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

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

The significance of pH and manometric testing after laparoscopic fundoplication

Laparoscopic antireflux surgery has become the standard operation for gastroesophageal reflux disease (GERD). This study examined the outcomes of laparoscopic antireflux surgery, hypothesizing that both subjective symptoms and objective pH would correlate with manometric parameters to reflect the absence of reflux after fundoplication. We evaluated 56 patients who underwent laparoscopic antireflux surgery. Preoperative and postoperative symptoms were documented by chart reviews and confirmed by telephone interviews with the patient. Preoperative pH probe and esophageal manometry studies were compared with postoperative studies performed 3 to 6 months after fundoplication. Subjective symptoms were correlated with objective measurements of acid reflux and lower esophageal sphincter pressure (LESP). The follow-up period was 3 to 29 months. Symptomatic improvement was seen in 91% of patients, and good to excellent improvement in preoperative symptoms was cited. Postoperatively, there was significant improvement in percentages of upright supine times when esophageal pH was less than 4 (p <0.001). There was an increase in LESP from an average of 16.9 mmHg preoperatively to 22.7 mmHg postoperatively (p <0.001). There was no correlation between postoperative LESP and symptoms or LESP and 24-h pH results. However, there was a predictive correlation between LESP and postoperative heartburn symptoms (p <0.001). These findings imply that symptom follow-up evaluation is adequate in the asymptomatic patient after laparoscopic fundoplication, and that routine physiologic testing is not necessary.     

Does laparoscopic antireflux surgery prevent the occurrence of transient lower esophageal sphincter relaxation?

Background: Transient lower esophageal sphincter relaxation (TLESR) is the most common mechanism underlying gastroesophageal reflux disease (GERD), causing 70% to 100% of the reflux episodes in normal subjects and 63% to 74% of the reflux episodes in patients with reflux disease. This study aimed to evaluate the effect of laparoscopic Nissen fundoplication on TLESR in patients with proven GERD. Methods: We prospectively followed 73 consecutive patients (13 men and 60 women; mean age, 43.7 ± 1.72 years) with proven diagnosis of GERD and reported TLESRs found during a 40-min esophageal manometric study. These patients had repeat testing 6 months after undergoing laparoscopic Nissen fundoplication. Results: Laparoscopic Nissen fundoplication increased the basal and nadir lower esophageal sphincter (LES) pressure and significantly reduced the number of TLESRs during the manometric study. No patients after surgery exhibited TLESR with nadir less than 2 mmHg. However, 8 of the 73 patients (11%) exhibited TLESR to a nadir exceeding 50% of basal pressure (mean nadir, 5.0 ± 1.07 mmHg). Conclusions: The number of TLESRs is reduced significantly by antireflux surgery. Even accounting for increased basal and nadir pressures, the incidence of TLESR is reduced, suggesting that there may be additional mechanisms involved in this process.     

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.     

Five-year comprehensive outcomes evaluation in 181 patients after laparoscopic Nissen fundoplication

BACKGROUND: We conducted an objective followup of 181 patients after laparoscopic Nissen fundoplication during a 5-year period after surgery. STUDY DESIGN: Patients underwent 24-hour pH recording, esophageal manometry, and symptom score assessment for six gastroesophageal reflux disease symptoms preoperatively and at 6 months, 2 years, and 5 years after surgery. RESULTS: Laparoscopic fundoplication was associated with a significant (p < 0.0001) increase in lower esophageal sphincter pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours, and symptom score, 6, 24, and 60 months after surgery when compared with preoperative values. Twenty-one patients (12%) have experienced recurrence of reflux-type symptoms, but only six have required repeat surgery. Lower esophageal sphincter tone dropped between 6 months and 5 years after surgery, but was still an effective antireflux barrier. Patient satisfaction with surgery dropped over the 5-year followup but remained high, at 86%, after 5 years. CONCLUSIONS: Laparoscopic Nissen fundoplication remains an effective antireflux procedure at 5 years.     

