Laparoscopic Collis-Nissen operation for shortened esophagus

Esophageal shortening as a complication of advanced gastroesophageal reflux disease is seen in 2-4 % of patients with GERD. The Collis gastroplasty with Nissen fundoplication creates an intraabdominal neoesophagus with a fundic wrap and is an effective procedure in the difficult intraoperative situation of esophageal shortening. After own experience with the open Collis gastroplasty and after reports on successful laparoscopic Collis-Nissen operation we performed 2 laparoscopic Collis-Nissen operations. The technique we used is a new modification of the laparoscopic technique described by Johnson and Hunter in 1998. The postoperative course was uncomplicated in both patients. The follow up included endoscopy and barium meal. The patients showed relief from reflux symptoms except a mild dysphagia. There was no persisting esophagitis. The laparoscopic Collis-Nissen gastroplasty is an effective minimal-invasive procedure in patients with shortened esophagus diagnosed intraoperatively.     

Long-term comparative outcome between laparoscopic total Nissen and Toupet fundoplication: Symptomatic relief,patient satisfaction and quality of life

Background Laparoscopic antireflux surgery has become an established method of treatment of gastroesophageal reflux disease. This study compares the long-term outcome of total (Nissen) and partial (Toupet) fundoplication, performed in a single institution, by evaluating symptoms and quality of life. Methods 266 patients who underwent laparoscopic Nissen or Toupet fundoplication completed a preoperative reflux symptom questionnaire. Postsurgery symptom evaluation, patient satisfaction and quality of life in reflux and dyspepsia (QOLRAD) questionnaires were sent to these patients in December 2004. The two groups were compared for each item nonparametrically. Results Completed questionnaires were received from 161 patients (61%) of whom 99 had a laparoscopic Nissen fundoplication and 62 laparoscopic Toupet fundoplication. Both procedures were equivalent in improving reflux symptom scores in the long term, 79/99 (80%) and 56/62 (90%) were either symptom free or had obtained significant symptomatic relief. Both groups had equivalent QoL scores on the QOLRAD questionnaire. An equivalent number of patients (86% and 83.9% after Nissen and Toupet, respectively) were sufficiently satisfied to recommend antireflux surgery to a friend or relative complaining of reflux symptoms. Conclusion In conclusion, in patients who have returned the questionnaire, long-term satisfaction, general symptom scores, and quality of life are equivalent after laparoscopic Nissen (complete) or Toupet (partial) fundoplication. There is however, a significant increased prevalence of persistent heartburn after laparoscopic Toupet fundoplication.     

Paradigm shift in the management of gastroesophageal reflux disease

OBJECTIVE: To compare the short-term results of the radiofrequency treatment of the gastroesophageal junction known as the Stretta procedure versus laparoscopic fundoplication (LF) in patients with gastroesophageal reflux disease (GERD). SUMMARY BACKGROUND DATA: The Stretta procedure has been shown to be safe, well tolerated, and highly effective in the treatment of GERD. METHODS: All patients presenting to Vanderbilt University Medical Center for surgical evaluation of GERD between August 2000 and March 2002 were prospectively evaluated under an IRB-approved protocol. All patients underwent esophageal motility testing and endoscopy that documented GERD preoperatively, either by a positive 24-hour pH study or biopsy-proven esophagitis. Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett's esophagus. Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett's were offered LF. All patients were studied pre- and postoperatively with validated GERD-specific quality-of-life questionnaires (QOLRAD) and short-form health surveys (SF-12). Current medication use and satisfaction with the procedure was also obtained. RESULTS: Results are reported as mean +/- SEM. Seventy-five patients (age 49 +/- 14 years, 44% male, 56% female) underwent LF and 65 patients (age 46 +/- 12 years, 42%, 58% female) underwent the Stretta procedure. Preoperative esophageal acid exposure time was higher in the LF group. Preoperative LES pressure was higher in the Stretta group. In the LF group, 41% had large hiatal hernias (>2 cm), 8 patients required Collis gastroplasty, 6 had Barrett's esophagus, and 10 had undergone previous fundoplication. At 6 months, the QOLRAD and SF-12 scores were significantly improved within both groups. There was an equal magnitude of improvement between pre- and postoperative QOLRAD and SF-12 scores between Stretta and LF patients. Fifty-eight percent of Stretta patients were off proton pump inhibitors, and an additional 31% had reduced their dose significantly; 97% of LF patients were off PPIs. Twenty-two Stretta patients returned for 24-hour pH testing at a mean of 7.2 +/- 0.5 months, and there was a significant reduction in esophageal acid exposure time. Both groups were highly satisfied with their procedure. CONCLUSIONS: The addition of a less invasive, endoscopic treatment for GERD to the surgical algorithm has allowed the authors to stratify the management of GERD patients to treatment with either Stretta or LF according to size of hiatal hernia, LES pressure, Barrett's esophagus, and significant pulmonary symptoms. Patients undergoing Stretta are highly satisfied and have improved GERD symptoms and quality of life comparable to LF. The Stretta procedure is an effective alternative to LF in well-selected patients.     

