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

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

Laparoscopic fundoplication in infants and children

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

A simplified approach to laparoscopic fundoplication

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

Laparoscopic partial fundoplication vs laparoscopic Nissen-Rosetti fundoplication

Background: Since 1992, all patients at our institution who have met standard accepted criteria for surgical intervention for complicated gastroesophageal reflux disease have been entered into a prospective sequential clinical study to evaluate outcomes of the laparoscopic approach to the Nissen-Rosetti procedure and a modified Toupet procedure. Methods: A standardized workup with upper GI series, esophagography, and endoscopy was used in all patients. Manometry, pH testing, and other special tests were used selectively. A measuring technique was used to determine wrap size without the use of dilators. The short gastric vessels were left intact in all patients. A cosurgeon approach was used, with technical factors described herein. Results: Some 226 of 231 cases were completed laparoscopically (98%)—125 patients in the Nissen-Rosetti group and 101 in the partial fundoplication group. There were no clinical failures in either group. The partial fundoplication group performed better than the Nissen-Rosetti group in all categories of comparison. Return to normal eating habits was much earlier in the partial wrap group (p < 0.0001). Postop distal esophageal sphincter pressures in the two groups were equal at 15 mmHg. Eight patients suffered significant dysphagia requiring endoscopy and dilatation, all in the Nissen-Rosetti group (p < 0.01). Minor complications occurred in 12% of the total group. There was a total surgical revision rate of 3%. There were no gastric or esophageal perforations. Average operative time was 30 min. Average hospital stay was 1.4 days. Hospital charges for the laparoscopic approach averaged $6,000 dollars compared to $12,000 for the open approach. Conclusion: Laparoscopic partial fundoplication is as effective as laparoscopic Nissen-Rosetti fundoplication, with a higher satisfaction rate and fewer side effects. Measuring for wrap and hiatus size eliminates the need for and risk of using stiff dilators. By utilizing cosurgeons and currently available technology, cost, operative time, hospital time, and complications can be reduced to a finite minimum. Received: 12 December 1995/Accepted: 12 August 1996     

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

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

Patterns of success and failure with laparoscopic Toupet fundoplication

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

Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy

Symptomatic gastroesophageal reflux after Nissen fundoplication may occur if the wrap herniates into the thorax. In an attempt to prevent recurrent hiatal hernia we employed polytetrafluoroethylene (PTFE) mesh reinforcement of posterior cruroplasty during laparoscopic Nissen fundoplication and hiatal herniorrhaphy. Three patients with symptomatic gastroesophageal reflux and a large (≥8 cm) hiatal defect underwent laparoscopic posterior cruroplasty and Nissen fundoplication. The cruroplasty was reinforced with a PTFE onlay. No perioperative complications occurred, and in follow-up (≤11 months) the patients are doing well. When repairing a large defect of the esophageal hiatus during fundoplication, the surgeon may consider reinforcement of the repair with PTFE mesh. Received: 5 March 1996/Accepted: 3 June 1996     

A comparison of laparoscopic Nissen fundoplication and Rossetti's modification in 239 patients

Background: Laparoscopic Nissen fundoplication and the Rossetti modification represent two different surgical approaches to resolving gastroesophageal reflux disease (GERD). Concerns have arisen that the Rossetti modification results in increased postoperative dysphagia. In this study, we compared a group of patients who underwent a laparoscopic Nissen fundoplication with a group who had undergone the Rossetti modification to determine if there was a significant difference in postoperative dysphagia. Additionally, we wanted to confirm that the Nissen procedure performed laparoscopically could resolve GERD as successfully as the Rossetti modification, with no difference in operative complications. Methods: We prospectively collected data on 101 patients who underwent laparoscopic Nissen fundoplication and compared outcomes with those of 138 patients who had undergone the laparoscopic Rossetti modification in a previous series. Results: All patients experienced resolution of reflux symptoms. No statistically significant differences were found between the groups in terms of intraoperative or postoperative complications, conversions to open procedure, or length of hospitalization. Paradoxically, there was a significant difference in operating time between the Rossetti and the Nissen groups (70.6 min vs 45.6 min, p= 0.006). Postoperative dysphagia requiring dilation was significantly higher in the Rossetti group (21.7% vs 8.9%, p= 0.008). However, there was a significantly higher percentage of patients in the Rossetti group who had had esophagitis preoperatively (95.7% vs 86.1%, p= 0.009), although the proportion of patients having Barrett's esophagus was higher in the Nissen group (9.4% vs 24.8%, p= 0.001). Conclusions: Both approaches resolved reflux symptoms without significant differences in complications, conversions, or length of stay. Preoperative differences between groups, as well as the method of sequentially comparing the two different procedures, prevent us from attributing greater postoperative dysphagia in the Rossetti group solely to the choice of surgical approach. Prospective randomized studies are needed to control for variables, such as surgical team experience and patient differences. Online publication: 17 April 2000     

Resolving gastroesophageal reflux with laparoscopic fundoplication

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

Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children

Infants and children requiring fundoplication for gastroesophageal reflux frequently have significant associated medical problems necessitating placement of a gastrostomy at the time of fundoplication. This article reviews the techniques, complications, and results of 141 laparoscopic Stamm gastrostomies performed in conjunction with laparoscopic fundoplication in infants and children. The three techniques employed were the T-fastener technique (63/141) which is best utilized in patients with thick abdominal walls; the trocar-site technique (53/141) which is technically easy to perform but prone to infection and fistula formation; and the U-stitch technique (26/141). General complications of laparoscopic gastrostomy include development of gastrocutaneous fistulae (2/141), perigastrostomy cellulitis (8/141), and the formation of granulation tissue at the gastrostomy site (45/141). The only perioperative death was due to a technical error during gastrostomy tube placement. Our preferred method for laparoscopic gastrostomy in most children is the U-stitch technique. Received: 19 March 1996/Accepted: 8 May 1996     

