Factors predictive of dysphagia after laparoscopic Nissen fundoplication

Background: Persistent postoperative dysphagia occurs in up to 24% of patients who undergo a laparoscopic Nissen fundoplication for reflux disease [7]. We hypothesized that patient history, pH testing, and esophageal manometry could be used to preoperatively identify patients at risk for this complication. Methods: Of 156 laparoscopic Nissen fundoplications performed over a 27-month period, we identified 19 patients (12%) who suffered from postoperative dysphagia longer than 3 months. The presenting complaint of preoperative swallowing difficulty was noted as was the presence of a known esophageal stricture. Preoperative pH testing and esophageal manometry were performed for all subjects. We compared the following parameters to an age and gender-matched control group: history of esophageal stricture, presence of preoperative dysphagia, DeMeester reflux score, upper esophageal sphincter pressure and relaxation, esophageal body motility, location of respiratory inversion point, and lower esophageal sphincter length, resting pressure, and relaxation. Data were compared via t-test and Fisher's exact test. Results: Patients who presented before surgery with complaints of difficulty swallowing were more likely to suffer from postoperative dysphagia (p= 0.029). Incidence of stricture, DeMeester score, and manometric measurements did not differ between the dysphagia and control groups (p > 0.05 for all parameters). Conclusions: Although preoperative studies are not helpful in identifying patients at risk for persistent dysphagia after laparoscopic Nissen fundoplication, patients presenting with the preoperative complaint of difficulty swallowing are at increased risk for this complication. Received: 1 April 1999/Accepted: 22 July 1999     

Resolving gastroesophageal reflux with laparoscopic fundoplication

Background: The purpose of this study was to evaluate the results of 138 cases of gastroesophageal reflux disease resolved laparoscopically with the Rossetti modification of the Nissen fundoplication and to compare them with findings from other studies in an effort to evaluate the procedure's ability to transfer from an academic setting to a community hospital setting. Methods: We performed laparoscopic Nissen fundoplication on 138 patients and followed them for up to 45 months. Measures included postoperative reflux persistence, complications, operating time, length of hospital stay, and others. These findings were compared, using the Fisher's exact test, chi-square test, and the two-sample t-test, with results from other studies using open and laparoscopic procedures. Results: No patient undergoing laparoscopic fundoplication experienced gastroesophageal reflux after surgery. Complications, not statistically significantly different from those in other studies, occurred in 15 (10.9%), and conversion to an open procedure was required in two (1.5%). The most common postoperative complaint has been dysphagia (21.7%). Operative time averaged 70.6 min, decreasing from an average of 236 min for the first 10 cases to 40.8 min for the last 10. This measure was statistically significantly lower than all other operative times to which it was compared, except one to which it was almost identical (69.9 min). Length of stay (LOS) averaged 2.3 days, ranging from a low of 7 h to a high of 9 days, which made it fall well within limits set by other studies. Overall, LOS fell from a 3.0-day average for the first 20 cases to a 1.9-day average for the last 20 cases. Conclusions: Laparoscopic Nissen fundoplication resolved gastroesophageal reflux in all 138 patients, and measures for complications, operating time, and LOS were well within values reported by other studies, indicating the ability of this procedure to be successfully transferred from academic medical centers to the community hospital setting. Received: 7 October 1996/Accepted: 14 May 1997     

Patterns of success and failure with laparoscopic Toupet fundoplication

Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy. Received: 29 June 1998/Accepted: 2 July 1999     

Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux

Background: This prospective study assesses the outcome results in 100 consecutive patients with gastroesophageal reflux disease (GERD) treated with a laparoscopic Toupet fundoplication. Methods: GERD was confirmed by 24-h pH study and/or esophagogastroduodenoscopy (EGD). Pre- and postoperative symptoms, operative times, and perioperative complications were recorded on standardized data forms. Early follow-up was at 3 months and late follow-up, including 24-h pH, manometry, and EGD was at 22 months. Results: Preoperative symptoms included heartburn (92%), regurgitation (58%), water brash (39%), and dysphagia (39%). Mean operative time was 3.2 hours. There were no conversions to celiotomy and there were no mortalities. The perioperative complication rate was 14%; 6% (5/83) of patients reported heartburn at 3 months and 20% (15/74) at 22 months. Early and late dysphagia was 20% (17/83) and 9% (7/74), respectively; 24-h pH testing was abnormal in 90% of symptomatic patients (9/10), 39% of asymptomatic patients (12/31), and 51% overall. Conclusions: Despite early improvement in reflux symptoms following laparoscopic Toupet fundoplications, there is a high incidence of recurrent GERD. Symptomatic follow-up underestimates the true incidence of 24-h pH-documented reflux. Based on these results we cannot recommend the laparoscopic Toupet repair for GERD patients with normal esophageal motility. Received: 24 March 1997/Accepted: 28 May 1997     

360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease

Background: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However, a relatively high incidence (7–11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication has recently been reported. Methods: Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic 360° fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months. Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform an effective tension-free closure of the hiatus. A polypropylene mesh (3 × 4 cm) was placed on the hiatus behind the esophagus and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses). Results: Between August 1995 and February 1998, the technique, complete with 360° fundoplication, was used for 67 patients with GERD. At mean follow-up of 22.5 months (range, 1–30), there was no evidence of postoperative paraesophageal hernia or complications related to the use of the mesh. Conclusions: This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed. Received: 9 July 1998/Accepted: 19 April 1999     

Laparoscopic fundoplication to enhance pulmonary function in children with severe reactive airway disease and gastroesopheagal reflux disease

Background: The relationship between severe reactive airway disease (RAD) and gastroesophageal reflux disease (GERD) has been noted but the relationship is poorly understood. This study reports our experience with laparoscopic fundoplication and it's effect on the pulmonary status of children with severe steroid-dependent reactive airway disease. Methods: Fifty-six patients with severe steroid-dependent RAD and medically refractory GERD underwent laparoscopic Nissen fundoplications. Mean age was 7 years and mean weight was 20 kg. All patients had the procedure completed successfully laparoscopically with an average operative time of 62 min. Average hospital stay was 1.6 days. Results: Forty-eight of 56 patients noted significant improvement in their respiratory symptoms in the first week. Fifty of 56 patients have been weaned off their oral steroids and four others have had a greater than 50% decrease in their dose. Sixteen patients had a documented increase in their FEV1 in the initial postoperative period (avg. 26%). Conclusion: Patients with steroid-dependent RAD and GERD refractory to medical management show improvement in their respiratory status following fundoplication and the majority can be weaned off of their oral steroids. Laparoscopic techniques allow this procedure to be performed safely even in this high-risk group of patients. Received: 25 March 1997/Accepted: 5 July 1997     

Laparoscopic toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs. 44%;P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results teria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after, surgery. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Laparoscopic fundoplication in infants and children

Background: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with gastroesophageal reflux treated by laparoscopic fundoplication. Methods: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric outlet procedures. Results: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%) and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children (85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%), in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of a surgical error in placing a gastrostomy (0.7%). Conclusion: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication rates similar to or better than open fundoplication. Received: 22 March 1996/Accepted: 12 June 1996     

Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility

Objective To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication and to evaluate the success rate of these procedures. Summary background data Nissen fundoplication (360°) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been recommended to use the Toupet procedure (270°) in these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia). Methods 200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview, endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry. Results After two years 85% (Nissen) and 85% (Toupet) of patients were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication compared to Toupet (19 vs. 8, p < 0.05) and did not correlate with preoperative motility. Concerning reflux control the Toupet proved to be as good as the Nissen procedure. Conclusion Tailoring antireflux surgery according to the esophageal motility is not indicated, as motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation as it has a lower rate of dysphagia and is as good as the Nissen fundoplication in controlling reflux.     