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.     

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??Laparoscopic anterior 180° partial fundoplication versus Nissen fundoplication in elderly patients with gastroesophageal reflux disease??A randomized controlled trial ZHAO Hong-zhi, QIN Ming-fang. Center of Tianjin Minimally Invasive Surgery, Nankai Hospital, Tianjin 300100, China
Corresponding author ??ZHAO Hong-zhi, E-mail??tjzhhzh@sina.com
Abstract Objective To compare two anti-reflux procedures??laparoscopic anterior 180° partial fundoplication and Nissen fundoplication??in elderly patients with gastroesophageal reflux disease (GERD). Methods From July 2008 to June 2012, 78 elderly patients with GERD were admitted in Tianjin Nankai Hospital. All the patients were allocated into two groups randomly. Thirty-nine patients were performed laparoscopic anterior 180° partial fundoplication (anterior 180° group) and the other 39 patients were performed Nissen fundoplication (Nissen group). Perioperative clinical parameters were recorded for comparing efficacy between two groups. Results Laparoscopic surgery was accomplished in all patients. The mean operation time of anterior180° group was significantly less than that of Nissen group (P<0.05). There was no significant difference of the mean duration of postoperative hospital stay between two groups (P>0.05). The symptoms in most patients were adequately relieved after operation. Endoscopy, radiology, esophageal manometry and 24-hour pH monitoring were repeated 1 month after surgery. All the results returned to normal compared with preoperative data. A total of 76 patients got follow-up. One patient was lost. One patient died of heart infarction. During follow-up period of 6-54 months (mean 28.5 months), there was no statistical significance between groups for the recurrence rate and satisfaction rate of operation. There was a lower incidence of dysphagia and epigastric bloating in the anterior 180° group. Conclusion For elderly patients with GERD??laparoscopic anterior 180°partial fundoplication has a good and durable anti-reflux effect compared with laparoscopic Nissen fundoplication. With shorter operation time and lower incidence of postoperative complications (dysphagia and epigastric bloating) compared with Nissen fundoplication, laparoscopic anterior 180°partial fundoplication can be employed as a more appropriate procedure for treatment of GERD in elderly patients.     

Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome

Background The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate. Methods In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. “Tension-free” repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis–Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction. Results There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis–Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique. Conclusions To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis–Nissen procedure in such cases.     

