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 .     

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.     

Effect of partial and total laparoscopic fundoplication on esophageal body motility

Background Abnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis. Methods The pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14). Results The LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B. Conclusions Laparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients. Presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, Texas, 27–29 April 2006     

Esophagography predicts favorable outcomes after laparoscopic Nissen fundoplication for patients with esophageal dysmotility

BACKGROUND: We undertook this study to determine if clearance of a food bolus at preoperative esophagography predicts acceptable outcomes after laparoscopic Nissen fundoplication for patients with manometrically abnormal esophageal motility. STUDY DESIGN: Patients with gastroesophageal reflux disease (GERD) or symptomatic hiatal hernia with evidence of esophageal dysmotility by stationary manometry underwent videoesophagography to document the ability of their esophagus to clear food boluses of varying consistencies. Sixty-six patients were identified who had manometric dysmotility yet were able to clear a food bolus at esophagography, and subsequently underwent laparoscopic Nissen fundoplication. These patients were compared with 100 randomly selected patients with normal motility who underwent laparoscopic Nissen fundoplication. Symptom reduction and satisfaction were assessed through followup. Patients with normal motility were compared with those with manometrically moderate and severe dysmotility. RESULTS: Preoperative patient demographic data, symptoms, and symptom scores were similar among patients with normal motility and moderate or severe dysmotility. After fundoplication, symptom reduction was notable for all patients regardless of preoperative motility (p < 0.01, paired Student's t-test). There was no notable difference in postoperative symptom scores (p = NS, Kruskal-Wallis ANOVA) or in patient satisfaction (p = NS, chi-square analysis) among patients stratified by esophageal motility. CONCLUSIONS: Patients with esophageal dysmotility documented by manometry who are able to clear a food bolus at contrast esophagography, have functional results after laparoscopic Nissen fundoplication similar to patients with normal motility. Preoperative esophagography predicts successful outcomes after laparoscopic Nissen fundoplication for patients with manometric esophageal dysmotility.     

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.     

Impact of laparoscopic nissen fundoplication with prosthetic hiatal closure on esophageal body motility: Results of a prospective randomized trial

HYPOTHESIS: Prosthetic crural closure does not adversely influence esophageal body motility. In most patients, postoperative increased dysphagia resolves spontaneously during the first months after surgery. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatal closure and those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: Forty consecutive patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease. INTERVENTIONS: A 360 degrees Nissen fundoplication with simple sutured crura (n = 20; nonmesh group) vs the same procedure with posterior 1 x 3-cm polypropylene onlay mesh prosthesis (n = 20; mesh group). MAIN OUTCOME MEASURES: Recurrences; postoperative dysphagia rate; localization, length, and pressure of the lower esophageal sphincter (LES); results of 24-hour pH monitoring; esophageal body motility; peristalsis; and esophageal amplitude of contraction and interrupted waves. RESULTS: Preoperatively, both groups had pathological LES pressure and DeMeester scores. These values improved significantly (P < .01) after surgery and remained stable at 1 year after surgery. Patients in the nonmesh group had a significantly lower LES pressure 1 year after surgery compared with those in the mesh group. There were no significant differences in postoperative mean LES length (4.1 vs 3.8 cm), LES relaxation (93.4% vs 92.4%), and intra-abdominal LES length (2.1 vs 2.1 cm). Patients in the mesh group had fewer simultaneous waves and interrupted waves 1 year after surgery, but the difference between groups was not significant. There were no significant differences in interrupted waves and amplitude of contraction between groups 1 year after surgery. CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic crural closure does not impair postoperative esophageal body motility compared with laparoscopic Nissen fundoplication with simple suture hiatal closure, although it is associated with a higher rate of short-term dysphagia.     