Comparison of laparoscopic total and partial fundoplication for gastroesophageal reflux

Approximately 25% of patients with gastroesophageal reflux, severe enough to be considered for surgical treatment have dysfunction of esophageal peristalsis in addition to dysfunction of the lower esophageal sphincter. A standard total (i.e., Nissen) fundoplication in these patients may be followed by dysphagia, so many experts recommend a partial fundoplication as an alternative. The goal of this study was to compare the clinical results and changes in esophageal function following laparoscopic total and partial fundoplication. Ninety-three patients with gastroesophageal reflux disease had laparoscopic antireflux operations. Total fundoplication was performed in 50 patients with normal esophageal peristalsis. Partial fundoplication was chosen for 43 patients with severe abnormalities of esophageal peristalsis. Partial fundoplication of patients has resolution of heartburn (93%) and regurgitation (97%) after partial as compared to total fundoplication. Dysphagia developed in four patients (8%) after total fundoplication (one patient required dilatation) and in no patients after partial fundoplication. Both operations produced similar changes in lower esophageal sphincter function, but only partial fundoplication was associated with improvement in esophageal dysfunction. Esophageal acid exposure became normal in 92% of patients after total and in 91% of patients after partial fundoplication. Partial fundoplication improves lower esophageal sphincter pressure and esophageal body function and, in patients with abnormal esophageal peristalsis, it corrects reflux without producing dysphagia. Partial and total fundoplication are both indicated in patients with gastroesophageal reflux disease, and the choice of which procedure to use should be based on each patient's specific esophageal motor function abnormalities. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco Calif., May 19–22, 1996.     

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

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

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

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

Laparoscopic antireflux surgery in the treatment of gastroesophageal reflux in patients with Barrett esophagus

BACKGROUND: Patients with gastroesophageal reflux and Barrett esophagus may represent a group of patients with poorer postoperative outcomes. It has been suggested that such patients should undergo open rather than laparoscopic antireflux surgery. HYPOTHESIS: The laparoscopic approach to antireflux surgery is appropriate treatment for patients with Barrett esophagus who have symptomatic gastroesophageal reflux disease. METHODS: The outcome of 757 patients undergoing laparoscopic surgery for gastroesophageal reflux disease from January 1, 1992, through December 31, 1998, was prospectively examined. Barrett esophagus was present in 81 (10.7%) of these patients (58 men and 23 women). The outcome for this group of patients was compared with that of patients undergoing surgery who did not have Barrett esophagus. RESULTS: The types of operation performed were similar for the 2 patient groups. The mean +/- SD length of columnar mucosa was 47.4 +/- 43.6 mm. The average +/- SD operation time was 79.0 +/- 33.4 minutes. Conversion to open surgery occurred in 6 patients. Postoperative outcomes were as follows. Esophageal manometry and 24-hour pH studies before and after laparoscopic fundoplication demonstrated a significant increase in lower esophageal sphincter resting and residual relaxation pressures and a significant decrease in distal esophageal acid exposure. Four patients have developed high-grade dysplasia or invasive cancer within 4 years of their antireflux surgery, and all of these have subsequently undergone esophageal resection. CONCLUSIONS: The outcome of laparoscopic antireflux surgery is similar for patients with Barrett esophagus compared with other patients with gastroesophageal reflux disease. This suggests that laparoscopic surgery is appropriate treatment for this patient group.     

The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with "typical" symptoms.

