Nissen fundoplication for reflux esophagitis. Long-term clinical and endoscopic results in 109 of 127 consecutive patients.

OBJECTIVE: This study evaluates the clinical and endoscopic long-term results of Nissen fundoplication in reflux esophagitis. SUMMARY BACKGROUND DATA: Nissen fundoplication has been reported to give good results in the treatment of gastroesophageal reflux with success rates up to 78-97%. Most of the previous studies on long-term results of fundoplication have, however, been based on interviews with only sporadic endoscopic examinations. METHODS: Of 127 patients consecutively treated with Nissen fundoplication for reflux esophagitis, 109 were available for follow-up after a median of 77 months. Upper gastrointestinal endoscopy was done in 105 cases, and all the patients with reflux symptoms or abnormal endoscopic observations were referred to esophageal 24-hour pH monitoring and manometry. RESULTS: No symptoms of gastroesophageal reflux were reported by 73 of the 109 patients, but dysphagia was present in 47. Endoscopy showed defective fundic wrap in 24 patients. Objective evidence of reflux was found in 24 patients (endoscopic esophagitis in 18 and pathologic 24-hour pH score without esophagitis in 6). Esophagitis was found in 14 of the 24 patients with defective wrap, but in only 4 of the 81 with infact wrap. CONCLUSIONS: Nissen fundoplication alleviated symptoms of gastroesophageal reflux and cured esophagitis in great majority of cases. The main determinant of outcome was the state of the fundic wrap.     

Excellent quality of life after Nissen fundoplication depends on successful elimination of reflux symptoms and not the invasiveness of the surgical approach

BACKGROUND: Quality of life, poor in patients with reflux disease, improves significantly after an antireflux operation. The aim of this study was to determine the relative importance of the operative approach used for a fundoplication, as well as the successful elimination of reflux symptoms on long-term quality of life in patients with gastroesophageal reflux disease. METHODS: A questionnaire, including the medical outcome study short-form health survey (SF-36), was completed by 105 patients who had undergone either a laparoscopic Nissen fundoplication (n = 72) or a transthoracic Nissen fundoplication (n = 33); median follow-up was 25 and 31 months, respectively. Patients were classified as completely or incompletely relieved of reflux symptoms based on the frequency of reflux symptoms and the use of acid-suppression medication. RESULTS: Patients selected for transthoracic Nissen fundoplication had significantly worse preoperative gastroesophageal reflux disease based on the presence of a large hiatal hernia, Barrett's esophagus, or stricture. Long-term quality of life was similar for the two approaches, but was significantly decreased in patients with recurrent reflux symptoms. Compared with laparoscopic Nissen fundoplication patients, transthoracic Nissen fundoplication patients were less likely to use acid-suppression medication and tended to be more satisfied with their operation. CONCLUSIONS: Long-term quality of life was independent of the invasiveness of the procedure, but significantly dependent on successful elimination of reflux symptoms and the necessity for acid suppression medication. Patients who underwent a transthoracic Nissen fundoplication, despite having more advanced disease preoperatively, tended to have less reflux symptoms and less long-term acid-suppression medication usage after their procedure. These findings support the continued use of a transthoracic antireflux procedure in patients with advanced gastroesophageal reflux disease.     

A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.

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

Early laparoscopic Nissen fundoplication for recurrent reflux esophagitis: a cost-effective alternative to omeprazole.

BACKGROUND: Eighty percent of patients treated medically for gastroesophageal reflux disease relapse after treatment. Many of these patients require indefinite treatment with omeprazole to prevent recurrence. Nissen fundoplication has been shown to be effective, safe and cost effective in the management of gastroesophageal reflux disease. We suggest a treatment algorithm, which encourages early surgical intervention in cases of recurrent esophagitis after a previously successful two-month course of omeprazole. METHODS: We have offered laparoscopic Nissen fundoplication since 1993. Patients who received Nissen fundoplication since 1990 were asked to report return to baseline activity, medications, and lifestyle changes. Concurrent chart review of patients treated with omeprazole was conducted to analyze cost. RESULTS: Patients receiving laparoscopic Nissen fundoplication were discharged significantly sooner and spent significantly less time convalescing when compared to those who underwent open Nissen fundoplication. Laparoscopic Nissen fundoplication became cost effective at 1.5 to 2 years when compared to omeprazole. CONCLUSION: Based on cost analysis, patient satisfaction, acceptable complication rate, and efficient use of time and resources, we recommend laparoscopic Nissen fundoplication as the appropriate treatment in patients who develop recurrent esophagitis after a two-month treatment with omeprazole.     