Laparoscopic fundoplication: 5-year follow-up

There are few published reports on outcomes of 5 or more years following laparoscopic fundoplication. Gastroesophageal reflux disease (GERD) specific quality of life questionnaires (QOLRAD), short form health surveys (SF12), and queries regarding current medication use and long-term satisfaction were mailed to all patients who underwent laparoscopic fundoplication at our institution. Results are reported as mean +/- SEM. Seventy-six patients underwent laparoscopic fundoplication (63 Nissen, 13 Toupet) between November 1992 and December 1997. Fifty-two patients completed questionnaires (68%). Mean follow-up was 5.1 +/- 0.2 years (range, 4-9 years). Mean QOLRAD scores were 5.8 +/- 0.2, (scale 0-7, a higher score reflecting improved QOL), which is comparable to the general population (6.0 mean). SF-12 mental and physical scores were 46.6 +/- 1.7 and 34.2 +/- 1.6, respectively, versus 50.7 and 51.2 for the general population. Forty-seven patients (92%) would have the procedure again. Eleven (21%) remained on antisecretory medications (15% proton pump inhibitor and 6% H2 receptor antagonists). None of the 11 patients underwent 24-hour pH testing to document persistent acid exposure. Furthermore, postoperative symptoms of heartburn, dysphagia, and abdominal bloating were rated as none to mild in the majority of patients. Laparoscopic fundoplication is an effective long-term treatment for GERD, resulting in high patient satisfaction, improved quality of life, and elimination of antisecretory medicines in the majority of patients.     

Laparoscopic fundoplication for gastroesophageal reflux disease: retrospective study of functional results in 243 patients

STUDY AIM: The aim of this retrospective study was to evaluate the 38 month-results of laparoscopic fundoplication for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: Two hundred forty three consecutive patients were operated laparoscopically. The surgical procedures were complete fundoplication with division of short vessels (Nissen: 80 patients), without division of short vessels (Nissen-Rossetti: 68 patients) or partial fundoplication of 270 degrees (Toupet: 95 patients). The mean follow-up was 38 months. Functional results were evaluated in 225 patients (92.5%) using a questionnaire with visual analog scales. RESULTS: The morbidity rate was 5%, higher after Nissen procedure (6.5%). With a follow-up of 3 months: a dysphagia coted 5/10, a gas bloat syndrome coted 4/10 and colon distension present in 61% of patients, were significantly more frequent after Nissen procedure. GERD recurred early in 4.5% of patients. With a follow-up of 38 months: dysphagia rate (coted 1/10) was significantly higher after Nissen. Dysphagia still persisted in 8 patients (9%) after Nissen. Colon distension and flatulence were more present after Nissen fundoplication. GERD recurrence rate was 12%. Pyrosis was significantly higher after Toupet fundoplication. Continuous medical treatment was necessary in 19 patients (8%). The satisfaction of patients was coted 7.5/10 without difference between to the three types of fundoplication. CONCLUSION: The total laparoscopic fundoplication for GERD seems to be a safe and efficient operation. This procedure proves to be more effective than partial fundoplicature but with a grater morbidity. Whatever the type of fundoplicature, the satisfaction of patients was good.     

Situs inversus totalis: giant hiatal hernia repair by laparoscopic Collis gastroplasty and Nissen fundoplication

We report the repair of a giant hiatal hernia by laparoscopic Collis gastroplasty and Nissen fundoplication in a patient with situs inversus totalis, highlighting the unique anatomic challenges in this case. The 52-year old female patient had Kartageners syndrome, a giant hiatal hernia, and a history of chronic severe gastroesophageal reflux disease with uncontrolled regurgitation. The laparoscopic procedure was accomplished with five ports placed in a mirror-image configuration, reversed from our standard positions. After visual confirmation of the complete reversal of the intraabdominal anatomy, we performed a modified Collis gastroplasty and Nissen fundoplication. Significant technical challenges were encountered intraoperatively. To the best of our knowledge, this report is the first of its kind in the literature. The use of advanced laparoscopic techniques is highly adaptable to unusual anatomy. Laparoscopic hiatal hernia surgery is feasible in patients with situs inversus.     

Surgical therapy for Barrett's esophagus

Given the anatomic and functional defects almost universally present in patients who have BE, antireflux surgery is the most reliable means of stopping acid and nonacid (alkaline) reflux. Because patients who have BE have end-stage GERD, they require durable and reliable control of reflux, and the Hill procedure and partial fundoplication are associated with unacceptably high failure rates. In addition, there is mounting evidence that the success rates for Nissen fundoplication are lower in patients who have BE than in patients who have less severe GERD. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, patients who have BE must be considered at risk for having a short esophagus. The failure rate may be reduced by the liberal addition of a Collis gastroplasty, but the long-term consequences of acid-secreting mucosa left above the fundoplication in patients who have BE remain unclear. Patients suspected of having a short esophagus on the basis of a large hiatal hernia, stricture, or long-segment BE should be considered for a transthoracic approach to their fundoplication, as this affords good esophageal mobilization and may obviate the need for a gastroplasty. Surgeons must pay particular attention to their own and published results and continue to refine the operation to maximize the likelihood of a good outcome in this difficult group of patients. It is only with excellent control of reflux that any differences in the risk of progression to dysplasia and cancer become apparent, and significant, between medically and surgically treated patients.     