A simplified approach to laparoscopic fundoplication

Background: There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural fibers when encircling the lower esophagus. Methods: We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult. Results: Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis (Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months. Conclusion: We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication to be both simple and effective. Received: 29 March 1996/Accepted: 28 May 1996     

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

Background

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

Methods

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

Results

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

Conclusions

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.     

Postoperative esophageal physiology studies may help to predict long-term symptoms following laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication is an established treatment for gastroesophageal reflux disease (GERD). Postoperative improvement in esophageal physiology can be indicative of successful surgery, but the degree to which it correlates with symptom control remains questionable. We have performed this study to assess the utility of postoperative esophageal physiology studies in predicting long-term symptomatic outcome. Methods Between August 1997 and August 2003, 145 patients with symptomatic GERD underwent laparoscopic Nissen fundoplication as part of a randomized trial. Four months after surgery patients were invited to have postoperative esophageal physiology studies. In November 2005, a postal questionnaire was sent to all patients in order to assess reflux symptomatology (DeMeester symptom score). Results Completed symptom questionnaires were returned by 108 patients (74%) after a median of 5.7 years postoperatively. Linear regression of manometry data showed a significant correlation between the level of postoperative neosphincter pressure either above or below the median and long-term scores for heartburn (p = 0.03), dysphagia (p = 0.02), regurgitation (p = 0.01), and total symptom score (p = 0.002). In contrast, there was no evidence of a significant correlation between results of postoperative esophageal pH studies and symptom scores. Conclusion Postoperative physiology studies, particularly manometry, may be predictive of long-term symptoms following laparoscopic Nissen fundoplication. Presented as an oral abstract on 20 April 2007 at SAGES 2007, Las Vegas, USA     

Dysphagia and clinical outcome after laparoscopic Nissen or Rossetti fundoplication: sequential prospective study

Laparoscopic fundoplication represents the most widely used operation in the surgical treatment of gastroesophageal reflux disease (GERD). Besides being operator-dependent, the clinical outcome (efficacy and side-effects) seems also to be dependent on the specific surgical technique. In this prospective trial we compared the results of two groups of patients who were submitted sequentially to the Rossetti or Nissen fundoplication procedure. Dysphagia, other side effects, and clinical outcome were evaluated early after surgery and at 6 and 12 months after the operation. Although both procedures were clinically effective, there was a significant trend toward less postoperative dysphagia in the Nissen group. In these patients the incidence of early dysphagia was significantly lower than that observed in those submitted to the Rossetti fundoplication. In addition, Nissen patients experienced a significantly smaller number of days with dysphagia. One year after surgery, however, the two procedures proved equally successful without any significant difference in dysphagia incidence. Complete fundic mobilization should therefore be advised to reduce the incidence of early troublesome dysphagia.     

Revisional laparoscopic antireflux surgery after unsuccessful endoscopic fundoplication

Background

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

Methods

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

Results

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

Conclusion

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

Complications of laparoscopic antireflux surgery in childhood

Background: The aim of this study was to assess the complications associated with the laparoscopic treatment of gastroesophageal reflux disease (GERD) in children. Methods: From March 1992 to March 1998, we used the laparoscopic approach to treat 289 children affected by gastroesophageal reflux disease. The patients' ages ranged between 4 months and 17 years (median, 4.3 years), and their body weight ranged between 5 and 52 kg. In 148 children (51.3%), we adopted a Nissen-Rossetti procedure and in 141 (48.7%) a Toupet technique. Results: The duration of surgery ranged between 40 and 180 min (median, 70). There were no deaths and no anesthesiological complications in our series. We recorded 15 (5.1%) intraoperative complications: six pleural perforations, four lesions of the posterior vagus nerve, two esophageal perforations, two gastric perforations, and one pericardiac perforation. Conversion to open surgery was necessary in only four cases (1.3%). We recorded 10 (3.4%) postoperative complications: one peritonitis due to an esophageal perforation not detected during the intervention that required a reoperation, five cases of herniation of the epiploon through a trocar orifice, three cases of dysphagia that disappeared spontaneously after a few months, and one case of delayed gastric emptying that subsequently required a pyloroplasty. We had six recurrences of GERD (2.1%). In two cases, a new fundoplication was performed using the laparoscopic approach; in the other four, the GERD was controlled with medical therapy. Conclusion: Our results show that laparoscopic fundoplication is an adequate treatment for children with GERD that has a low rate of complications. When severe complications do occur, they can be treated effectively via the laparoscopic approach. Received: 16 November 1999/Accepted: 16 December 1999/Online publication: 5 June 2000     

Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders

Background: The outcomes of a laparoscopic esophagomyotomy with posterior partial fundoplication were compared between groups of patients with primary motility disorders. Methods: In this study, 47 patients (26 women and 21 men, ages 24 to 77 years; mean, 47 years) with significant dysphagia or chest pain who failed conservative treatment underwent a laparoscopic esophagomyotomy and posterior partial fundoplication. Preoperative evaluation revealed four groups of primary motility disorders: achalasia (n= 12), nutcracker esophagus (n= 12), hypertensive lower esophageal sphincter (LES) (n= 16), and diffuse esophageal spasm (n= 7). Statistical analysis was performed by Cramer's V test. Results: Average follow-up period was 30.3 months. There was no mortality or early morbidity. Late morbidity included dysphagia or chest pain over 6 weeks in 10 patients (21%), recurrent gastroesophageal reflux disease (GERD) in 3 patients (6%), and recurrent motility disorder in 2 patients (4%). Overall, 94% of the patients ultimately had complete resolution of dysphagia or chest pain. There was no significant difference in outcomes between groups. Conclusion: Early results suggest that laparoscopic esophagomyotomy with posterior partial fundoplication provides safe and effective relief from dysphagia and chest pain in patients with each of the primary motility disorders. Received: 18 February 1999/Accepted: 16 December 1999/Online publication: 13 June 2000     

Long-term evaluation of patient satisfaction and reflux symptoms after laparoscopic fundoplication with Collis gastroplasty

Background Esophageal shortening is a complication of advanced gastroesophageal reflux disease (GERD). For patients with short esophagus, Collis gastroplasty combined with fundoplication provides excellent symptomatic relief from GERD disease. The literature lacks studies comparing satisfaction and reflux symptoms between patients who underwent Nissen fundoplication with Collis gastroplasty and those who had primary fundoplication alone. This study aimed to assess long-term satisfaction and GERD-related quality of life after laparoscopic Collis–Nissen fundoplication, and to compare them with those for Nissen fundoplication alone. Methods A nested case–control study was conducted. In this study, 14 cases of laparoscopic Collis–Nissen fundoplications were matched for age, gender, and length of the follow-up period to a cohort of 120 control subjects who underwent laparoscopic Nissen fundoplication. All the patients were mailed a follow-up survey which included a Short Form-12 (SF-12) health status (quality-of-life) questionnaire (a validated quality-of-life instrument), a Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire (a GERD-specific quality-of-life instrument), and queries regarding long-term satisfaction and medication use. Results Both groups showed a significant postoperative increase in QOLRAD mean scores (p = 0.01). However, the difference in the delta (postoperative–preoperative) score between the two groups was not significant (Fig. 1). There were no differences in mental (MCS) or physical (PCS) SF-12 scores between the two groups. The rate of satisfaction with the surgery was similar in the Nissen–Collis fundoplication (87.5%) and Nissen fundoplication (87%) groups. Fig. 1 Quality of Life in Reflux and Dyspepsia (QOLRAD) score in the two groups. (* p = 0.01 vs preoperative value)

---

Conclusions Collis gastroplasty combined with Nissen fundoplication is an effective procedure for patients with a shortened esophagus diagnosed intraoperatively during antireflux surgery. Patient satisfaction, postoperative quality of life, and QOLRAD score improvement after this procedure are comparable with those observed in patients treated with Nissen fundoplication alone.     