Long-term gastrointestinal symptoms after laparoscopic nissen fundoplication

Patients who have undergone fundoplication may be at risk for recurrent gastroesophageal reflux and may experience postoperative gastrointestinal symptoms. We investigated the long-term symptomatic outcome after laparoscopic Nissen fundoplication. Between 1993 and 1998 we treated 60 patients with laparoscopic fundoplication for gastroesophageal reflux disease. Signs of recurrence and gastrointestinal symptoms were assessed in 55 (92%) patients after a minimum follow-up of 1 year (median: 3.6 years). At follow-up, 52 patients (95%) were completely free of reflux symptoms. Mild gastrointestinal symptoms (flatulence, 60%; early satiety, 51%; meteorism, 42%; inability to vomit, 27%; dysphagia, 25%; diarrhea, 25%; epigastric pain, 24%; inability to belch, 22%) were found in a total of 51 patients (93%). Disturbing symptoms occurred in only 9 patients (16%). Laparoscopic Nissen fundoplication results in excellent control of gastroesophageal reflux disease at long-term follow-up. Despite a high rate of gastrointestinal symptoms, patient satisfaction showed the operation to be effective and well tolerated.     

Long-Term Results (6–10 Years) of Laparoscopic Fundoplication

Most papers report excellent results of laparoscopic fundoplication but with relatively short follow-up. Only few studies have a follow-up longer than 5 years. We prospectively collected data of 399 consecutive patients with gastroesophageal reflux disease (GERD) or large paraesophageal/mixed hiatal hernia who underwent laparoscopic fundoplication between January 1992 and June 2005. Preoperative workup included symptoms questionnaire, videoesophagogram, upper endoscopy, manometry, and pH-metry. Postoperative clinical/functional studies were performed at 1, 6, 12 months, and thereafter every other year. Patients were divided into four groups: GERD with nonerosive esophagitis, erosive esophagitis, Barrett’s esophagus, and large paraesophageal/mixed hiatal hernia. Surgical failures were considered as follows: (1) recurrence of GERD symptoms or abnormal 24-h pH monitoring; (2) recurrence of endoscopic esophagitis; (3) recurrence of hiatal hernia/slipped fundoplication on endoscopy/barium swallow; (4) postoperative onset of dysphagia; (5) postoperative onset of gas bloating. One hundred and forty-five patients (87 M:58 F) were operated between January 1992 and June 1999: 80 nonerosive esophagitis, 29 erosive esophagitis, 17 Barrett’s esophagus, and 19 large paraesophageal/mixed hiatal hernias. At a median follow-up of 97 months, the success rate was 74% for surgery only and 86% for primary surgery and ‘complementary’ treatments (21 patients: 13 redo surgery and eight endoscopic dilations). Dysphagia and recurrence of reflux were the most frequent causes of failure for nonerosive esophagitis patients; recurrence of hernia was prevalent among patients with large paraesophageal/mixed hiatal hernia. Gas bloating (causing failure) was reported by nonerosive esophagitis patients only. At last follow-up, 115 patients were off ‘proton-pump inhibitors’; 30 were still on medications (eight for causes unrelated to GERD). Conclusion confirms that laparoscopic fundoplication provides effective, long-term treatment of gastroesophageal reflux disease. Hernia recurrence and dysphagia are its weak points.     

Pediatric gastroesophageal reflux: Age-specific indications for operation

Pediatric gastroesophageal reflux is common and its complications may be serious. The diagnosis is being suspected and confirmed with increasing frequency in children because of heightened awareness of the symptoms peculiar to pediatric patients. Thirty-one children who underwent Nissen fundoplication for gastroesophageal reflux are reviewed. Diagnosis was obtained by barium meal, isotope scanning, esophagoscopy and pH monitoring. Failure to thrive, recurrent pneumonia, apnea, feeding difficulty and esophageal stricture unresponsive to medical management were the indications for operation. Children with brain damage or previous repair of esophageal atresia are at high risk for gastroesophageal reflux and its complications. A protective fundoplication is a desirable adjunct to feeding gastrostomy in brain-damaged children. Fundoplication eliminated reflux in 30 of 31 patients, relieved symptoms in 28 and improved symptoms in 2. Nissen fundoplication is a safe and effective surgical procedure for correction of gastroesophageal reflux in children.     

