The influence of esophageal length on outcomes after laparoscopic fundoplication

BACKGROUND: It has been suggested that laparoscopic antireflux surgery has been associated with an increased incidence of postoperative paraesophageal hiatus herniation, and that this comes (at least in part) from not performing an esophageal lengthening procedure in patients with preoperative esophageal shortening. This study was undertaken to determine whether patients with esophageal shortening have an increased risk of reoperation after laparoscopic antireflux surgery. STUDY DESIGN: All patients who underwent a laparoscopic fundoplication between December 1991 and March 1999, and who had undergone preoperative esophageal manometry in our department were included in this study. Preoperative, operative, and followup data were collected prospectively, and original manometry recordings were reviewed to determine the length of the esophagus (the distance between the midpoints of the upper and lower esophageal sphincters). An index of esophageal length versus height was also calculated by dividing esophageal length by height. Esophageal length and the index were then compared with clinical outcomes. In addition, outcomes for the 50 patients with the shortest index was compared with outcomes of the 50 patients with the longest index. RESULTS: This study included 484 patients from an overall experience of 774 laparoscopic antireflux procedures. Postoperative followup ranged from 3 months to 5 years (median 2 years). Mean esophageal length was 23 cm (range 14 to 30 cm). There was a significant correlation between height and esophageal length (r = 0.44, p < 0.0001). Although patients with large hiatus hernias tended to have a shorter esophagus, preoperative endoscopic esophagitis grading did not influence length. Esophageal length did not influence the overall requirement for further surgical reintervention, although an analysis of esophageal length in patients who developed specific complications demonstrated that postoperative paraesophageal herniation was more likely in patients with a shorter esophagus, and reoperation for a tight esophageal hiatus was less likely in patients with a short esophagus. The incidence of paraesophageal hernia in the 50 patients with the shortest index was 8% versus 2% in the 50 patients with the longest index (p = 0.36). CONCLUSIONS: Although the overall reoperation rate after laparoscopic fundoplication was not influenced by esophageal length, this study did demonstrate an association between esophageal shortening and postoperative paraesophageal herniation. But the increased risk of this problem is small, and for this reason a case cannot be made for patients with a manometrically short esophagus to routinely undergo an esophageal lengthening procedure.     

Short esophagus: how much length can we get?

Introduction  Laparoscopic antireflux surgery requires an adequate length of intra-abdominal esophagus. Short esophagus can cause wrap herniation and poor clinical outcomes. The aim of the study is to measure maximum length of esophageal elongation with transhiatal mediastinal dissection. Methods  This is a review of a prospective database created in the tertiary referral center between 2003 and 2006. One hundred and six patients with gastroesophageal reflux disease and suspected short esophagus on barium swallow were studied. Patients underwent antireflux surgery with extended transhiatal mediastinal dissection to elongate short esophagus. Routine measurement of intra-abdominal esophageal segment length with intraoperative esophagogastroscopy and laparoscopy was utilized to define the gastroesophageal junction (GEJ) in order to quantify total intra-abdominal esophageal length. Postoperative 24-h pH manometry, UGI series, and symptom scores were recorded to document the clinical outcomes. The aim of the dissection was to mobilize ≥3 cm of intra-abdominal esophagus. Results  Total esophageal elongation was achieved with a mean of 2.65 (range 2–18) cm. Resultant intra-abdominal esophageal length was measured with a mean of 3.15 (range of 3 to 5) cm. None of the preoperative “short esophagus” required Collis’ gastroplasty post extended mediastinal dissection. All preoperative symptom scores showed significant improvements with mean follow-up of 18 (9–36) months. Mean distal esophageal acid exposure normalized in all patients studied postoperatively. Conclusion  Short esophagus can be safely elongated with extended mediastinal esophageal dissection. This technique can obviate the need for Collis’ gastroplasty and improve overall outcome after antireflux surgery. We recommend that extended transhiatal mediastinal dissection be performed to establish 3 cm of intra-abdominal esophagus at the time of antireflux procedures.     