Comparison of patient satisfaction after redo and primary fundoplications

Background: Although much has been written about the results and patient satisfaction with fundoplication for the treatment of gastroesophageal reflux disease, the reports have focused primarily on surgical successes. With the growing number of fundoplications being performed, more patients are requiring reoperation because of recurrent symptoms or side effects. Reports of success rates for reoperation are available, but information regarding patient satisfaction is limited. Methods: All the patients undergoing fundoplication at our institution were sent short-form health surveys (SF-12), Gastroesophageal reflux disease–specific quality-of-life questionnaires (QOLRAD), and queries regarding long-term satisfaction. Results: Between November 1992 and July 2000, 221 patients (198 primary and 23 redo) underwent fundoplication. There were 19 open cases (3 primary and 16 redo). In the primary group, 173 patients underwent Nissen, 23 underwent Toupet, and 2 underwent Collis fundoplications. In the redo group, 12 patients underwent Nissen, 9 underwent Toupet, 1 underwent Collis, and l underwent Belsey fundoplications. Follow-up surveys were completed for 130 patients (112 primary and 18 redo) at a mean of 32.6 months (range, 0.8–98 months). In the primary group, 87% of the patients were satisfied with their operation, as compared with 75% in the redo group. There was a trend toward higher SF-12 mental scores (46 ± 12 vs 40 ± 14; p = 0.07) and QOLRAD scores (6.2 ± 1.3 vs 5.2 ± 2.0; p = 0.07) in the primary fundoplication group. There was a significant difference in the SF-12 physical scores between the groups (32 ± 13 for the primary group vs 18.5 ± 11 for the redo group; p = 0.0002). Additionally, 61% of the patients in the redo group were again using antireflux medications, whereas only 24% of the patients in the primary group were using medications again. Conclusion: Gastroesophageal reflux disease symptom scores and quality-of-life scores for patients undergoing redo fundoplication are lower than the scores of patients having primary fundoplication. Quality of life is similar between primary and redo fundoplication patients in the mental component. However, redo patients do not do as well physically more than 2 years after surgery. Presented at the Society of America Gastrointestinal Endoscopic Surgeons (SAGES), New York, New York, USA, 13–16 March 2002     

Prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: Seven-year follow-up

Laparoscopic Nissen fundoplication and proton pump inhibitor (PPI) therapy are both established treatments for gastroesophageal reflux disease (GERD). We have performed a prospective randomized study comparing these two treatments and now have long-term follow-up data. Between July 1997 and August 2001, 183 patients in Norwich took part in a randomized controlled trial comparing laparoscopic Nissen fundoplication and PPI therapy for the treatment of GERD. In October 2005, patients were followed up and asked to complete a reflux symptom questionnaire. Ninety-one patients were randomized to have surgery and 92 to have optimized PPI therapy. After 12 months, those who had been randomized to PPI were offered the opportunity to have surgery. Fifty-four patients went on to have antireflux surgery; the remaining 38 did not. In all three groups, there was a significant improvement in symptom score after the initial 12 months (P<0.01; Mann-Whitney U test). However, those who later had surgery despite having had optimal PPI treatment beforehand experienced further symptomatic improvement (P<0.01) at long-term follow-up (median 6.9 years, range, 4.3–8.3). Both optimal PPI therapy and laparoscopic Nissen fundoplication are effective treatments for GERD. However, surgery offers additional benefit for those who have only partial symptomatic relief whilst on PPIs. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006 (oral presentation).     