Laparoscopic conversion from Nissen to partial fundoplication for refractory dysphagia

Laparoscopic Nissen fundoplication is effective for treating gastroesophageal reflux and is usually well tolerated. Some patients, however, experience postoperative dysphagia refractory to conservative measures. We report our experience and operative technique for laparoscopic conversion of previous laparoscopic Nissen fundoplication to partial fundoplication to relieve dysphagia. We retrospectively reviewed the medical records of 6 patients with refractory dysphagia after laparoscopic Nissen fundoplication who underwent laparoscopic conversion to partial fundoplication using a laparoscopic linear stapler. There were no perioperative deaths and no fundoplication-related complications. In short-term follow-up, all patients reported improvement of dysphagia symptoms.     

Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication

Laparoscopic Nissen fundoplication has been applied with increasing frequency in the treatment of gastroesophageal reflux disease. The aim of this study was to determine the variahles that predict outcome of laparoscopic Nissen fundoplication. A multivariate analysis was performed on data from 199 consecutive patients undergoing laparoscopic Nissen fundoplication. Variables included age, sex, body mass index, primary symptoms, clinical response to acid suppression therapy, erosive esophagitis, 24-hour esophageal pH score, and the percentage of time the esophageal pH was less than 4 on 24-hour pH monitoring, lower esophageal sphincter competence, status of the esophageal body motility, hiatal hernia, carditis, intestinal metaplasia of cardiac epithelium limited to the gastroesophageal junction, and Barrett’s esophagus of any length. Clinical outcome was obtained from all patients at a median follow-up of 15 months (range 6 to 74 months) after surgery. One hundred seventy-three patients had an excellent or good outcome (87%) and 26 had a fair or poor outcome. Three factors were significantly predictive of a successful outcome: an abnormal 24-hour pH score (odds ratio = 5.4; 95% confidence interval [CI] = 1.9–15.3), a typical primary symptom (odds ratio = 5.1; 95% CI = 1.9–13.6), and a clinical response to acid suppression therapy (odds ratio = 3.3; 95% CI = 1.3 -8.7). We conclude that 24-hour pH monitoring provides the strongest outcome predictor of laparoscopic Nissen fundoplication and that outcome is based more on the correct identification of the disease than on its severity. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Bile reflux in benign and malignant barrett’s esophagus: Effect of medical acid suppression and nissen fundoplication

Bile reflux has been implicated in the pathogenesis and malignant degeneration of Barrett’s esophagus, but clinical studies in patients with adenocareinoma arising in Barrett’s esophagus are lacking. Ambulatory esophageal measurement of acid and bile reflux was performed with the previously validated fiberoptic bilirubin monitoring system (Bilitec) combined with a pH probe in 20 asymptomatie volunteers, 19 patients with gastroesophageal reflux disease (GERD) but no mucosal injury, 45 patients with GERD and erosive esophagitis, 33 patients with GERD and Barrett’s esophagus, and 14 patients with early adenocarcinoma arising in Barrett’s esophagus. Repeat studies were done in 15 patients under medical acid suppression and 16 patients after laparoscopie Nissen fundoplication. The mean esophageal bile exposure time showed an exponential increase from GERD patients without esophagitis to those with erosive esophagitis and benign Barrett’s esophagus and was highest in patients with early carcinoma in Barrett’s esophagus (P <0.01). Pathologic esophageal bile exposure was documented in 18 (54.5%) of 33 patients with benign Barrett’s esophagus and 11 (78.6%) of 14 patients with early adenoearcinoma in Barrett’s esophagus. Nissen fundoplieation but not medical acid suppression resulted in complete suppression of bile reflux. Bile reflux into the esophagus is particularly prevalent in patients with Barrett’s esophagus and early cancer. Bile reflux into the esophagus can be completely suppressed by Nissen fundoplication but not medical acid suppression alone. (J GASTROINTEST SURG 1998;2:333-341.) Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997     

Postoperative gastrointestinal complaints after laparoscopic Nissen fundoplication.