Preoperative determinants of an esophageal lengtheningprocedure in laparoscopic antireflux surgery

BACKGROUND: In a minority of patients undergoing antireflux surgery, an esophageal lengthening procedure is required to reduce the gastroesophageal junction (GEJ) below the esophageal hiatus. We evaluated risk factors associated with an irreducible GEJ to identify clinical features that were predictive of the need for a Collis gastroplasty in patients undergoing laparoscopic antireflux surgery. METHODS: Patients who required a Collis gastroplasty during a laparoscopic antireflux procedure (defined as the inability to reduce the GEJ > 2.5 cm below the esophageal hiatus despite extensive mobilization of the mediastinal esophagus) were compared to a random sample of patients who did not have a Collis gastroplasty. Predictors of the need for an esophageal lengthening procedure were identified using logistic regression modeling. Risks were expressed as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Twenty patients who had a Collis gastroplasty were compared to 133 patients who had adequate esophageal length. The presence of a stricture (OR 3.0; 95% CI 1.0, 9.7), paraesophageal hernia (OR 3.5; 95% CI 1.3, 9.6), Barrett's esophagus (OR 3.7, 95% CI 1.3, 10.7), and re-do antireflux surgery (OR 6.4; 95% CI 2.0, 20.7) were associated with the need for gastroplasty. Patients with none of these factors were extremely unlikely to require a gastroplasty (OR 0.08; 95% CI 0.02, 0.34). CONCLUSION: Patients undergoing laparoscopic antireflux surgery who are at high risk of needing an esophageal lengthening procedure can be easily identified preoperatively using simple clinical characteristics.     

Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery

BACKGROUND: Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. OBJECTIVE: To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. PATIENTS AND INTERVENTIONS: Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. RESULTS: During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3-2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2-3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6-580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8-6.5; P < 0.01). CONCLUSIONS: Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.     

Results of laparoscopic antireflux operations in patients who have Barrett's esophagus

In most patients who have Barrett's esophagus and who are undergoing open or laparoscopic antireflux surgery, there is a significant improvement in symptom control that is equivalent to that in patients who have uncomplicated gastroesophageal reflux disease. The requirement for reoperation in patients with Barrett's esophagus may be slightly higher, although in the two laparoscopic series published to date, the rate is still only approximately 6%. How much this will increase with longer follow-up, time alone will tell, but given the good results in approximately 95% of patients operated to date, the authors do not believe that the diagnosis of Barrett's esophagus should be considered a blanket contraindication for laparoscopic antireflux surgery. Clearly, in most patients with Barrett's esophagus, an antireflux operation will not result in regression of Barrett's mucosa. It is still unclear whether antireflux surgery provides any protection against subsequent development of esophageal adenocarcinoma. What is clear, however, is that after antireflux surgery, patients who have Barrett's esophagus are still at risk for developing adenocarcinoma and should remain in surveillance programs. The authors believe that laparoscopic antireflux surgery is a safe and effective approach for the cure of reflux-related symptoms in patients who have Barrett's esophagus.     

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.     

