, whereas in symptomatic patients it was 127.5 +/- 14.3 minutes (P = .047). CONCLUSIONS: Patients undergoing Nissen fundoplication had a satisfactory long-term quality of life. Clinical results did not deteriorate over time and showed to be related to postoperative esophageal clearance and gastric emptying, which could be regarded as early postoperative predictors of long-term clinical outcome.     

Prospective randomized trial of Nissen fundoplication and Angelchik prosthesis in the surgical treatment of medically refractory gastro-oesophageal reflux disease

Fifty patients with gastro-oesophageal reflux disease refractory to multiple courses of medical therapy were entered into a prospective randomized trial comparing Nissen fundoplication with the Angelchick prosthesis as a primary surgical procedure. The two groups were matched for age, sex, duration of symptoms before surgery, type of medical therapy, pattern of symptom presentation, endoscopic grade of oesophageal inflammation, manometric lower oesophageal pressure and 24-h pH profile. Twenty-five patients were randomized to each of the Nissen fundoplication and Angelchik prosthesis groups. Operation time and hospital stay were similar in both groups. Persistent dysphagia was reported in five of the patients with an Angelchik prosthesis compared with none in the Nissen fundoplication group. Three prostheses were removed because of severe dysphagia while no Nissen fundoplication required revision. No patient with preoperative dysphagia because of stricture reported swallowing difficulties after operation. At clinical assessment at 3, 6, 12 and 24 months after operation, 85-88 per cent of the patients having a Nissen fundoplication were graded Visick 1 or 2 compared with 60-72 per cent of patients in the Angelchik group.     

Laparoscopic fundoplication takedown with conversion to Roux-en-Y gastric bypass leads to excellent reflux control and quality of life after fundoplication failure

Background

Recent data suggest that reoperative fundoplication is associated with poor long-term control of reflux. For long-term reflux control, laparoscopic Roux-en-Y gastric bypass (LRYGB) may be a better option. This study assessed outcomes and quality-of-life data after fundoplication takedown and conversion to LRYGB for patients with failed fundoplications.

Methods

After institutional review board approval, the medical records of 25 patients who underwent fundoplication takedown and LRYGB conversion between March 2007 and July 2011 were reviewed. The data recorded included patient demographics, body mass index (BMI), preoperative symptoms, operative duration and findings, hospital length of stay (LOS), estimated blood loss (EBL), length of the follow-up period, and postoperative outcomes. The gastrointestinal quality of life index (GIQLI) and the gastrointestinal symptoms rating scale (GSRS) were used at the most recent follow-up visit to assess symptom severity and quality of life.

Results

The patients in this study had undergone 40 total prior antireflux surgeries. They had a median age of 55?years (range 36?C72?years), a BMI of 34.4?kg/m² (range 22?C50?kg/m²), an operative duration of 345?min (range 180?C600?min), an EBL of 181?ml (range 50?C500?ml), and an LOS of 7?days (range 2?C30?days). Five patients had concomitant incisional hernia repair. There was no mortality. Of the 10 patients (40?%) who had had complications, 5 required reoperation. During a 14-month follow-up period (range 1?C48?months), 96?% of the patients were reflux-free with a GIQLI score of 114 (range 80?C135) and a GSRS score of 25 (range 17?C45). Excess weight loss was 60?%, and comorbidity resolution was 70?%. Most of the patients (96?%) were satisfied with their outcome and would undergo the surgery again, and 62?% reported that their personal relationships and sexual life had improved.

Conclusions

Patients who undergo LRYGB after failed fundoplications have excellent symptomatic control of reflux, excellent quality of life, and high rates of satisfaction with their outcome. Nevertheless, because the procedure is challenging and associated with considerable morbidity, it should be performed by surgeons experienced in antireflux and bariatric surgery.