OBJECTIVES: Approximately 80% of patients complain of various symptoms immediately after laparoscopic Nissen fundoplication. These symptoms typically are treated medically without an extensive evaluation to identify the cause. We reviewed our experience of laparoscopic Nissen fundoplication to determine the course of postoperative symptomatology in our patient population, and present a rational approach to this problem. METHODS: Over a 10-year period, 628 patients underwent primary laparoscopic Nissen fundoplication for gastroesophageal reflux disease; patients were evaluated with a standard set of questions for postoperative gastrointestinal complaints. Three- and 6-month follow-up data were compared by using the chi square test. RESULTS: One-year follow-up data were available for 615 patients (98%). All of these patients had symptoms during the first 3 postoperative months. Early satiety (88%), bloating/flatulence (64%), and dysphagia (34%) were the most common; however, 94% of patients had resolution of their symptoms by the 1-year follow-up visit, and most had resolved after 3 months. Patients with persistent reflux or dysphagia after 3 months typically had an anatomic failure of the operation. CONCLUSIONS: Most patients who have undergone laparoscopic Nissen fundoplication for gastroesophageal reflux disease will have gastrointestinal complaints during the initial 3 postoperative months. Nearly all of these patients will have resolved their symptomatology after 3 months. Those with persistent symptoms after 3 months warrant evaluation for operative failure.     

Effects of antireflux procedures on respiratory symptoms

BACKGROUND: Antireflux surgery can reduce respiratory symptoms associated with gastroesophageal reflux. However, there is a paucity of data on the durability of this benefit. To evaluate the long-term effects of antireflux surgery on respiratory complaints associated with gastroesophageal reflux, we reviewed our experience. METHODS: Retrospective review of 2,123 antireflux procedures completed between 1986 and 1998 identified 65 patients (3.1%) with associated respiratory symptoms. There were 32 men and 33 women, ranging in age from 20 to 80 years (median 59 years). Respiratory symptoms included wheezing in 43 patients, sputum production in 37, cough in 30, choking episodes in 24, and hoarseness in 17. Preoperative medication use included steroids in 23 patients and bronchodilators in 18. RESULTS: Antireflux operations included the uncut Collis-Nissen fundoplication in 29 patients, Belsy Mark IV repair in 13, open Nissen fundoplication in 13, and laparoscopic Nissen fundoplication in 10. Perioperative complications occurred in 19 patients who underwent open procedures and in none who had laparoscopic procedures. There was one death in the open-operation group and none in the laparoscopic group. Median follow-up was 65 months (range 1 to 174 months) and was complete in 62 patients (96.9%). Improvement in respiratory symptoms (83%) and reduction in-respiratory medication use (78%) were significant as compared to a calculated 33% placebo-effect improvement (p < 0.05). CONCLUSIONS: Antireflux operations significantly reduce respiratory complaints associated with gastroesophageal reflux. This benefit appears to be long term.     

Histologic and clinical outcome after laparoscopic Nissen fundoplication for gastroesophageal reflux disease and Barrett’s esophagus

Background The effectiveness of laparoscopic Nissen fundoplication for the regression of Barrett’s esophagus in gastroesophageal reflux disease remains controversial. The aim of this study, therefore, was to review endoscopic findings and clinical changes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease, particularly for patients with Barrett’s esophagus. Methods From September 1995 through June 2004, 127 patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication. All the patients had clinical and endoscopic follow-up evaluation. We further analyzed the course of 37 consecutive patients with Barrett’s esophagus (29% of all laparoscopic fundoplications performed in our institution) using endoscopic surveillance with appropriate biopsies and histologic evaluation. The median follow-up period for all the patients after fundoplication was 34 months (range, 3–108 months). The median follow-up period for the patients with Barrett’s esophagus was 19 months (range, 3–76 months). Results During the 9-year period, 70 women (55 %) and 57 (45%) men were treated with laparoscopic Nissen fundoplication. The median age of these patients was 42 years (range, 7–81 years). The clinical results were considered excellent for 67 patients (53%), good for 51 patients (40%), fair for 7 patients (6%), and poor for 2 patients (1%). Endoscopic surveillance showed regression of the macroscopic columnar segment in 23 patients with Barrett’s esophagus (62%). Regression at a histopathologic level occurred for 15 patients (40%). The histopathology remained unchanged for 14 patients with Barrett’s esophagus (38%). Conclusion Laparoscopic Nissen fundoplication effectively controls intestinal metaplasia and clinical symptoms in the majority of patients with Barrett’s esophagus.     

