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.     

Outcome of laparoscopic antireflux surgery in patients with nonerosive reflux disease

As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa. Presented in abstract form at the Annual Meeting of the American Gastroenterology Association, Orlando, Florida, May 15, 1999.     

Laparoscopic antireflux surgery with routine Mesh-Hiatoplasty in the treatment of gastroesophageal reflux disease

One of the most frequent complications after laparoscopic antireflux surgery is intrathoracic migration of the wrap ("slipped" Nissen fundoplication). The most common reasons for this are inadequate closure of the crura or disruption of the crural closure. The aim of this prospective study was to evaluate surgical outcomes in patients who underwent laparoscopic antireflux surgery with simple nonabsorbable polypropylene sutures for hiatal closure in comparison to patients who underwent routine mesh-hiatoplasty. Between 1993 and 1998, a group of 361 patients underwent primary laparoscopic Nissen or Toupet fundoplication with the use of simple nonabsorbable polypropylene sutures for hiatal closure. Since December 1998, in all patients (n = 170) who underwent laparoscopic antireflux surgery, a 1 × 3 cm polypropylene mesh was placed on the crura behind the esophagus to reinforce them. Functional outcome, symptoms of gastroesophageal reflux disease, and postoperative complications such as recurrent hiatal hernia with or without intrathoracic migration of the wrap have been used for assessment of outcomes. In the initial series of 361 patients, postoperative herniation of the wrap occurred in 22 patients (6.1%). Of these 22 patients, 17 of them (4.7%) had to undergo laparoscopic redo surgery. The remaining five patients were free of symptoms. In comparison to these results, in a second group of 170 patients there was only one (0.6%) who had postoperative herniation of the wrap into the chest. There have been no significant differences in objective data such as DeMeester scores or lower esophageal sphincter pressure between the two groups. Postoperative dysphagia was increased during the early period after surgery in patients undergoing mesh-hiatoplasty but resolved without any further treatment within the first year after laparoscopic antireflux surgery. We concluded that routine hiatoplasty with the use of a polypropylene mesh is effective in preventing postoperative herniation of the wrap and leads to a significantly better surgical outcome than closure of the hiatal crura with simple sutures, without any additional long-term side effects. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation); and the Ninth International Congress of the European Association for Endoscopic Surgery, Maastricht, The Netherlands, June 15, 2001; and published as an abstract in Gastroenterology 120:A 480, 2001.     

Laparoscopic antireflux surgery in the elderly

BACKGROUND: Both gastroesophageal reflux and paraesophageal hernias are more common in the elderly, but often these patients are not referred for surgery because of their age. In this study we determined the outcome for laparoscopic antireflux surgery in patients aged 70 years or older, in whom either symptoms of gastroesophageal reflux or a large paraesophageal hernia was the indication for surgery. METHOD: From a prospectively maintained clinical database of patients undergoing laparoscopic antireflux surgery, all patients aged 70 years or older were identified and their outcome was determined. RESULTS: Two hundred ten patients were identified. In 129 a large paraesophageal hiatus hernia was the primary indication for surgery, and in 81 patients the indication was reflux. Mean operation time was significantly longer in patients undergoing surgery for a large hiatus hernia (109 vs. 72 min), and conversion to open surgery was required more often (11.6% vs. 4.4%), compared to patients with reflux alone. Follow-up information was available for 95% of patients. Postoperative symptom scores for heartburn and dysphagia improved significantly and patients' satisfaction with surgery was high. CONCLUSION: Laparoscopic antireflux surgery in patients aged 70 years or older has a satisfactory clinical outcome. Elderly patients should not be refused laparoscopic antireflux surgery only because of their age.     

腹腔镜抗反流手术治疗胃食管反流病的总体疗效及手术指征选择

目的:探讨腹腔镜抗反流手术治疗胃食管反流病的疗效及手术指征选择。方法:总结2000年至2013年收治的185例胃食管反流病病人的临床资料和术后近期远期结果(生活质量、病人满意率、抗反流手术相关并发症及复发),分析腹腔镜抗反流手术的安全性和有效性。结果:185例病人均顺利施行腹腔镜抗反流手术(食管裂孔修补+胃底折叠),手术用时50~200 min,术中失血10~100 mL,无中转开腹和手术死亡病例。20例病人发生围手术期并发症,经针对性处理后痊愈;术后并发慢性吞咽困难16例,多为轻、中度;163例GERD病人术后日常生活质量改善明显,手术满意率达88.1%;166例病人术前胃食管反流症状典型,术后152例症状明显改善(91.6%),14例无缓解。随访见8例术后复发,其中2例合并食管裂孔疝复发。结论:腹腔镜手术治疗胃食管反流病安全可行、疗效可靠,但术前应严格把握手术适应证。     