Preoperative esophageal transit studies are a useful predictor of dysphagia after fundoplication

Fundoplication performed for gastroesophageal reflux disease may be complicated by postoperative dysphagia despite successful reduction in reflux symptoms. This is more likely in those patients with reflux who have concurrent esophageal dysmotility. The aim of this study was to establish whether esophageal transit studies using a technetium-99m jello bolus (jello esophageal transit) could detect the presence of motility disorders preoperatively and hence predict surgical outcome. Transit studies in 33 healthy volunteers yielded a normal range of 2 to 24 seconds using ninety-fifth percentile distribution. In the second phase of the study, 26 patients accepted for laparoscopic fundoplication were enrolled: jello esophageal transit, manometry, and endoscopy were attempted preoperatively in all subjects. A clinical dysphagia score was assigned from a questionnaire. Six months after surgery, five patients had dysphagia and of these four were found to have abnormal preoperative jello esophageal transit, for a sensitivity of 80%. Of the 21 patients who had no dysphagia after surgery, 20 patients had normal preoperative jello esophageal transit, showing a specificity of 95%. This esophageal transit study is noninvasive, reliable, and sensitive. When performed prior to fundoplication, it appears to be of significant value in detecting a subtle functional motility disorder that predisposes to postoperative dysphagia. Jello esophageal transit may assist the surgeon in planning treatment of gastroesophageal reflux disease. Presented at the World Congress of Gastroenterology, Vienna, Austria, September 16, 1998 (poster presentation).     

Effects of laparoscopic Nissen fundoplication on esophageal motility

Background This study aimed to evaluate the long-term impact of laparoscopic Nissen fundoplication on esophageal motility in patients with preoperative esophageal dysmotility. Methods This study prospectively followed 580 patients who underwent laparoscopic Nissen fundoplication between 1992 and 1999. Esophageal manometry, 24-h pH monitoring, and symptom score assessment were performed before surgery, then 6 months, 2 years, and 5 years after surgery. Preoperatively, 533 of the patients (93.5%) had normal esophageal contractile pressure (group 1), whereas 38 of the patients (6.5%) had reduced contractile pressure (<30 mmHg) (group 2). Results Esophageal contractile pressures increased significantly in the patients with low preoperative values, whereas it remained unchanged in the patients with normal preoperative contractile pressures. Both groups reported a significant reduction in the dysphagia symptom score after surgery. Conclusion Nissen fundoplication produces a significant long-lasting increase in esophageal contractile pressures in patients with preoperative esophageal dysmotility (i.e., contractile pressure lower than 30 mmHg). Preoperative esophageal dysmotility is therefore not a contraindication to laparoscopic Nissen fundoplication. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Fort Lauderdale, FL, 13–16 April 2005     

Gastric banding interferes with esophageal motility and gastroesophageal reflux

BACKGROUND: Gastroesophageal reflux and progressive esophageal dilatation can develop after gastric banding (GB). HYPOTHESIS: Gastric banding may interfere with esophageal motility, enhance reflux, or promote esophageal dilatation. DESIGN: Before-after trial in patients undergoing GB. SETTING: University teaching hospital. PATIENTS AND METHODS: Between January 1999 and August 2002, 43 patients undergoing laparoscopic GB for morbid obesity underwent upper gastrointestinal endoscopy, 24-hour pH monitoring, and stationary esophageal manometry before GB and between 6 and 18 months postoperatively. MAIN OUTCOME MEASURES: Reflux symptoms, endoscopic esophagitis, pressures measured at manometry, esophageal acid exposure. RESULTS: There was no difference in the prevalence of reflux symptoms or esophagitis before and after GB. The lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakened after GB, in correlation with preoperative values. There was a trend toward more postoperative nonspecific motility disorders. Esophageal acid exposure tended to decrease after GB, with fewer reflux episodes. A few patients developed massive postoperative reflux. There was no clear correlation between preoperative testing and postoperative esophageal acid exposure, although patients with abnormal preoperative acid exposure tended to maintain high values after GB. CONCLUSIONS: Postoperative esophageal dysmotility and gastroesophageal reflux are not uncommon after GB. Preoperative testing should be done routinely. Low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindications to GB. Patients with such findings should be offered an alternative procedure, such as Roux-en-Y gastric bypass.     