Laparoscopic Nissen fundoplication: preliminary report.

Twelve patients presenting with symptomatic esophagitis associated with hiatal hernia and gastroesophageal reflux underwent operative management under laparoscopic guidance. The antireflux procedure employed was the Nissen fundoplication. The authors completed the operation laparoscopically in nine patients. Postoperatively, patients were evaluated with repeat fiberoptic endoscopy, esophageal manometry, and barium contrast studies. Postoperative results were considered excellent on the basis of these studies and complete control of symptoms. The mortality rate was 0%. The only major operative complication was a pneumonia that occurred in one patient. At 1 month follow-up, six patients were totally asymptomatic. The authors conclude that laparoscopic treatment of gastroesophageal reflux associated with a hiatal hernia is feasible by a procedure that has already proven its value during open surgery.     

Experience with the Nissen fundoplication for correction of gastroesophageal reflux in infants.

In the past 15 years at Children's Hospital in Washington, D.C., approximately 500 infants under 1 year of age have been evaluated because of symptomatic gastroesophageal reflux. A contrast esophagogram will demonstrate reflux in the majority of affected infants. However, this diagnostic method is not always reliable. Timed monitoring of esophageal pH, and extended radionuclide scan even in infants can document accurately the frequency and character of episodic reflux. Following diagnosis, most infants are treated by conservative therapy, which includes the upright position. Of the 500 patients, 72 infants (14%) were selected for operative correction using the Nissen fundoplication. The indications for surgery in these infants with gastroesophageal reflux were: (A) failure to thrive, (35); (B) chronic respiratory infection, (24); (C) apnea spells, (8); and (D) esophagitis. One infant was found to have a stricture. In these symptomatic patients, three had previous operative correction of esophageal atresia, and two had congenital gastric dislocation in the chest. Results: 61 excellent; six recurrences, of whom five are satisfactory after a second operation; two lost to follow-up but doing well when last seen; three deaths from causes unrelated to reflux. The selection of infants with gastroesophageal reflux for surgical correlation is primarily based on life-threatening clinical effects. The Nissen fundoplication has worked well in this group of infants.     

Comparison of long-term outcome of laparoscopic and conventional nissen fundoplication: a prospective randomized study with an 11-year follow-up

OBJECTIVE: The aim of this study was to compare the long-term objective and subjective outcomes of laparoscopic and open Nissen fundoplication in a randomized clinical trial with an 11-year follow-up. SUMMARY BACKGROUND DATA: Laparoscopic Nissen fundoplication has become the method of choice in antireflux surgery, replacing its open counterpart despite the lack of long-term results from controlled clinical studies. METHODS: Between April 1992 and June 1995, 110 consecutive patients were randomized to either laparoscopic (LAP) or conventional (open) Nissen fundoplication. The objective long-term follow-up consisted of an upper gastrointestinal endoscopy and a clinical assessment; the subjective long-term outcome was investigated by personal interviews using a structured questionnaire. RESULTS: Forty-nine patients in the LAP group and 37 patients in the open group were available for evaluation. Late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in both groups. With the benefit of hindsight, 73.7% of the patients in the open group and 81.8% in the LAP group would again choose surgical treatment (P = 0.3042). In the LAP group, there were 5 (13.2%) partially or totally disrupted plications compared with the 14 (40.0%) disrupted plications in the open group (P = 0.0152). There were 10 incisional hernias in the open group compared with none in the LAP group (P < 0.001). CONCLUSIONS: At long-term follow-up, the open and LAP approaches for the Nissen fundoplication have similar long-term subjective symptomatic outcome despite the significantly higher incidence of incisional hernias and defective fundic wraps at endoscopy in the open group defining laparoscopic Nissen fundoplication as the procedure of choice in surgical management of gastroesophageal reflux disease.     