Obesity is not a contraindication to laparoscopic nissen fundoplication

Obesity has been shown to be a significant predisposing factor for gastroesophageal reflux disease (GERD). However, obesity is also thought to be a contraindication to antireflux surgery. This study was undertaken to determine if clinical outcomes after laparoscopic Nissen fundoplications are influenced by preoperative body mass index (BMI). From a prospective database of patients undergoing treatment for GERD, 257 consecutive patients undergoing laparoscopic Nissen fundoplication were studied. Patients were stratified by preoperative BMI: normal (<25), overweight (25-30), and obese (>30). Clinical outcomes were scored by patients with a Likert scale. Overweight and obese patients had more severe preoperative reflux, although symptom scores for reflux and dysphagia were similar among all weight categories. There was a trend toward longer operative times for obese patients. Mean follow-up was 26 ± 23.9 months. Mean heartburn and dysphagia symptom scores improved for patients of all BMI categories (P < 0.001). Postoperative symptom scores and clinical success rates did not differ among BMI categories. Most patients undergoing laparoscopic Nissen fundoplication are overweight or obese with moderate dysphagia and severe acid reflux. Clinical outcomes after laparoscopic Nissen fundoplication did not differ among patients stratified by preoperative BMI. Obesity is not a contraindication to laparoscopic Nissen fundoplication. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004     

Extended transmediastinal dissection: an alternative to gastroplasty for short esophagus

HYPOTHESIS: The significance of short esophagus and its impact on failure after laparoscopic Nissen fundoplication are unknown. Although patients with severe esophageal shortening that requires Collis gastroplasty comprise a small percentage of patients undergoing fundoplication, we hypothesize that patients with moderate esophageal shortening requiring extended mediastinal dissection make up a larger subgroup and that extended laparoscopic mediastinal dissection is a good treatment strategy for such patients. DESIGN AND SETTING: Retrospective comparative analysis in an academic and private practice-based tertiary referral center. PATIENTS: A total of 205 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernias over 4 years. Outcomes in patients requiring either a type I (<5 cm) or type II (>5 cm) mediastinal dissection were compared. INTERVENTIONS: Laparoscopic Nissen fundoplication with or without extended mediastinal dissection and esophageal physiology testing. MAIN OUTCOME MEASURES: Symptom assessments, operative reports, and outcomes were prospectively recorded on standardized data sheets. Postoperative symptom assessment and esophageal physiology testing were performed. RESULTS: A total of 133 (65%) of the 205 patients underwent type I dissection, and 72 (35%) of the 205 patients underwent type II dissection. Failure occurred in 15 (11%) of 133 patients and 6 (10%) of 72 patients, respectively. The presence of a large hiatal or paraesophageal hernia predicted the need for type II dissection. CONCLUSIONS: No difference was seen in failure rates between patients who required a type II dissection and those who did not. This finding suggests that aggressive application of laparoscopic transmediastinal dissection to obtain adequate esophageal length may reduce fundoplication failure in patients with esophageal shortening and provide a success rate similar to that of patients with normal esophageal length. More liberal application of Collis gastroplasty in these patients is not warranted.     

Laparoscopic Collis gastroplasty and Nissen fundoplication

Background: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In our experience, ∼20–25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap. Methods: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying the technique clinically in 1996. We performed 220 laparoscopic antireflux procedures between January 1996 and July 1997. Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy. Results: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed by patient-initiated symptom scores. Conclusions: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of a minimally invasive approach. Received: 8 September 1997/Accepted: 17 December 1997     

Does major depression in patients with gastroesophageal reflux disease affect the outcome of laparoscopic antireflux surgery?