Effects of manometrically discovered nonspecific motility disorders of the esophagus on the outcomes of antireflux surgery

Nonspecific motility disorders (NMDs) of the esophagus are common manometric findings in patients evaluated for gastroesophageal reflux disease (GERD). However, it is unclear how these disorders affect the outcomes of antireflux surgery. The purpose of this study was to assess symptomatic outcomes of patients with and without NMDs undergoing surgical treatment for GERD. A prospectively gathered database of all patients undergoing antireflux surgery was retrospectively reviewed for preoperative symptoms, symptom severity using the GERD-HRQL (best score 0, worst score 50), esophageal manometry measurements, presence of NMD, type of operation, any transient or permanent postoperative dysphagia, severity of postoperative dysphagia (best score 0, worst score 5), and postoperative symptom severity. A total of 239 patients were studied; 24% had a NMD identified by preoperative esophageal manometry, and 17% of this +NMD group had preoperative dysphagia or atypical chest/epigastric pain compared to 28% of those without a NMD (-NMD group) (P=NS). Preoperative symptom scores were +NMD 33 vs. -NMD 27 (P=0.01). Postoperative symptom scores were +NMD 5 vs. -NMD 3 (P=NS). There were no differences in preoperative or postoperative dysphagia scores. Transient postoperative dysphagia was 15.8% in the +NMD group vs. 16.4% in the -NMD group (P=NS). Postoperative dilation was 0% in the +NMD group vs. 2% in the -NMD group (P=NS). Manometrically discovered NMDs do not appear to affect preoperative symptoms or symptomatic outcomes of patients surgically treated for GERD. These findings my reflect the severity of GERD and may improve with antireflux surgery.     

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: Quality of life, symptomatic outcome, and patient satisfaction

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) Underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluted using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Clinical outcome of Laparoscopic antireflux surgery for patients with irritable bowel syndrome

Background The prevalence of irritable bowel syndrome (IBS) is higher among subjects with gastroesophageal reflux disease (GERD). This study aimed to assess the effect of IBS on the postoperative outcome of antireflux surgery.Methods For this study, 102 patients who underwent laparoscopic fundoplication were screened preoperatively for IBS with the Rome II criteria. There were 32 patients in the IBS group and 70 patients in the non-IBS group. Most of the patients (97%) (31 of 32 IBS and 68 of 70 non-IBS patients) had both pre- and postoperative IBS evaluation. A visual analog GERD-specific scoring scale was used to evaluate GERD symptoms prospectively.Results In both groups, GERD symptom scores were statistically improved postoperatively. Of the 31 IBS patients 25 (80.6%) showed a reduction in their symptoms below the Rome II criteria for IBS diagnosis postoperatively.Conclusion Irritable bowel syndrome does not have a negative effect on the outcome of laparoscopic antireflux surgery. Surgical correction of GERD may improve the severity of irritable bowel symptoms.     

Laparoscopic improves perioperative outcomes of antireflux surgery at US academic centers

Background

Open and laparoscopic antireflux surgeries are standard for the treatment of gastroesophageal reflux disease (GERD). The in-hospital outcomes of laparoscopic and open antireflux procedures were analyzed and compared at US academic medical centers.

Methods

Using International Classification of Diseases, Ninth Revision, Clinical Modification codes for 5,737 patients with GERD that underwent open (n = 1,377) or laparoscopic (n = 4,360) antireflux surgery were identified from the University Health-System Consortium Database over a 3-year period (2004-2007). Demographic and outcome data measured included length of stay, overall complications, in-hospital mortality, observed-to-expected mortality ratio (risk-adjusted mortality), and hospital costs.

Results

Laparoscopic antireflux procedures offered significantly lower mean length of stay, in-hospital morbidity, and hospital costs. Both procedures had a low observed to expected in-hospital mortality. Open surgery was associated with significantly higher procedure-related and pulmonary complications.

Conclusions

In the context of US academic centers, approximately three quarters of antireflux procedures are being performed using the laparoscopic approach. These data suggest that laparoscopy has improved in-hospital outcomes when compared with open surgery and is preferred for the surgical treatment of GERD.     

