Effect of surgeon on outcome of antireflux surgery

Background We sought to determine whether subjective outcomes one or more years after antireflux surgery are affected by the operating surgeon. Methods We reviewed records of patients who had antireflux surgery from June 2000 to June 2002 and mailed the patients a 19-item survey that focused on current medication use, postoperative symptom improvement, and satisfaction with surgery. We tested the significance of predictor variables using chi-squared and Fisher exact tests for categorical variables and analysis of variance for continuous variables. Results We mailed the survey to 74 patients. Ninety-one percent of the operations were initially laparoscopic, with 5 (7%) subsequently converting to open. Ninety-five percent of patients were taking protein pump inhibitors (PPIs) preoperatively. Surgeons (n = 7) were divided into four groups, with the four surgeons who did two or fewer procedures in one group. Fifty-two of 74 patients (70%) responded to the survey (mean age, [SD] 44 [21] years, 37% male). The mean duration of followup was 2.1 [0.46] years. Thirty-eight percent of patients were taking medications for gastroesophageal reflux disease at the time of survey completion. It was found that the surgeon had an influence on patients’ perceptions of the success of the surgery and whether having surgery was a good idea. We did not identify a statistically significant effect of the surgeon on preoperative symptom severity, postoperative ability to belch, dysphagia, medication use, and lifestyle. Conclusion A patient’s surgeon has an effect on satisfaction with antireflux surgery. Further research should clarify specific practices of the surgeon (patient selection, operative technique, followup) associated with best outcome. Presented in poster form at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, Colorado, March 31–April 3, 2004. This work was supported in part by the Canadian Association of General Surgeons and the physicians of Ontario through the Physicians’ Services Incorporated Foundation. Dr. Urbach is a Career Scientist of the Ontario Ministry of Health and Long-Term Care, Health Research Personnel Development Program.     

Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy

Background: Recent reports have suggested that antireflux surgery should not be advised with the expectation of elimination of medical treatment. We reviewed our results with laparoscopic fundoplication as a means of eliminating the symptoms of gastroesophageal reflux disease (GERD), improving quality of life, and freeing patients from chronic medical treatment for GERD. Methods: A total of 297 patients who underwent laparoscopic fundoplication (Nissen, n = 252; Toupet, n = 45) were followed for an average of 31.4 months. Preoperative evaluation included endoscopy, barium esophagram, esophageal manometry, and 24-h pH analysis. A preoperative and postoperative visual analogue scoring scale (0–10 severity) was used to evaluate symptoms of heartburn, regurgitation, and dysphagia. A GERD score (2–32) as described by Jamieson was also utilized. The need for GERD medications before and after surgery was assessed. Results: At 2-year follow-up, the average symptom scores decreased significantly in comparison to the preoperative values: heartburn from 8.4 to 1.7, regurgitation from 7.2 to 0.7, and dysphagia from 3.7 to 1.0. The Jamieson GERD score also decreased from 25.7 preoperatively to 4.1 postoperatively. Only 10% of patients were on proton pump inhibitors (PPI) at 2 years after surgery for typical GERD symptoms. A similar percentage of patients (8.7%) were on PPI treatment for questionable reasons, such as Barretts esophagus, sensitive stomach, and irritable bowel syndrome. Seventeen patients (5.7%) required repeat fundoplication for heartburn (n = 9), dysphagia (n = 5), and gas/bloating (n = 3). Conclusions: Laparoscopic fundoplication can successfully eliminate GERD symptoms and improve quality of life. Significant reduction in the need for chronic GERD medical treatment 2 years after antireflux surgery can be anticipated. Presented at the combined meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the 8th World Congress of Endoscopic Surgery, New York, NY, USA, 13–16 March 2002     

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease using multiple Plicator implants: 12-month multicenter study results

Background

The full-thickness Plicator^® (Ethicon Endosurgery, Sommerville, NJ, USA) was developed for endoscopic treatment of gastroesophageal reflux disease (GERD). The goal is to restructure the antireflux barrier by delivering transmural pledgeted sutures through the gastric cardia. To date, studies using this device have involved the placement of a single suture to create the plication. The purpose of this study was to evaluate the 12-month safety and efficacy of this procedure using multiple implants to restructure the gastroesophageal (GE) junction.