Nissen fundoplication for gastroesophageal reflux in infants

Some degree of gastroesophageal reflux is very common in infants and tends to reverse with time. Therefore, the indications for an antireflux operation are not well defined. Furthermore, the complication rate and the ability of the fundoplication to grow remain to be determined. To answer these questions, we reviewed the records of patients 6 months of age or younger who underwent a Nissen fundoplication with gastrostomy tube placement between 1979 and 1985. There were 45 patients (25 boys and 20 girls) with birth weights of 0.65 to 4.3 kg. The consequences of gastroesophageal reflux were more varied than in older children. Severe respiratory problems were common, including recurrent aspiration or bronchopulmonary dysplasia in 60% and frequent apneic and bradycardiac spells in 17%. Failure to gain weight was present in 20% and intractable vomiting in 2.0%. As expected, 78% of these patients had congenital anomalies or acquired problems which, in many cases, were important to the prognosis. The diagnosis was confirmed by barium swallow in all but one patient in whom gross reflux during feedings was present. Initially, medical management was tried for 3 to 4 weeks. In one patient, however, the severity of the respiratory problems precluded trial beyond 12 days. The recommendation for operation was based only on the severity of symptoms attributed to gastroesophageal reflux. All patients underwent Nissen fundoplication with gastrostomy tube placement at 2 weeks to 6 months of age and weighing 1.02 to 6.95 kg. The only surgical complication was one gastrostomy leak. Prematurity or preexisting anomalies led to a 20% incidence of late unrelated deaths between 2 weeks and 23 months postoperatively. Improvement in symptoms occurred in our survivors with follow-up of 5 to 72 months. We conclude: Significant gastroesophageal reflux in infancy most frequently produces respiratory problems that can be life threatening. Nissen fundoplication can be a safe and effective procedure in infants 6 months of age or younger. Fundoplication appears to have good growth potential, and no late complications or feeding problems have occurred. Consequently, surgical correction can be recommended for infants not responding to conservative medical therapy.     

腹腔镜Nissen胃底折叠联合His角重建术治疗胃食管反流病的短期疗效

目的探讨腹腔镜Nissen胃底折叠术联合His角重建治疗胃食管反流病（GERD）的效果。 方法回顾性分析2018年10月至2021年2月于首都医科大学宣武医院普通外科接受Nissen胃底折叠（360°）+His角重建术和单纯Nissen胃底折叠术GERD患者的临床资料，观察比较两种术式抗反流效果的差异、患者对手术治疗满意度等情况。 结果本研究共纳入GERD患者98例，其中Nissen+His角重建组为52例，Nissen组为46例。术后6个月时，2组患者GERD相关症状（食管症状：反流、胃灼热、胸背痛及剑突下顶胀感。食管外症状：咳嗽、喘息、咽部异物感）评分均显著低于治疗前（P<0.05）。术后症状评分中，Nissen+His角重建组反流、胃灼热症状评分低于Nissen组，差异有统计学意义（反流：Z=－2.466，P=0.014；胃灼热：Z=－2.674，P=0.007）；2组其他症状评分差异均无统计学意义（P>0.05）。2组术后功能性并发症（包括吞咽困难、腹胀、难以嗳气、排气增多及慢性腹部疼痛）发生率相似，经保守治疗均获得明显缓解。Nissen+His角重建组患者对手术治疗满意度为94.2%（49/52），Nissen组患者满意度为91.3%（42/46），2组患者手术满意度差异无统计学意义（P=0.866）。 结论Nissen胃底折叠+His角重建术与Nissen胃底折叠术均有较好的抗反流疗效，手术并发症少、轻微，患者满意度高。与Nissen组相比，Nissen+His角重建组控制反流、胃灼热症状更佳，该结果需要前瞻性、大样本、长期随访结果予以证实。     

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

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

Nissen fundoplication for reflux peptic esophagitis.

One hundred sixty-five patients with reflux peptic esophagitis have been treated by Nissen fundoplication. When compared with a group of 104 patients reported five years ago, the incidence of persistent or recurrent esophagitis remains approximately the same (10% versus 8%). This is consistent with the assumption that the Nissen procedure when initially successful tends to remain so and that late recurrence appears to be uncommon. The unpleasant postoperative sequela which we have termed the "gas-bloat syndrome" was noted in 1971 to be present in the early postoperative period in approximately one-half the patients. Late follow-up, however, averaging four years indicates a marked reduction in this disorder with either absence or clinical insignificance in 87% of patients. Nonetheless, moderate symptoms persist in 11% and severe symptoms requiring active treatment in 2%. Manometric study of the lower esophageal sphincter indicates nearly a three-fold increase in resting pressure following Nissen fundoplication (p less than .001). It is hoped that manometric study will provide a more reliable prognostic measure of sphincter restoration than the measurement of pH across the gastroesophageal junction.