OBJECTIVE: To evaluate prospectively the outcome of laparoscopic fundoplication in a large cohort of patients with typical symptoms of gastroesophageal reflux. SUMMARY BACKGROUND DATA: The development of laparoscopic fundoplication over the past several years has resulted in renewed interest in the surgical treatment of gastroesophageal reflux disease (GERD). METHODS: One hundred patients with typical symptoms of GERD were studied. The study was limited to patients with positive 24-hour pH studies and "typical" symptoms of GERD. Laparoscopic fundoplication was performed when clinical assessment suggested adequate esophageal motility and length. Outcome measures included assessment of the relief of the primary symptom responsible for surgery; the patient's and the physician's evaluation of outcome; quality of life evaluation; repeated upper endoscopy in 30 patients with presurgical esophagitis; and postsurgical physiologic studies in 28 unselected patients, consisting of 24-hour esophageal pH and lower esophageal sphincter manometry. RESULTS: Relief of the primary symptom responsible for surgery was achieved in 96% of patients at a mean follow-up of 21 months. Seventy-one patients were asymptomatic, 24 had minor gastrointestinal symptoms not requiring medical therapy, 3 had gastrointestinal symptoms requiring medical therapy, and 2 were worsened by the procedure. Eighty-three patients considered themselves cured, 11 were improved, and 1 was worse. Occasional difficulty swallowing not present before surgery occurred in 7 patients at 3 months, and decreased to 2 patients by 12 months after surgery. There were no deaths. Clinically significant complications occurred in four patients. Median hospital stay was 3 days, decreasing from 6.3 in the first 10 patients to 2.3 in the last 10 patients. Endoscopic esophagitis healed in 28 of 30 patients who had presurgical esophagitis and returned for follow-up endoscopy. Twenty-four-hour esophageal acid exposure had returned to normal in 26 of 28 patients studied after surgery. Lower esophageal sphincter pressures had also returned to normal in all patients, increasing from a median of 5.1 mmHg to 14.9 mmHg. CONCLUSIONS: Laparoscopic Nissen fundoplication provides an excellent symptomatic and physiologic outcome in patients with proven gastroesophageal reflux and "typical" symptoms. This can be achieved with a hospital stay of 48 hours and a low incidence of postsurgical complications.     

Pathophysiological Measurement and Results After Laparoscopic Fundoplication for Gastroesophageal Reflux Disease

Purpose: Both surgical and conservative treatments for gastroesophageal reflux disorder (GERD) are controversial. The aim of this prosepective study was to examine outcomes after laparoscopic antireflux surgery. Methods: The subjects were 143 patients who underwent laparoscopic antireflux surgery. Following diagnostic procedures 126 patients were allocated to a total fundoplication group (360°C, Nissen-DeMeester) and 17, to a posterior semifundoplication group (250–270°, Toupet). All complications were registered, and pathophysiological and outcome data were examined 3, 6, and 9 months after surgery. Results: By 6 months after surgery the mean lower esophageal sphincter (LES) pressure had improved significantly, to 14.8 mmHg in the Nissen-DeMeester group, and to 12.1 mmHg in the Toupet group, corresponding to successful prevention of esophageal reflux in both groups. Dysphagia was more common in the early postoperative period after total fundic wrap (17% vs 12%), but this difference disappeared in time. All patients reported complete relief of reflux symptoms, although two of those who underwent the Nissen-DeMeester fundoplication experienced relapse of GERD and required open reconstruction (1.4%). The laparoscopic procedure was converted to open surgery in three patients (2%). There were no associated deaths and the perioperative complication rate was 4.2%. Conclusion: Laparoscopic antireflux surgery is an effective treatment for GERD. More than 93% of the patients in this series rated their outcome as good to excellent following the operation. Received: December 10, 2001 / Accepted: May 7, 2002 Reprint requests to: K. Ludwig     

Effectiveness of esophageal manometry in predicting the outcome of children with primary GER after floppy Nissen-Rossetti wrap