Methods

A multicenter, prospective, open-label trial was conducted at four tertiary centers. Eligibility criteria included symptomatic GERD [GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire, off of medication], and pathologic reflux (abnormal 24-h pH) requiring daily proton pump inhibitor therapy. Patients with Barrett’s epithelium, esophageal dysmotility, hiatal hernia >3 cm, and esophagitis (grade III or greater) were excluded. All patients underwent endoscopic full-thickness plication with linear placement of at least two transmural pledgeted sutures in the anterior gastric cardia.

Results

Forty-one patients were treated. Twelve months post treatment, 74% of patients demonstrated improvement in GERD-HRQL scores by ≥50%, with mean decrease of 17.6 points compared with baseline (7.8 vs. 25.4, p < 0.001). Using an intention-to-treat model, 63% of patients had symptomatic improvements of ≥50%, with mean GERD-HRQL decrease of 15.0 (11.0 vs. 26.0, p < 0.001). The need for daily proton pump inhibitor (PPI) therapy was eliminated in 69% of patients at 12 months on a per-protocol basis, and 59% on an intention-to-treat basis. Adverse events included postprocedure abdominal pain (44%), shoulder pain (24%), and chest pain (17%). No long-term adverse events occurred.

Conclusions

Endoscopic full-thickness plication using multiple Plicator implants can be used safely and effectively to improve GERD symptoms and reduce medication use.     

抗胃食管反流外科治疗的远期疗效观察

目的探讨胃食管反流外科治疗的远期疗效。方法1988年11月至2004年1月手术治疗129例胃食管反流病(GERD),分别采用N issen手术(65例)、贲门斜行套叠术(39例)、Belsey4号手术(17例)、Toupet手术(3例)、Thal手术(1例)、Dor手术(4例)等6种方法治疗。116例得到随访,计算临床症状评分,并与术前比较。手术前后分别有95例及51例行食管压力测定检查,56例及35例行24 h食管pH值监测及DeM eester评分;术前常规行内镜检查,术后48例行内镜检查,对结果进行比较。结果在随访的116例患者中,临床症状评分由术前的(4.1±0.4)分降为术后的(1.1±1.0)分,较术前显著降低(t=27.21,P<0.01)。手术疗效优42例(36.2%),良60例(51.7%),可7例(6.0%),差7例(6.0%),手术远期优良率87.9%(102/116)。N issen、Belsey 4号和贲门斜行套叠术三者间疗效无差异。结论外科手术是治疗GERD的有效方法,N issen手术、贲门斜行套叠术和Belsey 4号手术疗效相近。     

Laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)

Background: Laparoscopic antireflux surgery is currently a growing field in endoscopic surgery. The purpose of the Consensus Development Conference was to summarize the state of the art of laparoscopic antireflux operations in June 1996. Methods: Thirteen internationally known experts in gastroesophageal reflux disease were contacted by the conference organization team and asked to participate in a Consensus Development Conference. Selection of the experts was based on clinical expertise, academic activity, community influence, and geographical location. According to the criteria for technology assessment, the experts had to weigh the current evidence on the basis of published results in the literature. A preconsensus document was prepared and distributed by the conference organization team. During the E.A.E.S. conference, a consensus document was prepared in three phases: closed discussion in the expert group, public discussion during the conference, and final closed discussion by the experts. Results: Consensus statements were achieved on various aspects of gastroesophageal reflux disease and current laparoscopic treatment with respect to indication for operation, technical details of laparoscopic procedures, failure of operative treatment, and complete postoperative follow-up evaluation. The strength of evidence in favor of laparoscopic antireflux procedures was based mainly on type II studies. A majority of the experts (6/10) concluded in an overall assessment that laparoscopic antireflux procedures were better than open procedures. Conclusions: Further detailed studies in the future with careful outcome assessment are necessary to underline the consensus that laparoscopic antireflux operations can be recommended. Received: 29 November 1996/Accepted: 14 December 1996     