Laparoscopic Nissen fundoplication without division of short gastric vessels in children

Purpose

It has been suggested that routine division of short gastric vessels (SGVs) results in a more “floppy” Nissen fundoplication leading to improved outcomes, that is, less dysphagia and lower incidences of recurrent gastroesophageal reflux disease (GERD). The aim of this retrospective study was to assess whether laparoscopic Nissen fundoplication without division of SGVs (Rossetti modification) (laparoscopic Nissen-Rossetti fundoplication [LNRF]) is associated with acceptable clinical outcome in children.

Method

The charts of 368 children who underwent LNRF between January 1996 and September 2004 by 1 primary surgeon were retrospectively reviewed. Children were divided into 2 groups: LNRF + gastrostomy (A) and LNRF alone (B). Mean follow-up period of all groups was 4.2 years.

Results

Laparoscopic Nissen-Rossetti fundoplication was completed in 99% (365/368). Mean operating time for group A was 74 minutes and 61 minutes for group B. None in group A required postoperative esophageal dilatation, and 9 in group B (22.5%) required 12 dilatations; 3.6% developed recurrent GERD, 3.7% in group A and 2.5% in group B.

Conclusion

Laparoscopic Nissen-Rossetti fundoplication can be performed with acceptable long-term outcome in children, especially in the majority also requiring chronic gastrostomy access. Short-term, reversible dysphagia may be seen in a small percentage of children having fundoplication alone.     

Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy

Background: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question. Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median follow-up time of 8.3 months (range, 3–51). Results are expressed as the mean ± SEM. Results: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES) pressure from 41.4 ± 4.2 mmHg to 14.2 ± 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux (percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 ± 0.6% (range, 0.1–4%), and the mean DeMeester score was 11.7 ± 4.6 (range, 0.48–19.7). Conclusions: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24 h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment. Received: 12 May 1998/Accepted: 15 December 1998     

Assessment of Quality of Life after Laparoscopic Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease

Background In this study two different quality of life items are compared, and correlation of patient satisfaction with preoperative and postoperative symptoms after laparoscopic Nissen fundoplication (LNF) for chronic gastroesophageal reflux disease is evaluated. Materials and Methods Between December 2002 and December 2004, 60 patients with a diagnosis of chronic gastroesophageal reflux disease scheduled for laparoscopic Nissen fundoplication were recruited prospectively and volunteered to participate in this study. Patients underwent endoscopy, and their disease-specific symptoms were scored on a scale. Quality of life was measured preoperatively and in the first and sixth postoperative months with two questionnaires: Short Form-36 (SF 36) (preoperatively) and the Gastroesophageal Reflux Disease—Health-Related Quality of Life (GERD-HRQL) (postoperatively). Results In more than 90% of the patients, typical symptoms (regurgitation and pyrozis) were controlled postoperatively (p < 0.001). In the first postoperative month, however, dysphagia (early dysphagia) was seen in 46 (76%) patients, whereas in the sixth postoperative month (late dysphagia) its incidence decreased to only 2 (3.3%) patients. Similarly, in the first postoperative month 42 (70%) patients had gas bloating, but the incidence of this symptom decreased to 26 (43.3%) patients by the sixth month (p = 0.01). The quality-of-life measurements obtained from both SF 36 and GERD-HRQL showed that quality of life of the patients improved significantly in the related domain of each item after surgery (p < 0.001). Conclusions Laparoscopic Nissen fundoplication is an effective operation that controls the typical symptoms and improves the quality of life of patients, but new-onset symptoms affect postoperative well-being. For closer evaluation of the benefits of the operation, we need new questionnaires that comprehensively evaluate the symptom spectrum of GERD both preoperatively and postoperatively.