Psychiatric disorders affect outcomes of antireflux operations for gastroesophageal reflux disease

apd: 20 October 2000     

Clinical outcomes after laparoscopic antireflux surgery in patients with and without preoperative endoscopic esophagitis

A wide spectrum of endoscopic findings exists in patients with gastroesophageal reflux disease (GERD). This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients who had GERD with and without preoperative endoscopic esophagitis. From 1992 to 2001, a total of 414 patients who underwent LARS with 6 months or more of follow-up were prospectively entered into a database. Among these patients, 84 (20%) had no endoscopic evidence of esophagitis on preoperative endoscopy (group 1), whereas 330 (80%) did have esophagitis (group 2). Perioperative outcomes, GERD symptom relief, and the use of acid-reducing medication were assessed. Preoperative DeMeester scores in groups 1 and 2 were 44 ± 29 and 61 ± 62 (P < 0.05) and mean esophageal peristaltic amplitude was 86 ± 32 mm Hg vs. 60 ± 42 mm Hg, respectively (P < 0.05). Although procedure time was significantly shorter in group 1, other perioperative outcomes were similar. At postoperative follow-up, the use of proton pump inhibitors was reduced in both groups (86% to ≤14%). With the exception of postoperative dysphagia, there was no difference in GERD symptom relief between groups 1 and 2. The presence or absence of preoperative esophagitis has minimal effect on favorable symptomatic outcomes after LARS. Thus LARS is an effective treatment option for patients, irrespective of endoscopic evidence of esophagitis, leading to excellent symptom relief and a marked reduction in the use of proton pump inhibitors. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation). Supported by the Washington University Institute for Minimally Invasive Surgery.     

Psychometric documentation of a quality-of-life questionnaire for patients undergoing antireflux surgery (QOLARS)

Background The purpose of our study was to develop a quality-of-life (QoL) questionnaire for patients with gastroesophageal reflux disease (GERD) who have undergone laparoscopic fundoplication. This questionnaire was developed to be more comprehensive than existing measures.Methods Between 1994 and 2002, 252 patients underwent laparoscopic fundoplication for GERD in the 1^st Department of Surgery, Semmelweis University. We undertook a retrospective analysis: each of 252 operated patients was given a questionnaire and was requested to complete it and return it in an enclosed envelope. A total of 116 patients returned completed questionnaires. The patients included 55 men and 61 women, with a mean age of 46 years (range 14–77). These patients were used in the psychometric evaluation. The questionnaire consisted of 50 questions (including the Visick score, EORTC-QLQ-C30, and a modified GERD-HRQL).Results Internal consistency reliability was high (alpha value overall, 0.95, range, 0.74–0.96). Using convergent and divergent validity, construct validity was evaluated by examining Pearson correlation coefficients between items and scales. Construct validity was demonstrated based on observed correlations. Known groups validity was upheld because patients who experienced more symptoms and patients who has higher Visick scores reported worse QoL than those with less symptoms or lower Visick scores.Conclusions Our questionnaire is a short and user-friendly instrument with excellent psychometric properties. It has been found to be valid and reliable.     

Influence of spastic motor disorders of the esophageal body on outcomes from laparoscopic antireflux surgery

Background: The clinical outcomes of laparoscopic antireflux surgery (LARS) in patients with the spectrum of nonspecific spastic esophageal motor disorders (NSSDs) are not known. Methods: From a prospective database of patients undergoing LARS between 1997 and 2000, those with preoperative manometry at our institution and follow-up at 6 months were identified. Results: Of the 121 patients, 35 had NSSDs. There were no differences in symptoms between groups preoperatively, but in the immediate postoperative period NSSD patients had more symptoms than nonspastic patients. At 18-month mean follow-up, NSSD patients reported significantly more heartburn (22% vs 7%), waterbrash (14% vs 4%), and medication usage (17% vs 5%) than nonspastic patients (p < 0.05 for each). Despite this difference, nearly all patients reported subjective improvement postoperatively, and the degree of improvement was similar between groups. Conclusions: Patients with NSSDs are more likely to have esophageal symptoms following LARS than subjects without these abnormalities. However, these patients still experience significant improvement in preoperative symptoms. Presented at the 8^th World Congress Society of American Gastrointestinal Endoscopic Surgeons (SAGES). New York, NY, USA, March 2002     

A poor response to proton pump inhibition is not a contraindication for laparoscopic antireflux surgery for gastro esophageal reflux disease

Background We aimed to determine if a poor response to proton pump inhibitors (PPIs) can predict a poor outcome following laparoscopic antireflux surgery (LARS) in our surgically treated population. Methods A total of 324 patients undergoing LARS were included in this study. Following standardized assessment, patients recorded the efficacy of their medication on visual analogue scales. Pre- and postoperative symptom scores were recorded, with outcomes measured by modified Visick scores. Results There were 233 good responders (>50% relief) and 91 poor responders (<49% relief). Both groups demonstrated a significant decline in postoperative symptom scores. Ninety-four percent of good responders had an excellent or good outcome, compared to 87% of poor responders. Twenty-seven patients reported a fair or poor outcome, despite improved postoperative symptom scores. Fifteen of these patients reported continuing heartburn; five had positive pH tests. Conclusion Our results do not support the assumption that a poor response to PPIs equates to a poor outcome after LARS.     