Background: It is known that psychological factors can affect end points of surgical treatment. The current study aimed to evaluate the outcome of laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who experience concomitant major depression in comparison with GERD patients who have no known comorbidity. Methods: Among a sample of more than 550 patients who underwent LARS, a group of 38 GERD patients with concomitant major depression (MD) were included in this study. The patients included 24 women and 14 men, with a mean age of 51 years. A group of 38 control patients (non-MD) matched in terms of age, gender, and esophageal manometry findings was selected from the database for comparison of surgical outcomes between patients with GERD accompanied by concomitant major depression and GERD patients with no known comorbidity. In each group, 23 patients received a Toupet fundoplication and 15 patients underwent a "floppy" Nissen fundoplication. The following factors were evaluated before surgery, 3 months afterward, and 1 year after LARS: symptoms (heartburn, regurgitation, chest pain, bloating, and dysphagia), quality of life (Gastrointestinal Quality of Life Index [GIQLI]), lower esophageal sphincter pressure (LESP), and 24-h pH monitoring (DeMeester score). Results: Before and after surgery, there were no significant differences between the two groups in terms of LESP and DeMeester score. Preoperative GIQLI showed significant differences (p < 0.05) between the two groups (MD group, 71.8 ± 8.6 vs non-MD group, 91.1 ± 9.8), and significant differences (p < 0.01–0.001) between the mean data and that for healthy individuals (122.6 ± 8.5). The GIQLI scores had improved significantly at 3 months and at 1 year after surgery (p < 0.05–0.001) in all the patients (1 year postoperatively: MD group, 99.3 ± 8.6 vs non-MD group, 121.9 ± 9.7). Before surgery, when symptoms were compared between the two groups, significant differences (p < 0.001) were found in the percentage of chest pain (81.6% vs 37.4%) and bloating (92.2% vs 37.4%), showing that these symptoms were more predominant and graded as much more severe among patients with MD. In both groups, all the symptoms but dysphagia showed a significant improvement in severity (p < 0.05–0.0001). A comparison of both groups postoperatively showed that significant differences were still present in chest pain (44.7% vs 2.6%), bloating (68.4% vs 18.4), and dysphagia (50.1% vs 2.6%). A significant difference (p < 0.001) was observed only in patients with major depression and depending on the kind of wrap procedure (Nissen vs Toupet), showing that dysphagia (78.9% vs 21.1%) and chest pain (82.4% vs 17.6%) were much more predominant in patients who underwent "floppy" Nissen fundoplication. Conclusions: Even if they are good surgical candidates from a physiologic point of view, GERD patients with concomitant major depression should be selected carefully. In these patients, LARS can normalize physiologic data, but some patients have demonstrated less symptomatic relief, suffered from postoperative dysphagia, and showed less quality-of-life improvement. Eventually, laparoscopic Toupet fundoplication used with these patients could result in a better subjective outcome.     

Laparoscopic Nissen fundoplication in infants and children: analysis of 106 consecutive patients with special emphasis in neurologically impaired vs. neurologically normal patients

Background The laparoscopic Nissen fundoplication has become a frequently performed procedure in infants and children who suffer from gastroesophageal reflux disease (GERD). In this study we describe our 8-year experience with 106 consecutive laparoscopic Nissen fundoplications. Methods From January 1994 to May 2002, we included 106 consecutive patients (57 neurologically normal (NN) and 49 neurologically impaired (NI)). The indications were symptomatic GERD, pulmonary symptoms or a combination of both. Patient’s outcome was assessed by symptom evaluation, technical examinations and a questionnaire. Results Mortality was 0% and conversion rate was 2.8%. Major postoperative complications occurred in 12 patients, mostly neurologically impairment. Dysphagia occurred in 23 patients of which 4 required dilatations and 2 a redo Nissen. Gas bloating occurred in 15 children, with spontaneous regression in all. Recurrent pneumopathies were seen in four children. Documented recurrence of reflux occurred in three symptomatic patients. Redo laparoscopic surgery was performed in six patients. A questionnaire was sent to each patient’s parents. This showed that most patients had a normal or clearly improved quality of life (93.1% NN, 90.5% NI). Most patients were satisfied with the result and up to 39.5% gave a maximum satisfaction score. Conclusion The laparoscopic Nissen fundoplication can safely be performed with a low conversion rate and no surgical mortality in neurologically normal and neurologically impaired children. Neurologically impaired children are more susceptible to per- and postoperative complications. A good quality of life and a high index of satisfaction could be achieved in most patients.     

Does Barrett's esophagus impact outcome after laparoscopic Nissen fundoplication?