Laparoscopic fundoplication for gastroesophageal reflux: effects on esophageal motility

Laparoscopic Nissen-Rossetti fundoplication is now recognized as a valid therapy for the treatment of gastroesophageal reflux disease. This retrospective study evaluates the effects of laparoscopic fundoplication on esophageal motility and correlates these effects to postsurgical symptoms. A total of 123 patients underwent laparoscopic fundoplication at our institution. Pre- and postoperative esophageal manometric data were analyzed with regard to the effect of surgery and postsurgical outcome. Postoperative lower esophageal sphincter pressure was significantly increased compared wtih preoperative values (1.7 +/- 0.8 kPa vs 0.9 +/- 0.7 kPa). Duration and amplitude of esophageal body contractions were not modified. The percentage of deglutition-induced complete peristaltic waves and the velocity of propagation were significantly decreased after surgery (P < 0.05). Postoperative symptoms were significantly correlated with postoperative lower esophageal sphincter pressure only. Laparoscopic fundoplication significantly increases lower esophageal sphincter pressure. It significantly decreases esophageal body peristaltic efficiency, a decrease that is most likely of minor clinical significance.     

Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication

BACKGROUND: Preoperative esophageal manometry and 24-hour pH monitoring commonly are used in preoperative evaluation of patients undergoing fundoplication. Here we review our experience with the selective preoperative workup of patients undergoing fundoplication to treat gastroesophageal reflux disease. STUDY DESIGN: A series of 628 consecutive antireflux procedures was reviewed. History and physical examination, upper endoscopy, and upper gastrointestinal videofluoroscopy were obtained preoperatively on all patients; the first 30 patients also underwent esophageal manometry and pH monitoring (routine evaluation group). Thereafter, pH monitoring only was performed for atypical reflux symptoms, and manometry only was performed for a history of dysphagia, odynophagia, or for abnormal motility on videofluoroscopy (selective evaluation group). All patients underwent a laparoscopic floppy Nissen fundoplication, and then endoscopy and fluoroscopy at 3 months and 12 months postoperatively. RESULTS: Eighty-five of the patients in the selective evaluation group (14%) required manometry, and 88 (15%) underwent pH monitoring. Eighteen of the 115 patients who underwent manometry (16%) had evidence of dysmotility. None of these 18 patients had increased dysphagia postoperatively; 8 of 18 reported improvement with swallowing. Five patients in the selective group (0.8%) had persistent postoperative dysphagia caused by technical error (four patients) or with no identifiable cause (one patient). The estimated charge or collection reduction with use of the selective evaluation was 1,253,100 US dollars or 395,000 US dollars, respectively. CONCLUSIONS: Selective use of manometry and pH monitoring was cost effective and safe in this series. Although esophageal manometry and 24-hour pH monitoring might be necessary with abnormal findings on videofluoroscopy or atypical symptoms, in our experience, their routine use is not essential in preoperative evaluation of patients undergoing fundoplication for gastroesophageal reflux disease.     

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fimdoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 ±1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (≤30 mm Hg mean distal esophageal body pressure or ≤80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2l–24, 2000 (poster presentation).     

Fundoplication improves disordered esophageal motility

Patients with gastroesophageal reflux disease (GERD) and disordered esophageal motility are at risk for postoperative dysphagia, and are often treated with partial (270-degree) fundoplication as a strategy to minimize postoperative swallowing difficulties. Complete (360-degree) fundoplication, however, may provide more effective and durable reflux protection over time. Recently we reported that postfundoplication dysphagia is uncommon, regardless of preoperative manometric status and type of fundoplication. To determine whether esophageal function improves after fundoplication, we measured postoperative motility in patients in whom disordered esophageal motility had been documented before fundoplication. Forty-eight of 262 patients who underwent laparoscopic fundoplication between 1995 and 2000 satisfied preoperative manometric criteria for disordered esophageal motility (distal esophageal peristaltic amplitude ≤30 mm Hg and/or peristaltic frequency ≤80%). Of these, 19 had preoperative manometric assessment at our facility and consented to repeat study. Fifteen (79%) of these patients had a complete fun-doplication and four (21%) had a partial fundoplication. Each patient underwent repeat four-channel esophageal manometry 29.5 ± 18.4 months (mean ± SD) after fundoplication. Distal esophageal peristaltic amplitude and peristaltic frequency were compared to preoperative data by paired t test. After fun-doplication, mean peristaltic amplitude in the distal esophagus increased by 47% (56.8 ± 30.9 mm Hg to 83.5 ± 36.5 mm Hg; P < 0.001) and peristaltic frequency improved by 33% (66.4 ± 28.7% to 87.6 ± 16.3%; P< 0.01). Normal esophageal motor function was present in 14 patients (74%) after fundoplication, whereas in five patients the esophageal motor function remained abnormal (2 improved, 1 worsened, and 2 remained unchanged). Three patients with preoperative peristaltic frequencies of 0%, 10%, and 20% improved to 84%, 88%, and 50%, respectively, after fundoplication. In most GERD patients with esophageal dysmotility, fundoplication improves the amplitude and frequency of esophageal peristalsis, suggesting refluxate has an etiologic role in motor dysfunction. These data, along with prior data showing that postoperative dysphagia is not common, imply that surgeons should apply complete fun-doplication liberally in patients with disordered preoperative esophageal motility. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