Quality of life and patient satisfaction after laparoscopic antireflux surgery using the QOLARS questionnaire

Background Currently, evaluation of patient satisfaction and quality-of-life data to estimate the outcome of laparoscopic antireflux surgery is an important issue. This study aimed first to report the midterm results for the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic fundoplication and to evaluate surgical outcome, including quality of life and patient satisfaction. The second aim was to determine whether preoperative quality-of-life measurement can predict which patients will be satisfied with antireflux surgery. Methods The current prospective study evaluated the outcome of the quality-of-life data for 41 patients (13 men and 28 women) who underwent laparoscopic fundoplication in the author’s department of surgery between 1 January 2002 and 31 May 2003. The mean age of the patients was 41 years. Quality of life was measured by using a new quality-of-life instrument (QOLARS) developed and validated by the author’s study group. The patients completed the QOLARS questionnaire before surgery, then 6 weeks, 1 year, and 3 years after surgery. Results Before surgery, all the patients had a poor quality of life. The general quality-of-life and heartburn scores improved significantly within 6 weeks after surgery and showed further improvement by the end of the first postoperative year, then remained stable 3 years after surgery. The patients who became completely free of reflux-related symptoms were divided into two groups according to their satisfaction with the operative result. The patients dissatisfied with surgery had significantly worse median preoparative scores in four domians (physical functioning, emotional functioning, sleep disturbance, constipation) than the patients satisfied with the procedure. Conclusions The findings show that QOLARS is a sensitive tool for assessing surgical outcome after laparoscopic antireflux surgery. The quality-of-life response closely follows the clinical outcome of surgical treatment, reflecting its side effects as well. This study suggests that a generic quality-of-life scale can preoperatively identify patients with GERD who are likely to be dissatisfied with antireflux surgery.     

Quality of life in GERD patients: Medical treatment versus antireflux surgery

Medical and surgical treatments are able to improve symptoms in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the outcome in GERD patients without therapy, under continuous medical treatment, and after laparoscopic antireflux surgery. Five hundred seventy-nine consecutive patients underwent medical or surgical treatment for GERD-induced symptoms. Patients were studied in detail before and after treatment by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI) and the Health-Related Quality of Life (HRQL) questionnaire. Surgery was indicated and performed in 351 patients with persistent or recurrent GERD symptoms and/or complications, and in patients preferring surgery to medical treatment, despite the use of an adequate medication. The remaining 228 patients were treated with proton pump inhibitors (PPI) in the standard dose, or if required, the double dose. The outcome was assessed 3 and 12 months after treatment. While symptoms and quality of life were highly impaired in GERD patients without therapy compared with normal people, a significant improvement was obtained by PPI therapy. Following surgery, quality of life was normalized in all subsections and was significantly higher compared with the medically treated group. These results stayed constant in short-term and intermediate follow-up. Medical and surgical therapies are both able to improve symptoms and quality of life in GERD patients. Nevertheless, the outcome is significantly better following surgery. It can be suggested that surgical treatment may be the more successful therapy in the long-term. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–19, 2005 (poster presentation).     

Long-term outcome of laparoscopic antireflux surgery in the elderly

The aim of this retrospective study was to compare results and five-year surgical outcome of laparoscopic antireflux surgery (LARS) in patients younger than 65 years and elderly patients aged 65 years or older. From January 1992 to December 1998, 2684 patients underwent LARS in 31 surgical units; 369 elderly patients (group 1) were compared with 2315 younger patients (group 2). Elderly patients have a higher American Society of Anesthesiologists score (mean, 2.38 versus 1.98). The conversion rate was higher in group 1 (10.2%, n = 38 versus 6.1%, n = 142), as was the morbidity rate (7.6% in group 1 versus 4.5% in group 2). Mean hospital stay was longer for group 1 (7.6 ± 5.6 days versus 5.9 ± 2.8 days). Functional evaluation was excellent in both groups (91-93%) at 3 months and 2 and 5 years. LARS in the elderly is a safe and efficient procedure. Good results appear to be sustainable in the long term. The study participants are listed at the end of the article.     