BACKGROUND: This study was undertaken to compare patients with gastroesophageal reflux disease (GERD) with or without Barrett's esophagus for severity and frequency of symptoms and their response to antireflux surgery. METHODS: Eighty patients with GERD and Barrett's esophagus and 93 concurrent patients with GERD alone, all of whom underwent laparoscopic Nissen fundoplication, were compared by using symptom scores graded by a Likert scale. RESULTS: Before fundoplication, patients with Barrett's esophagus had higher DeMeester scores. Symptom scores were not different for patients with versus without Barrett's esophagus before or after laparoscopic Nissen fundoplication. CONCLUSIONS: Before and after fundoplication, patients with Barrett's esophagus, despite more severe reflux, have symptoms nearly identical in frequency and severity when compared with patients with GERD alone. Regardless of presence of Barrett's, all improve dramatically with laparoscopic Nissen fundoplication. Barrett's esophagus does not impact presentation before or outcome after laparoscopic Nissen fundoplication.     

Symptom-focused results after laparoscopic fundoplication for refractory gastroesophageal reflux disease—a prospective study

Background and aims  Symptoms of gastroesophageal reflux disease (GERD) are common in the general population. Although the results of laparoscopic fundoplication are well documented, there have been no reports on the operative outcome in patients refractory to or with only partial response to medical therapy for GERD. Patients–methods  Thirty-two patients with GERD, whose continuous high doses of medical treatment with proton-pump inhibitors produced no or only partial symptom relief, underwent laparoscopic Nissen fundoplication. Symptoms were evaluated with a standardized questionnaire preoperatively and 12 months after surgery. Results  The complete follow-up evaluation was obtained in 30 out of the 32 patients. The main symptoms before surgery were regurgitation (93%), heartburn (60%), epigastric pain (47%), and globus sensation (47%). All patients were relieved from heartburn, vomiting, and globus sensation. Dysphagia was relieved in 75% of the patients and regurgitation in 86%. Dysphagia as a new symptom occurred in 9%. The overall morbidity rate was 16%. Patient satisfaction rate was 87%. Conclusion  Laparoscopic fundoplication seems to be an effective treatment for severe, drug-resistant GERD. The high patient satisfaction rate and the positive therapeutic response in 95% of patients justify this procedure in this strictly selected group of patients.     

Assessment of Quality of Life after Laparoscopic Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease

Background In this study two different quality of life items are compared, and correlation of patient satisfaction with preoperative and postoperative symptoms after laparoscopic Nissen fundoplication (LNF) for chronic gastroesophageal reflux disease is evaluated. Materials and Methods Between December 2002 and December 2004, 60 patients with a diagnosis of chronic gastroesophageal reflux disease scheduled for laparoscopic Nissen fundoplication were recruited prospectively and volunteered to participate in this study. Patients underwent endoscopy, and their disease-specific symptoms were scored on a scale. Quality of life was measured preoperatively and in the first and sixth postoperative months with two questionnaires: Short Form-36 (SF 36) (preoperatively) and the Gastroesophageal Reflux Disease—Health-Related Quality of Life (GERD-HRQL) (postoperatively). Results In more than 90% of the patients, typical symptoms (regurgitation and pyrozis) were controlled postoperatively (p < 0.001). In the first postoperative month, however, dysphagia (early dysphagia) was seen in 46 (76%) patients, whereas in the sixth postoperative month (late dysphagia) its incidence decreased to only 2 (3.3%) patients. Similarly, in the first postoperative month 42 (70%) patients had gas bloating, but the incidence of this symptom decreased to 26 (43.3%) patients by the sixth month (p = 0.01). The quality-of-life measurements obtained from both SF 36 and GERD-HRQL showed that quality of life of the patients improved significantly in the related domain of each item after surgery (p < 0.001). Conclusions Laparoscopic Nissen fundoplication is an effective operation that controls the typical symptoms and improves the quality of life of patients, but new-onset symptoms affect postoperative well-being. For closer evaluation of the benefits of the operation, we need new questionnaires that comprehensively evaluate the symptom spectrum of GERD both preoperatively and postoperatively.