Long-term results of laparoscopic antireflux surgery

Background: It is estimated that laparoscopic antireflux surgery has replaced the open approach in centers worldwide. Findings show it to be an established treatment option for chronic gastroesophageal reflux disease with an excellent clinical outcome and success rates between 85% and 95%. This prospective study aimed to evaluate surgical outcome and analysis of failure after 500 laparoscopic antireflux procedures followed up for as long as 5 years. Methods: Between September 1993 and May 2000, 500 laparoscopic antireflux procedures were performed in our surgical unit. In 345 patients, a laparoscopic "floppy" Nissen fundoplication was performed, and in 155 patients, a Toupet fundoplication was carried out with standard mobilization of the upper part of the gastric fundus and with division of the short gastric vessels. Preoperative and postoperative data including 24-h pH monitoring, esophageal manometry, and analysis of failure were prospectively reviewed. Results: Conversion to open surgery was necessary in two patients (0.4%). Morbidity was 7%, including 24 patients (4.8%) for whom a laparoscopic redoprocedure was necessary because of failed primary intervention. There was no mortality. During a follow-up period of 3 months to 5 years, 24-h pH monitoring and esophageal manometry showed normal values in 95% of the patients including patients who had undergone redosurgery. Conclusion: The results of the current study demonstrate that laparoscopic antireflux surgery is feasible and effective, and that it can be performed safely without mortality and with low morbidity, yielding good to excellent results over a follow-up period up to 5 years.     

Impact of antireflux surgery on Barrett's esophagus

BACKGROUND AND AIMS: The rising incidence of Barrett's carcinoma is a matter of major concern in Western societies. We realized a review of the literature to evaluate the impact of antireflux surgery on prevention of Barrett's carcinoma. METHODS: We used MedLine- and PubMed-based review of the literature published since 1970 on surgical treatment of Barrett's esophagus. RESULTS: There is no report in the literature that describes de novo development of Barrett's metaplasia after successful antireflux surgery. Compared with medical therapy, the risk for malignant degeneration of Barrett's metaplasia is reduced in surgical patients according to some studies. On the other hand, regression of Barrett's metaplasia after antireflux surgery is rare and Barrett's carcinoma after surgery has been observed repeatedly. The combination of antireflux surgery and ablation of metaplastic mucosa in order to obtain regression has led to encouraging preliminary results; however, experience is still limited and numerous studies currently are underway. Dysplastic Barrett's esophagus (BE) is a precancerosis and should not be treated as BE without dysplasia; strategies other than antireflux surgery need to be discussed. CONCLUSION: A prophylactic effect of early antireflux surgery upon de novo development of Barrett's metaplasia is probable. The impact of surgery on malignant degeneration of Barrett's epithelium remains uncertain. Data currently available show no clear benefit of antireflux surgery on cancerogenesis in patients with Barrett's metaplasia.     

Gastroplastia de Collis robótica

The true short esophagus is an entity of controversy among surgeons. Studies have been published about its diagnosis and laparoscopic treatment, without existing to date, publication of the treatment with robotic approach. We present, as a case report, our experience in robotic surgery for hiatal hernia with true short esophagus treated with Collis gastroplasty and Toupet fundoplication. Robotic surgery on the true short esophagus can facilitate mediastinal dissection and allow a more accurate suture technique. Studies are needed to compare the long-term results of this surgical technique between the conventional laparoscopic approach and the robotic approach.     

Esophageal Shortening during the Era of Laparoscopic Surgery

An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia ≥ 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n= 11) or open transthoracic Collis gastroplasty (n= 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63–100%) without a corresponding increase in sensitivity (28–42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.     

Current state, techniques, and results of laparoscopic antireflux surgery

The introduction of laparoscopic fundoplication has dramatically changed the face of antireflux surgery. Central to the success of laparoscopic fundoplication is careful preoperative patient evaluation and attention to surgical technique. Emerging evidence has questioned the long-term durability of laparoscopic partial fundoplications underscoring the place of laparoscopic Nissen fundoplication as the procedure of choice for most patients. The technique of laparoscopic Nissen fundoplication should incorporate crural closure, complete fundic mobilization by short gastric vessel division, and the creation of a short, loose fundoplication by enveloping the anterior and posterior fundic walls around the esophagus. Relief of typical reflux symptoms can be anticipated in over 90% of patients. The outcome of atypical reflux symptoms is less predictable, on average two thirds of patients benefiting. The cost of laparoscopic fundoplication compares favorably to long-term medical therapy and open fundoplication. Current trends indicate that laparoscopic fundoplication is being used increasingly as an alternative to long-term medical therapy.     