Background Surgical treatment of gastroesophageal reflux (GER) can result in many postoperative problems because of an incorrect indication or an unsuitable fundoplication. Many preoperative tests have been suggested to perform a “tailored fundoplication,” but there is no clear evidence as to which is the best. The aim of our study was to define the effectiveness of esophageal manometry in predicting the outcome of children who need fundoplication because of refractory primary gastroesophageal reflux. Methods Thirty-two children were included in the study. Patients with gastroenterologic and respiratory symptoms numbered 10 (31%) and 22 (69%), respectively. The preoperative motility pattern was (1) inappropriate relaxations alone in nine patients (28%) and associated with esophageal body dysmotility in one patients (3%); (2) low-pressure lower esophageal sphincter (LES), alone in 13 patients (41%) and associated with body dysmotility in eight (25%). Motility pattern of the esophageal body was abnormal in nine children. Manometric anomalies were absent only in one case. Results Low pressure of the LES associated with atypical esophageal motility disorders was significantly higher in the gastroenterological group and in the older patients. Low pressure of the LES associated with good esophageal activity was significantly higher in the respiratory group and in the patients younger than 24 months. There was no correlation between motility pattern and outcome, and no statistically significant differences were found between pressure values at the different levels and symptoms, outcome, and age groups. Conclusions Esophageal manometry is not mandatory to predict the outcome of patients undergoing laparoscopic Nissen-Rossetti fundoplication for refractory primary GER treatment. An erratum to this article is available at .     

Laparoscopic antireflux surgery

Background: Concern has been raised about operating on patients with gastroesophageal reflux disease (GERD) and normal lower esophageal sphincter (LES) pressure for the fear that a fundoplication may fail to control reflux and result in a high rate of postoperative dysphagia. We hypothesized that fundoplication is effective in patients with GERD irrespective of the preoperative LES pressure, and that in patients with normal LES pressure, a total fundoplication does not result in a high incidence of dysphagia. Methods: We studied 280 unselected patients with GERD who underwent laparoscopic fundoplication. They were divided in three groups based on the preoperative LES pressure (normal, 14–24 mmHg): group A (LES pressure, 0–6 mmHg; 61 patients; 22%); group B (LES pressure, 7–13 mmHg; 178 patients; 64%); group C (LES pressure, ?14 mmHg; 41 patients; 14%). De novo dysphagia was defined as new onset of postoperative dysphagia lasting more than 10 weeks. The average follow-up period was 17 ± 22 months. Results: There was no difference in resolution of symptoms among the three groups. Heartburn and regurgitation resolved or improved respectively in 96% of group A, 90% of group B, and 91% of group C patients. In addition, there was no difference in the incidence of de novo dysphagia, which occurred in 8% of group A, 7% of group B, and 2% of group C. Conclusions: We conclude that fundoplication controlled GERD irrespective of preoperative LES pressure, and that a normal LES pressure before surgery was not associated with a higher rate of postoperative dysphagia.     

Problems associated with a Nissen fundoplication following tracheoesophageal fistula and esophageal atresia repair

Gastroesophageal reflux is frequently associated with esophageal atresia and tracheoesophageal fistula repair. Following unsuccessful medical treatment, 14 (45%) of 31 patients underwent a Nissen fundoplication. Five of these 14 patients had prolonged dysphagia requiring supplemental gastrostomy feeding. Four of these five patients underwent postoperative manometry and extended pH monitoring, which revealed a normal lower-esophageal sphincter pressure (greater than 15 mm Hg), normal pH results, and marked esophageal dysmotility. The fundoplication creates a mechanical obstruction for those patients with a dyskinetic esophagus who cannot generate the pressure to open the "new sphincter". To avoid this complication, antireflux surgery should be deferred, if possible, in those patients with severe gastroesophageal reflux and marked esophageal motility abnormalities.     

Role of the lower esophageal sphincter and hiatal hernia in the pathogenesis of gastroesophageal reflux disease