The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children

Background The benefits of surgery for gastroesophageal reflux disease (GERD) in infants and children have been questioned in the recent literature. The goal of this review was to determine the best current practice for the diagnosis and management of this disease. Methods The literature was reviewed for all recent English language publications on the management of GERD in 8- to 10-year-old patients. Results In infants and children, GERD has multiple etiologies, and an understanding of these is important for determining which patients are the best surgical candidates. Proton pump inhibitors (PPIs) have become the mainstay of current treatment for primary GERD. Although laparoscopic surgery appears to be better than open surgery, there remains some morbidity and complications that careful patient selection can minimize. Conclusion Surgery for GERD should be performed only after failure of medical management or for specific problems that mandate it.     

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。     

Comparative results of endoluminal gastroplasty and laparoscopic antireflux surgery for the treatment of GERD

Background: Transoral endoluminal gastroplasty (EG) by the Bard Endocinch device is available for the treatment of gastroesophageal reflux disease (GERD). This study assessed the early (12 months) outcomes in patients undergoing EG performed by one gastroenterologist compared with another set of patients referred by the same gastroenterologist for laparoscopic antireflux surgery (LAS) at a foregut surgery center. Methods: From June 2000 to July 2002, 87 consecutive patients cared for by a single gastroenterologist were diagnosed with refractory GERD and underwent either EG (n = 47) or referral for LAS (n = 40). Preoperative evaluation included symptom assessment, pH studies, and motility studies. Outcomes were assessed by symptomatic improvement and dependence on anti-acid medications. Data analyzed by chi-square or Mann-Whitney tests are reported as mean ± SEM. Results: Preoperative symptom duration, Johnson-DeMeester (JD) score, % time pH < 4, and reflux episodes were statistically similar in both treatment groups. The follow-up times for EG and LAS groups were 7.3 ± 0.9 and 8 ± 0.4 months, respectively. Of EG patients, 94% were available for follow-up, and all LAS patients had follow-up data. Overall, 66% of patients were satisfied with EG as compared to 93% after LAS (p = 0.1). Postoperative PPI/motility agent use was 32% for EG and 13% for LAS (p = 0.03). Identifiable causes of EG failure were premature procedure termination due to hypoxia or bleeding (three patients), intractable vomiting (two patients), and delayed gastric emptying (five patients). Three EG patients subsequently had LAS within 6 months of the procedure. Conclusions: LAS offers greater reduction in medication use than EG, as well as more durable patient satisfaction. Benefits of EG may include short-term symptomatic improvement while considering definitive surgical management. Presented at the annual meeting of the Society of American Gastrointestinal Surgery (SAGES), Los Angeles, CA, USA, 15 March 2003     

Nissen fundoplication: three causes of failure (video)

Background Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure for gastroesophageal reflux disease. The rate of failure following fundoplication varies from 2% to 30%, and revision is required in many of the patients who have recurrent or new foregut symptoms. Common causes of failure include hiatal hernia, wrap disruption, slipped wrap, and misplaced wrap. Methods This video depicts three different causes of failure of LNF, each demonstrated while perfoming a redo fundoplication. The first case shows a common cause of failure, a misplaced wrap. Less common causes of failure are seen in the second and third cases: a retained foreign body and fundus herniation through the retroesophageal space. In the first two cases, following the dissection of the original wrap, the proper construction of a Nissen fundoplication is shown. Results The first patient developed recurrent reflux symptoms that can be explained by the misplaced wrap. In case two, the patient’s dysphagia was a result of a retained foreign body from the initial procedure creating a fibrotic reaction and esophageal stricture. The final case shows how chronic failure can sometimes have an acute presentation. We see the patient’s gastric fundus has herniated through the retroesophageal space and it has become incarcerated and volvulized, creating a closed loop obstruction and acute distention. Conclusions The surgeon watching this video can appreciate the identification of various causes of LNF failure, the approach to dissection of the old wraps, and the important steps in the creation of a Nissen fundoplication. This article contains a supplementary video.     

Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons

Background/Purpose

The purpose of the study was to identify influential factors contributing to the variation with which antireflux procedures (ARPs) are performed at freestanding children's hospitals in the United States.

Methods

We conducted an online survey of pediatric surgeons working in Child Health Corporation of America (CHCA) member hospitals in which we examined decision making for ARPs.

Results

Thirty-six percent (n = 121) of contacted surgeons responded. Eighty percent reported requiring preoperative upper gastrointestinal series before ARPs, and 13% require a pH probe study. Although surgeons ranked their own opinion as the most important in preoperative decision making, parents and referring physicians played significant roles in hypothetical scenarios. In children with negative/equivocal objective studies, more than half of surgeons reported offering ARP when the referring specialist felt that ARP was indicated. Despite equivocal studies, 20% of the surgeons reported offering ARP when the parents were convinced that ARP would help. In a patient with both a positive pH probe and upper gastrointestinal series, 46% of surgeons reported declining ARP if parents were hesitant.

Conclusions

These data suggest that a surgeon's final decision to perform ARP may be just as influenced by nonobjective factors, such as referring physician and parental opinions, as it is by objective studies. Our survey reinforces the need for further examination of specific factors in preoperative decision making for ARPs in the pediatric population.     

Influence of spastic motor disorders of the esophageal body on outcomes from laparoscopic antireflux surgery

Background: The clinical outcomes of laparoscopic antireflux surgery (LARS) in patients with the spectrum of nonspecific spastic esophageal motor disorders (NSSDs) are not known. Methods: From a prospective database of patients undergoing LARS between 1997 and 2000, those with preoperative manometry at our institution and follow-up at 6 months were identified. Results: Of the 121 patients, 35 had NSSDs. There were no differences in symptoms between groups preoperatively, but in the immediate postoperative period NSSD patients had more symptoms than nonspastic patients. At 18-month mean follow-up, NSSD patients reported significantly more heartburn (22% vs 7%), waterbrash (14% vs 4%), and medication usage (17% vs 5%) than nonspastic patients (p < 0.05 for each). Despite this difference, nearly all patients reported subjective improvement postoperatively, and the degree of improvement was similar between groups. Conclusions: Patients with NSSDs are more likely to have esophageal symptoms following LARS than subjects without these abnormalities. However, these patients still experience significant improvement in preoperative symptoms. Presented at the 8^th World Congress Society of American Gastrointestinal Endoscopic Surgeons (SAGES). New York, NY, USA, March 2002     

Psychiatric disorders affect outcomes of antireflux operations for gastroesophageal reflux disease

apd: 20 October 2000     

Outcome of laparoscopic antireflux surgery in patients with nonerosive reflux disease

As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa. Presented in abstract form at the Annual Meeting of the American Gastroenterology Association, Orlando, Florida, May 15, 1999.     

Laparoscopic partial posterior (Toupet) fundoplication improves esophageal bolus propagation on scintigraphy