Clinical and histologic follow-up after antireflux surgery for Barrett's esophagus.

There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett's esophagus, as defined by the recently standardized criteria. We report the clinical, endoscopic, and histologic results of patients with Barrett's esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett's esophagus required preoperative endoscopic evidence of columnar-lined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic [n = 84] or open [n = 6] nissen, laparoscopic Toupet [n = 11], laparoscopic Collis-Nissen [n = 1], Collins-Toupet [n = 1] or open Dor [n = 1]). Short-segment Barrett's esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic-type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett's esophagus. A substantial number of patients with Barrett's esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy.     

Reflux disease without mucosal damage: is there a place for surgery?

Patients in whom regurgitation is a major problem usually require antireflux surgery even though they may have no evidence of esophageal mucosal damage. The most common symptom of reflux is heartburn, and there is good evidence that the severity of this symptom does not correlate with the degree of mucosal damage in the esophagus. With the advent of laparoscopic surgery and the great reduction in the morbidity of antireflux surgery, many patients now are looking for cure of their reflux rather than just symptom relief. Patients in this category do well with laparoscopic antireflux surgery regardless of whether thee have endoscopic evidence of mucosal damage or not; indeed, if the data in the literature are a guide, it seems that esophageal mucosal damage is not a necessary indication for antireflux surgery. An "acid-sensitive esophagus" is not yet an established indication for laparoscopic antireflux surgery, however.     

Laparoscopic surgery: an excellent approach in elderly patients

HYPOTHESIS: A review of the literature will show that laparoscopy is safe and effective for the treatment of surgical diseases in elderly patients. DATA SOURCES: An electronic search using the PubMed and MEDLINE databases was performed using the term laparoscopy in elderly patients. Literature published in the English language in the past decade was reviewed. Pertinent references from articles and books not identified by the search engines were also retrieved. Relevant surgical textbooks were also reviewed. STUDY SELECTION: All relevant studies that could be obtained regardless of the study design were included. DATA EXTRACTION: All studies that contained material applicable to the topic were considered. Data on patient characteristics and surgical outcomes were abstracted. DATA SYNTHESIS: Sixteen studies evaluated laparoscopic cholecystectomy in the elderly. Compared with open cholecystectomy, elderly patients undergoing the laparoscopic procedure had a lower incidence of complications and a shorter hospitalization. In the 4 studies reporting the results of laparoscopic antireflux surgery in the elderly, the morbidity, mortality, and length of hospital stay were similar to those of younger patients. The elderly had equally good postoperative symptom relief. Ten reports of laparoscopic colon resection in the elderly demonstrated earlier return of bowel function, shorter hospitalization, and less cardiopulmonary morbidity. CONCLUSIONS: Despite underlying comorbidities, individuals older than 65 years tolerate laparoscopic procedures extremely well. Complications and hospitalization are lower than in open procedures. Surgeons need to inform primary care physicians of the excellent result of laparoscopic procedures in the elderly to encourage earlier referrals.     