The relative importance of the lower esophageal sphincter (LES) and hiatal hernia in the pathogenesis of gastroesophageal reflux disease is controversial. To identify the role of hiatal hernia and LES in reflux disease, 375 consecutive patients with foregut symptoms and no previous foregut surgery were evaluated. All patients underwent upper endoscopy, stationary manometry, and 24-hour esophageal pH monitoring. Hiatal hernia was diagnosed endoscopically, when the distance between the crural impression and the gastroesophageal junction was ≥2 cm. The LES was considered structurally defective when the resting pressure was ≤6 mm Hg, the overall length was less than 2 cm, and/or the abdominal length was less than 1 cm. Factors predicting abnormal esophageal acid exposure (composite score >14.7) were analyzed using multivariate analysis. The presence of a hiatal hernia and a defective LES were identified as independent predictors of abnormal esophageal acid exposure. LES pressure and abdominal length were reduced in patients with hiatal hernia by 4 mm Hg and 0.4 cm, irrespective of the presence of gastroesophageal reflux disease. It is concluded that both a structurally defective LES and hiatal hernia are important factors in the pathogenesis of reflux disease. It is hypothesized that in the presence of a structurally normal LES, the altered geometry of the cardia imposed by a hiatal hernia facilitates the ability of gastric wall tension to pull open the sphincter. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998 (poster presentation).     

Esophageal motility in the assessment of esophageal function

Esophageal manometry assesses lower esophageal sphincter (LES) pressure and its relaxation. In addition, it detects the ability of the esophageal body to initiate a peristaltic contraction and the contraction's amplitude in response to a water bolus. The study is indicated in patients with symptoms suggestive of an esophageal motor disorder and to assist in the diagnosis of some miscellaneous disorders. The most common disorders diagnosed by esophageal manometry are the primary motility disorders, such as achalasia. Manometry is indicated in the subset of patients with gastroesophageal reflux disease (GERD) who are being considered for antireflux surgery or have symptoms after antireflux surgery.     

Static and dynamic function of the lower esophageal sphincter before and after laparoscopic nissen fundoplication

The means by which fundoplication protects against reflux is disputed. We studied the resting and dynamic features of the lower esophageal sphincter (LES) and 24-hour pH monitoring in 26 patients before and after laparoscopic Nissen fundoplication. Resting features were LES pressure, abdominal length, and total length. Dynamic function was assessed by the residual pressure in the LES during a swallow measured as the bolus flowed though the LES. All patients experienced near-total relief of heartburn and all but one had normal postoperative acid scores. Resting LES characteristics were restored to normal. Mean residual pressure on swallowing was 7.1±3.2 mm Hg in the patients postoperatively compared with 1.2±1 mm Hg preoperatively and 4.0±2.4 mm Hg in normal subjects. Eighteen of 26 patients had residual LES pressure within the normal range (<8.2 mm Hg). There was a tendency for residual pressures to be lower as experience with the procedure was gained. Incomplete LES relaxation is not necessary for effective functioning of a Nissen fundoplication. In construction of a Nissen fundoplication, creating a large retroesophageal window and deliberate dissection of the back of the posterior fundus from the left crus allows the creation of an effective antireflux procedure with restoration of static LES parameters to normal and minimal limitation of LES relaxation.     

A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.

OBJECTIVE: The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. SUMMARY OF BACKGROUND DATA: Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. METHODS: Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. RESULTS: The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. CONCLUSIONS: Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.     

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.     

Techniques and outcomes of laparoscopic surgery in gastroesophageal reflux disease

BACKGROUND: The purpose of this study is to report personal experience in laparoscopic antireflux surgery and to analyze the clinical and functional outcomes of this procedure, also in relation to the different techniques used. METHODS: From 1996 to 2000, 20 patients with gastroesophageal reflux disease associated with hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24 hrs-pH monitoring, endoscopic evidence of esophagitis and hiatal hernia, and defective lower esophageal sphincter. A Nissen fundoplication was performed in 13 patients with normal esophageal body motility, and a 270 degrees posterior fundoplication in seven patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 135 min and mean postoperative hospital stay 5 days. Operative morbidity was 15%. All the patients were completely cured of reflux symptoms; transient mild postoperative dysphagia occurred in two patients (10%). There was a significantly improvement of the results in postoperative esophageal manometry and 24 hrs-pH monitoring. CONCLUSIONS: This preliminary experience suggests that laparoscopic surgery represents a safe and effective procedure for the treatment of gastroesophageal reflux disease. Precise selection of patients and adequate surgical technique are essential.