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.     

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.     

Gastroesophageal reflux disease associated with poor esophageal body motility is effectively treated by laparoscopic toupet fundoplication

Summary Background The Nissen fundoplication, an effective treatment for gastroesophageal reflux disease (GERD), may frequently cause dysphagia in patients with poor esophageal body motility. Methods The laparoscopic Toupet fundoplication was performed in 24 patients with gastroesophageal reflux disease (GERD) with poor esophageal body motility of whom 18 (75%) presented with intermittent (n=16) or persistent (n=2) dysphagia for solids. Patients were followed-up for up to 12 months following surgery. Results Perioperative complications occurred in 4 patients (16.7%) including gastric perforation (n=1), intraabdominal hematoma (n=1), deep venous thrombosis of the calf (n=1) and pneumonia (n=1). There was no mortality and no conversion to open laparotomy among our patients 95.8% of patients were satisfied with surgery (Visick grade 1 or 2). Postoperatively 2 patients (8.4%) complained of dysphagia, one required reoperation due to too tight approximation of the hiatal crura. Conclusions The laparoscopic Toupet fundoplication is an effective treatment for GERD with poor esophageal body motility.      

Laparoscopic hiatal hernia repair in patients with poor esophageal motility or paraesophageal herniation

Laparoscopic repair for gastroesophageal reflux disease is now an accepted therapy. However, controversy exists with regard to the choice of operation between complete 360-degree Nissen fundoplication versus partial 270-degree Toupe fundoplication. In addition there is some controversy with regard to the proper choice of operation in patients with poor esophageal motility. Another class of hiatal hernia patients are those patients with paraesophageal herniation. Questions regarding the approach to these patients include whether or not to use a reflux procedure at the time of repair and the role of mesh in repair of these large hernias. This retrospective study was undertaken to compare the results of laparoscopic Nissen fundoplication and Toupe fundoplication in patients with both normal and abnormal esophageal motility. In addition the subset of patients with paraesophageal herniation was studied in an effort to ascertain the best surgical approach in these patients. In this study a retrospective analysis was performed on 188 consecutive patients during the period 1995 to 2001. All patients who presented with hiatal hernia surgical problems during this period were included. Endoscopy was performed in all patients with esophageal reflux. Manometry was performed in all patients except those presenting as emergency incarcerations. pH probe testing was performed in those patients in whom it was deemed necessary to establish the diagnosis. Upper gastrointestinal radiographs were used to define anatomy in paraesophageal hernia patients when possible. All patients with esophageal reflux were first treated with a trial of medical therapy. Patients with esophageal reflux and normal esophageal motility underwent 360-degree Nissen fundoplication. Those patients with poor esophageal motility (less than 65 mm of mercury) underwent laparoscopic 270-degree Toupe fundoplication. Patients presenting with paraesophageal herniation underwent laparoscopic repair. When possible esophageal manometry was performed on these patients preoperatively and if normal peristalsis was documented a Nissen fundoplication was performed. If poor esophageal motility was documented before surgery a Toupe fundoplication was performed. Mesh reinforcement of the diaphragmatic hiatus was used if necessary to complete a repair without tension. Patients were followed both by their primary gastroenterologist and their surgeon. Follow-up studies including endoscopy, pH probe, and upper gastrointestinal series were used as necessary in the postoperative period to document any problems as they occurred. Of the 188 patients in the study 141 patients underwent Nissen fundoplication, 21 patients underwent Nissen fundoplication and repair of paraesophageal hernia, 15 underwent Toupe fundoplication, seven underwent Toupe and paraesophageal hernia repair, and four paraesophageal hernia repair alone. One hundred eighty-three patients underwent a laparoscopic operation. Five patients of the 188 