BACKGROUND: Impaired esophageal clearance is important in the pathogenesis of gastroesophageal reflux disease (GERD). It is unknown whether esophageal clearance improves following antireflux surgery. The aim of this study was to investigate the effect of laparoscopic Nissen fundoplication (NF), laparoscopic partial posterior (Toupet) fundoplication (PPF) or medical therapy on esophageal clearance. METHODS: This was a prospective nonrandomized crossover study. Sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying, and assessment of symptoms prior to surgery or medical therapy and 6 months after treatment. In 20 GERD patients with normal esophageal peristalsis an NF was performed, in 20 patients with impaired esophageal peristalsis a PPF was chosen, and 20 patients received proton-pump inhibitor (PPI) treatment. RESULTS: On endoscopy, esophagitis had resolved in all patients after surgery; two patients with medical therapy still had esophagitis. On manometry, a significant improvement of lower esophageal sphincter competence was seen in both surgical groups. LES relaxation was complete after PPF, but incomplete after NF. Esophageal peristalsis did not improve after medical therapy, was significantly improved after PPF, but had worsened after NF. On scintigraphic esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after PPF. A significant deterioration of esophageal emptying was observed after NF. There was a strong correlation between scintigraphic and manometric evaluation of peristalsis preoperatively (r(s) = -0.87, p < 0.05) and postoperatively (r(s) = -0.82, p < 0.05). There was no change in dysphagia after medical therapy and after NF but a significant improvement after PPF. Globus sensation was significantly improved after PPF but did not change after medical therapy or NF. Postprandial bloating and inability to belch were significantly more common after NF than after PPF. CONCLUSION: Laparoscopic partial posterior (Toupet) fundoplication can restore a preoperatively defective esophageal bolus propagation on scintigraphy with the same antireflux effect as the laparoscopic Nissen fundoplication, but with lower side-effects.     

Pathophysiology of gastro-oesophageal reflux disease (GERD) with respect to reflux-induced carcinogenesis

Summary   Background: Gastro-oesophageal reflux disease has a complex pathophysiology. Therefore, therapeutic considerations should not only include the peptic component of the disease. Methods: A variety of studies in rats and in humans demonstrate the consequences of gastro-oesophageal reflux and medical and surgical interventions in terms of inflammation, epithelial growth stimulation, apoptosis and oxidative stress in the epithelium of the oesophagus. Results: Gastro-oesophageal reflux disease consists of a variety of pathophysiologically important factors. These include changes in the anatomy, gastro-oesophageal motility, epithelial growth, inflammation, apoptosis and molecular structure and may lead to carcinogenesis. Surgery restores the antireflux barrier and improves oesophageal and gastric motility, thus preventing the consequences of the disease. Conclusions: Antireflux surgery provides a causative therapy of gastrointestinal reflux disease.      

Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease

The use of the laparoscopic approach to perform antireflux procedures has increased dramatically since its introduction in 1991. To date, no prospective randomized studies comparing open surgery to the minimal invasive approach in children have been reported. Many retrospective reviews and case series have demonstrated that laparoscopic antireflux procedures are safe and effective once the learning curve is achieved. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize the available evidence to identify the risks and benefits of laparoscopic antireflux procedures.     

Endoscopic grading of the gastroesophageal valve in patients with symptoms of gastroesophageal reflux disease (GERD)

Background: It has been suggested that endoscopic grading of the gastroesophageal flap valve is a good predictor of the reflux status. Methods: To test this hypothesis, 268 symptomatic patients underwent endoscopic grading of the gastroesophageal valve using Hill's classification, with grades I through IV. Esophageal acid exposure, lower esophageal sphincter characteristics, and the degree of esophageal mucosal injury were compared among the groups. Results: The prevalence of a mechanically defective sphincter, abnormal esophageal acid exposure, erosive esophagitis, and Barrett's esophagus increased with increasing alteration of the gastroesophageal valve. The presence of a grade IV valve indicated increased esophageal acid exposure in 75% of patients. As a predictor, this is similar to lower esophageal sphincter pressure but not as good as the presence of esophageal mucosal injury. Conclusions: Endoscopic grading of the gastroesophageal valve provides useful information about the reflux status but is less useful as an indicator of gastroesophageal reflux disease (GERD) than the presence of esophageal mucosal injury. Received: 28 April 1999/Accepted: 23 June 1999     

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 gastroesophageal dissociation in neurologically impaired children with gastroesophageal reflux disease

Purpose

Neurologically impaired children with severe gastroesophageal reflux disease (GERD) are a challenging group of patients. We theorized that a laparoscopic gastroesophageal dissociation (LGED) may decrease reflux-related readmissions and healthcare visits, and improve quality of life (QOL) for them and their caregivers.