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

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

Left side thoracoscopically assisted gastroplasty

Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay. Received: 3 August 1999/Accepted: 10 November 1999/Online publication: 17 April 2000     

Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease (GERD)

Background: A prospective study was conducted to evaluate the physiologic and clinical consequences of laparoscopic Nissen fundoplication (LNF), using strict indications for surgery. Methods: From 1992 to 1997, 50 patients underwent LNF. Indications for operative treatment were either failure of conservative treatment or foresight to see long-term use of strong acid suppressive therapy. Patients were evaluated by barium esophagogastric study (BES), esophagoscopy, 24-h pH monitoring (pHM), stationary esophageal manometry, gastric-emptying studies (GES), pancreatic polypeptide stimulation test (PPT) and clinical evaluation using questionnaires. Results: Perioperative complications necessitated conversion to laparatomy in two cases, and there was no mortality. Severe dysphagia resulted in reoperation in two patients. The average maximum lower esophageal sphincter pressure (MLESP) increased from 6.1 mmHg to 12.7 mmHg. Endoscopy showed improved grading of the esophagitis, and the total percentage of pH less than 4 during 24 h decreased from a mean of 9.2 to 0.95. Three patients demonstrated impaired PPTs postoperatively; two had (mild) diarrhea. The overall success rate after the operation was 90%. Conclusions: The results of LNF in a limited number of patients with severe and/or resistant gastroesophageal reflux disease (GERD) receiving continuous medical treatment with proton pump inhibitors (PPIs) on a maintenance base are comparable with LNF results in centers with a more liberal policy concerning indications for LNF surgery. Received: 15 September 1997/Accepted: 12 October 1997     

Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery

Background: This study retrospectively assesses the mechanisms of 13 esophageal or gastric injuries resulting from dilator or nasogastric tube placement during laparoscopic foregut surgery and is intended to assist in determining methods of prevention. Methods: Information regarding esophageal or gastric injury during laparoscopic foregut surgery was obtained from six experienced laparoscopic surgeons. The specific mechanisms of injury were determined by discussion with the operating surgeon and review of the operative reports. Results: Eleven cases of esophageal or gastric perforation occurred during bougie insertion and two perforations occurred secondary to nasogastric tube placement during Nissen fundoplication or Heller myotomy. Five perforations required conversion to open operation for repair including two delayed thoracotomies. The 13 injuries occurred during the performance of 1,620 laparoscopic foregut operations for an overall incidence of 0.8%. Conclusion: Foregut injury resulting from esophagogastric intubation during laparoscopic surgery is more common than expected. Risk factors include esophageal anatomy, intrinsic pathologic changes of the esophagus, and inexperience. Prevention must focus on close communication between the surgeon and anethesiologist and safe techniques of dilator insertion.     

Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders

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

Complications of pediatric laparoscopic surgery

Background: Surgical complications of laparoscopy most often occur during Veress needle or primary trocar placement. Veress needle punctures are insignificant and require no further treatment, whereas trocar-induced vascular injuries can be catastrophic. The frequency of vascular and viscus injuries is difficult to calculate because several complications are not reported in the literature. Methods: During a 10-year-period (1984–1995), at the Division of Pediatric Surgery at ``Federico II' University of Naples, 430 laparoscopic procedures were performed in 395 children with a mean age of 5 years. The incidence of complications related to laparoscopy was 1.8% with eight complications, one of which was rather severe. The complications included one abdominal wall hematoma, two perforations of abdominal viscus (stomach, ovary), one umbilical scar complication, one postoperative hydrocele, one subcutaneous emphysema, and one pneumothorax during a Nissen procedure. The only severe complication occurred in a young girl with neurologic problems and a kyphoscoliosis operated on via laparoscopy for a gastroesophageal reflux. She suffered injuries of both right common iliac vessels and several intestinal perforations due to blind introduction of the first umbilical trocar. Results: In this case rapid conversion, complex vascular reconstruction, and multiple intestinal sutures were performed. The Nissen fundoplication with pyloroplasty was performed traditionally and the patient left the hospital free of symptoms after 20 days. The other seven complications were resolved without any problem intra- or postoperatively. Conclusions: The authors believe that the open approach with a blunt trocar is most important in helping to avoid complications in pediatric laparoscopy. Received: 5 July 1996/Accepted: 19 November 1996     

Laparoscopic Nissen fundoplication in children under 2 years of age

Background: Antireflux operations have been recommended for infants and children suffering from complications related to gastroesophageal reflux (GER). In recent years, the laparoscopic approach has been used increasingly for antireflux surgery in adult patients. This is our initial experience with Nissen fundoplication in infants and children under 2 years of age. Patients: We operated on 11 patients weighing between 3.0 and 10.0 kg. The main indications for surgery were GER-induced aspiration pneumonia and failure to thrive, in spite of intensive conservative treatment. All patients except one had an associated neurological abnormality, including six patients with familial dysautonomia. Results: All attempted operations were completed successfully laparoscopically, with only a few postoperative complications and acceptable short-term results. The clinical considerations and technical aspects unique to this specific group of patients are discussed. Conclusion: Laparoscopic Nissen fundoplication is feasible, safe, and effective, even in very small babies. Received: 16 April 1997/Accepted: 30 June 1997     

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     

Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy

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

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.