Comparative results of endoluminal gastroplasty and laparoscopic antireflux surgery for the treatment of GERD

Background: Transoral endoluminal gastroplasty (EG) by the Bard Endocinch device is available for the treatment of gastroesophageal reflux disease (GERD). This study assessed the early (12 months) outcomes in patients undergoing EG performed by one gastroenterologist compared with another set of patients referred by the same gastroenterologist for laparoscopic antireflux surgery (LAS) at a foregut surgery center. Methods: From June 2000 to July 2002, 87 consecutive patients cared for by a single gastroenterologist were diagnosed with refractory GERD and underwent either EG (n = 47) or referral for LAS (n = 40). Preoperative evaluation included symptom assessment, pH studies, and motility studies. Outcomes were assessed by symptomatic improvement and dependence on anti-acid medications. Data analyzed by chi-square or Mann-Whitney tests are reported as mean ± SEM. Results: Preoperative symptom duration, Johnson-DeMeester (JD) score, % time pH < 4, and reflux episodes were statistically similar in both treatment groups. The follow-up times for EG and LAS groups were 7.3 ± 0.9 and 8 ± 0.4 months, respectively. Of EG patients, 94% were available for follow-up, and all LAS patients had follow-up data. Overall, 66% of patients were satisfied with EG as compared to 93% after LAS (p = 0.1). Postoperative PPI/motility agent use was 32% for EG and 13% for LAS (p = 0.03). Identifiable causes of EG failure were premature procedure termination due to hypoxia or bleeding (three patients), intractable vomiting (two patients), and delayed gastric emptying (five patients). Three EG patients subsequently had LAS within 6 months of the procedure. Conclusions: LAS offers greater reduction in medication use than EG, as well as more durable patient satisfaction. Benefits of EG may include short-term symptomatic improvement while considering definitive surgical management. Presented at the annual meeting of the Society of American Gastrointestinal Surgery (SAGES), Los Angeles, CA, USA, 15 March 2003     

Austrian experiences of antireflux surgery

Background: Antireflux surgery (ARS) is a well established treatment for GERD (gastroesophageal reflux disease). The present study gives an overview of experience in Austria regarding the frequency of open and laparoscopic ARS and how Austrian departments meet the requirements for surgery. Methods: A questionnaire was sent to 115 surgical departments in Austria to evaluate in how many institutions antireflux surgery (open and/or laparoscopically) was performed since 1990, and which pre- and postoperative tests were obligatory, optional, or not performed. Units were divided into specialized and nonspecialized. Results: The laparoscopic approach has gained in importance by about 300% in the past 5 years in the few hospitals performing this procedure. Esophageal manometry and 24-h pH monitoring were rarely done in nonspecialized units, despite the fact that GERD is mainly a functional disorder of the esophagus and stomach. In contrast to the nonspecialized units, the specialized unit performed upper endoscopy, esophageal manometry and 24-h esophageal pH monitoring as obligatory tests. Conclusions: ARS, both open and laparoscopic, is not commonly performed in surgical departments in Austria but the frequency has significantly increased in recent years. Laparoscopic ARS is a safe procedure in hospitals performing this frequently. Laparoscopic ARS should only be performed in specialized units with significant experience in gastroesophageal diseases, where functional testing of the esophagus can be done.     

The use of medication after laparoscopic antireflux surgery

Background  Laparoscopic antireflux surgery (LARS) significantly improves symptoms of gastro-esophageal reflux disease (GERD) and quality of life. Nevertheless, 14–62% of patients report using antisecretory medication after surgery, although only a tiny percentage has proven recurrence of GERD. We sought to determine symptoms of GERD, quality of life, and use of medication before and after LARS, and to compare our findings with those from previous studies. Methods  Five hundred fifty-three patients with GERD who underwent LARS were evaluated before and at 1 year after surgery. After surgery, multidisciplinary follow-up care was provided for all patients by surgeons, psychologists, dieticians, and speech therapists. Results  Symptoms of GERD and quality of life improved significantly and only 4.2% of patients still required medication after surgery [proton pump inhibitors (PPI) (98.4 vs. 2.2%; p < 0.01), prokinetics (9.6 vs. 1.1%; p < 0.01), and psychiatric medication (8 vs. 1.6%; p < 0.01)]. Conclusion  LARS significantly reduced medication use at 1-year follow-up. However, these effects might be attributed, in part, to the multidisciplinary follow-up care. Further studies are therefore required to investigate which patients may benefit from multidisciplinary follow-up care and whether its selective application may reduce the need for medication after LARS.