Use of laparoscopy in general surgical operations at academic centers

BackgroundLaparoscopy is commonly being used in many different types of general surgical procedures. The aim of the present study was to examine the use of laparoscopy and perioperative outcomes in 7 general surgical operations commonly performed at U.S. academic medical centers.MethodsThe clinical data of patients who underwent 1 of the 7 general surgical operations from 2008 to 2012 were obtained from the University HealthSystem Consortium database. The University HealthSystem Consortium database contains data from all major teaching hospitals in the United States. The 7 analyzed operations included only elective, inpatient procedures (except for appendectomy): open and laparoscopic antireflux surgery for gastroesophageal reflux, colectomy for colon cancer or diverticulitis, bariatric surgery for morbid obesity, ventral hernia repair for incisional hernia, appendectomy for acute appendicitis, rectal resection for rectal cancer, and cholecystectomy for cholelithiasis. The outcome measures included the number of procedures, rate of laparoscopy, rate of conversion to laparotomy, and in-hospital mortality.ResultsDuring the 3.5-year period, 53,958 patients underwent bariatric surgery, 13,918 patients underwent antireflux surgery, 8654 patients underwent appendectomy, 8512 patients underwent cholecystectomy, 29,934 patients underwent colectomy, 17,746 patients underwent ventral hernia repair, and 4729 patients underwent rectal resection. The present rate of laparoscopic use was 94.0% for bariatric surgery, 83.7% for antireflux surgery, 79.2% for appendectomy, 77.1% for cholecystectomy, 52.4% for colectomy, 28.1% for ventral hernia repair, and 18.3% for rectal resection. In-hospital mortality was greatest for colorectal resection (.38%–.58%). In-hospital mortality for bariatric surgery (.06%) was comparable to that for appendectomy (.01%), cholecystectomy (.27%), antireflux surgery (.15%), and ventral hernia repair (.20%). The rate of laparoscopic conversion to open surgery was lowest for bariatric surgery (.89%) and greatest for rectal resection (16.4%).ConclusionWithin the context of academic centers and elective, inpatient procedures, bariatric surgery had the greatest use of laparoscopy and the lowest rate of laparoscopic conversion to open surgery. The mortality for laparoscopic bariatric surgery is now comparable to that of laparoscopic cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery.     

Preoperative predictability of the short esophagus: endoscopic criteria

Background  Short esophagus is a common cause of failure of antireflux surgery. Minimally invasive intervention for short esophagus is technically difficult. Reliable predictors of short esophagus would allow appropriate referral and better outcomes. The aim of this study is to investigate the preoperative predictability of the short esophagus in patients undergoing antireflux surgery. Methods  Eighty-five patients with Collis gastroplasty and antireflux surgery (1994–2007) at a single institution form group A. Control group (B) comprises 205 consecutive patients undergoing primary antireflux surgery (2004–2007). Retrospective review of prospectively collected data was completed. Esophageal length index (ELI) was calculated as the ratio of endoscopic esophageal length (in cm) to height (in meters). Results  Patients requiring Collis gastroplasty (group A) tend to be older while there were no significant differences in sex, height, weight, and body mass index distribution between groups. Mean endoscopic esophageal length (EEL) as measured from incisor to esophagogastric junction was significantly shorter in group A (32.4 cm) as compared with group B (36.2c m) (p < 0.0001). Esophageal length index (ELI) of less than 19.5 had 83% negative predictive value with 95% specificity. Conclusions  Patients with an ELI of less than 19.5 or with stricture have higher risk for having a short esophagus.     

Utilization of laparoscopic antireflux surgery at a single Veterans Affairs facility compared with the Veterans Affairs national trend

BACKGROUND: The widespread use of laparoscopy in the early 1990s has led to an increase in the utilization of antireflux procedures for the treatment of gastroesophageal reflux disease (GERD). This trend has been observed in the private sector, but not within the Department of Veterans Affairs (VA) health care system. Published data suggest that among patients undergoing antireflux surgical procedures, those in the VA were less likely than those in the private sector to undergo laparoscopic surgery. The objective of this study was to determine the trend in the use of laparoscopic antireflux surgical procedures at our VA facility and compare it with the national VA trend. METHODS: All antireflux operations performed at our VA facility from 1991 to 2002 were recorded along with techniques used. National VA data on the utilization of antireflux procedures from 1991 to 1999 was extracted from a recent publication by Finlayson et al. RESULTS: In contrast to the trend observed nationally across VA hospitals, the rate of utilization of antireflux surgery at our VA facility has increased compared with baseline in 1991. Of 83 fundoplications performed from 1991 to 2002, 76 (92%) were attempted or completed laparoscopically. The conversion rate from laparoscopic to open approach was 6.6%. CONCLUSIONS: We have observed an increase in the utilization of antireflux surgery since 1991 at our VA facility. In addition, most fundoplications were performed laparoscopically. These findings are in contrast to published national VA data. The presence of surgeons with interest in laparoscopy, institutional support, and a dedicated esophageal function laboratory may explain these findings.     

Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease

Background Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures. Methods This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created. Results The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann–Whitney U test are not statistically significant. Conclusions For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon’s experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.     

Laparoscopic reoperation after failed antireflux surgery

INTRODUCTION: Laparoscopic surgery for the treatment of gastroesophageal reflux disease has been established as being safe, effective, and the best alternative to continuous life-long medical therapy. Antireflux surgery is not, however, devoid of complications and failures. Treatment of these patients represents a major challenge, especially when reoperation is indicated. PATIENTS: One-hundred consecutive patients had a reoperation in our clinic. Previous antireflux procedures were laparoscopic (52 patients), laparotomy (39 patients), and thoracotomy (9 patients). RESULTS: Peri- or postoperative complications occurred in 30 patients (30%). Operative complications were stomach perforation (14), significant bleeding (6), esophageal mucosal perforation (4), gastrocutaneous fistula (2), small bowel enterotomy followed by fistula (1), and tension pneumothorax (1). Reoperation was required in only 2 patients because of a missed stomach perforation or persistent chest leak. The conversion rate (from laparoscopic to open procedure) was 17% overall. CONCLUSION: Laparoscopic reoperation after a failed antireflux procedure is a major surgical challenge, and it is not devoid of morbidity. The surgeon must have extensive experience in laparoscopic surgery and should be able to perform reoperative open surgery through the abdomen and chest. Laparoscopic redo surgery is feasible with good results. Many patients in whom previous open surgery has failed enjoy the advantages of a laparoscopic redo procedure.     

Barrett's esophagus can and does regress after antireflux surgery: a study of prevalence and predictive features

BACKGROUND: To investigate the factors leading to histologic regression of metaplastic and dysplastic Barrett's esophagus (BE). STUDY DESIGN: The study sample consisted of 91 consecutive patients with symptomatic Barrett's esophagus. Pre- and posttreatment endoscopic biopsies from 77 Barrett's patients treated surgically and 14 treated with proton pump inhibitors (PPI) were reviewed. An expert pathologist confirmed the presence of intestinal metaplasia (IM) with or without dysplasia. Posttreatment histology was classified as having regressed if two consecutive biopsies taken more than 6 months apart plus all subsequent biopsies showed loss of IM or loss of dysplasia. Clinical factors associated with regression were studied by multivariate analysis, as was the time course of its occurrence. RESULTS: Histopathologic regression occurred in 28 of 77 patients (36.4%) after antireflux surgery and in 1 of 14 patients (7.1%) treated with PPIs alone (p < 0.03). After surgery, regression from low-grade dysplastic to nondysplastic BE occurred in 17 of 25 patients (68%) and from IM to no IM in 11 of 52 (21.2%). Both types of regression were significantly more common in short (< 3 cm) than long (> 3 cm) segment Barrett's esophagus; 19 of 33 (58%) and 9 of 44 (20%) patients, respectively (p = 0.0016). Eight patients progressed, five from IM alone to low-grade dysplasia and three from low- to high-grade dysplasia. All those who progressed had long segment BE. On multivariate analysis, presence of short segment Barrett's and type of treatment were significantly associated with regression; age, gender, surgical procedure, and preoperative lower esophageal sphincter and pH characteristics were not. The median time of biopsy-proved regression was 18.5 months after surgery, with 95% occurring within 5 years. CONCLUSIONS: This study refutes the widely held assumption that once established, Barrett's esophagus does not change. More than one-third of patients with visible segments of Barrett's esophagus undergo histologic regression after antireflux surgery. Regression is dependent on the length of the columnar-lined esophagus and time of followup after antireflux surgery.