underwent an initial open operation-two of these patients because of the size of their paraesophageal hernia. Three of these patients had reoperations of remote operations done years before at other institutions. Twenty-two patients with poor esophageal motility (11.7 %) were included in the study. Fifteen patients required Toupe fundoplication whereas seven patients required Toupe fundoplication and repair of paraesophageal hernias. Mesh repair of paraesophageal hernias was accomplished in ten patients. Patients undergoing Toupe fundoplication had a 13 per cent dysphagia rate less than 4 weeks postoperatively and a 0% dysphagia rate greater than four weeks postoperatively. Patients undergoing Nissen fundoplication had a 16 per cent dysphagia rate less than 4 weeks postoperatively, 2 per cent dysphagia rate greater than 4 weeks postoperatively and no dysphagia at 6 weeks postoperatively. Recurrent symptomatic reflux occurred in 1.4 per cent of Nissen fundoplications and 6.7 per cent of Toupe fundoplications. Of Nissen and paraesophageal repairs 14.2 per cent had reflux and 14.3 per cent of Toupe and paraesophageal repairs had recurrent symptomatic reflux. Overall, complication rate was low. Use of mesh to repair large paraesophageal hernias resulted in a recurrence rate of 0 per cent. There was no instance of infection or bowel fistulization related to the use of mesh. We conclude that laparoscopic Nissen fundoplication in patients with normal esophageal motility is associated with a low rate of dysphagia and a low rate of recurrent reflux. Toupe fundoplication when used in reflux patients with poor esophageal motility is associated with a low rate of dysphagia and an acceptable rate of recurrent reflux. Laparoscop     

Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak

BACKGROUND: About a decade ago, partial (240 degrees) fundoplication became popular for treating gastroesophageal reflux disease in cases where the patient's primary esophageal peristalsis was weak. A total (360 degrees) fundoplication was reserved for patients with normal peristalsis (tailored approach). The theory was that partial fundoplication was an adequate antireflux measure, and by posing less resistance for the weak esophageal peristalsis to overcome, it would give rise to less dysphagia. Short-term results seemed to confirm these ideas. STUDY DESIGN: This study reports the longterm followup of patients in whom a tailored approach (type of wrap chosen to match esophageal peristalsis) was used, and the results of a nonselective approach, using a total fundoplication regardless of the amplitude of esophageal peristalsis. We analyzed clinical and laboratory findings in 357 patients who had an operation for gastroesophageal reflux disease between October 1992 and November 2002. Group 1 was composed of 235 patients in whom a tailored approach was used between October 1992 and December 1999 (141 patients, partial fundoplication and 94 patients, total fundoplication). Group 2 contained 122 patients in whom a nonselective approach was used (total fundoplication regardless of quality of peristalsis). RESULTS: In group 1, heartburn from reflux (ie, pH monitoring test was abnormal) recurred in 19% of patients after partial fundoplication and in 4% after total fundoplication. In group 2, heartburn recurred in 4% of patients after total fundoplication. The incidence of postoperative dysphagia was similar in the two groups. CONCLUSIONS: These data show that laparoscopic partial fundoplication was less effective than total fundoplication in curing gastroesophageal reflux disease, and compared with a partial (240 degrees) fundoplication, a total (360 degrees) fundoplication was not followed by more dysphagia, even when esophageal peristalsis was weak.     

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. Methods A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. Results In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 ± 5.2 mmHg (range, 6.0–30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% ± 8.3% (range, 70–100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett’s progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1–46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. Conclusion The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360° fundoplication should not be contraindicated for patients with severe esophageal dysmotility.     

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.