Nissen and Toupet fundoplications effectively inhibit gastroesophageal reflux irrespective of natural anatomy and function

Background: The physiology of Nissen fundoplication (NF) and Toupet fundoplication (TF) is controversial. The aim of this study was to determine the contribution of elevated intragastric pressure to the antireflux mechanism after surgically created fundoplication in explanted porcine stomachs. Methods: The stomachs and 6–8 cm of distal esophagus were removed from 15 pigs and placed in anatomic position. Five NF, 2 cm in length with three interrupted sutures, were performed, taking full-thickness bites of stomach and partial-thickness bites of esophagus around a 60 French dilator. Five 270° TF 2 cm in length with six interrupted sutures were performed taking full-thickness bites of stomach and partial-thickness bites of esophagus around a 60 French dilator. Each stomach served as its own control. The pylorus was tied off and the stomach was inflated with Ringer's lactate while the pressure was monitored. Results: Before NF, reflux could be easily induced with a mean intragastric pressure of 5.5 ± 3.7 mmHg. After NF reflux could not be induced but the sutures pulled out of the stomach at a mean pressure of 36.8 ± 11.7 mmHg (p < 0.01 vs control). Before TF, reflux could easily be induced with a mean intragastric pressure of 3.0 ± 3.0 mmHg. After TF, reflux could not be induced and the sutures pulled out of the esophagus or stomach with a mean pressure of 30.8 ± 9.0 mmHg (p < 0.01 vs control). Porcine stomachs in vivo are resistant to reflux, but when explanted they reflux easily. NF and TF are so effective at interrupting reflux that the sutures tear out instead of allowing reflux. Conclusions: While not yet statistically significant, it appears that sutures tear out of the esophagus (TF) more readily than they tear out of the stomach (NF). TF and NF prevent reflux in the absence of anatomic or functional components of the lower esophageal sphincter.     

The influence of surgical technique on clinical outcome of laparoscopic Nissen fundoplication

Background: During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided, the crura reapproximated, or the wrap sutured to the crus. Methods: Since first performing LNF, we have consistently utilized a <2.5-cm wrap performed over a >50 Fr dilator. Other technical details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF, two were converted to open operation (2%). In the remaining 103 patients with ≥3-month follow-up (mean 17 months), the initial 46 (group 1; 45%, mean age ± SEM = 47 ± 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients (65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the subsequent 57 LNFs (group 2; 55%, 47 ± 2 years), all patients underwent SGV division, posterior crural closure, and suture of the wrap to the crus. Results: Clinical outcome at ≥3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and 13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of these technical variables were significantly related to the improved outcome in group II. Conclusion: Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure of the crura, and fixation of the wrap to the crus during LNF. Received: 28 March 1996/Accepted: 11 June 1996     

腹腔镜Nissen胃底折叠术治疗老年重度胃食管反流病的长期疗效观察

目的通过对老年重度胃食管反流病(gasroesophageal reflux disease,GERD)患者行腹腔镜Nissen胃底折叠术(laparoscopic Nissen fundoplication,LNF)的长期随访结果和对照组对比分析,评价该方法远期的安全性和有效性。 方法回顾分析自2005年1月至2011年1月因重度GERD行LNF治疗的老年患者21例,与同期对照组44例对比,分析两组患者的远期治疗效果。 结果两组患者均成功行LNF治疗,术后早期症状均获得缓解,手术时间和术后短期并发症两组比较无明显差异,术后胃镜见食管炎症状均较术前有所好转。术后平均随访7.4年,两组复发率比较无统计学差异,老年组远期吞咽困难发生率高于对照组。 结论LNF治疗老年重度GERD安全、有效,但远期吞咽困难发生率较高于对照组。     

Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy

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

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

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

达芬奇机器人辅助与腹腔镜Nissen胃底折叠术治疗成人胃食管反流病的Meta分析

目的系统评价达芬奇机器人辅助Nissen胃底折叠术(robot-assisted Nissen fundoplication,RAF)与传统腹腔镜Nissen胃底折叠术(conventional laparoscopic Nissen fundoplication, CLF)比较治疗成人胃食管反流病(gastroesophageal reflux disease, GERD)的有效性和安全性。 方法计算机系统检索Pubmed、EMbase、Cochrane Library、Web of science、CNKI、WanFang Data和CBM数据库,同时追溯相关文献的参考文献,查找RAF与CLF比较治疗成人GERD的随机对照研究和队列研究,检索时间均限定为从建库至2018年6月30日。由2位研究员独立筛选文献、提取资料并进行纳入研究的质量评价,采用Stata/SE 12进行Meta分析,通过I²统计量反映纳入研究的异质性。 结果共纳入11篇文献,累计683例患者,其中RAF组267例、CLF组416例。Meta分析结果表明,与CLF组相比,RAF组手术时间更长(WMD＝28.83, 95%CI：12.89～44.76, P<0.05)、费用较高(P<0.05);两组围手术期并发症发生率、术中中转率、术后气胸发生率、术后吞咽困难发生率、再手术率、住院时间比较,差异无统计学意义(P>0.05)。 结论研究结果表明,RAF在治疗成人GERD中有着良好的安全性和有效性。然而,鉴于RAF更长的手术时间和更高的手术费用,使其在临床上应用受到限制。     

A prospective multicenter study on laparoscopic treatment of gastroesophageal reflux disease in Italy

Background: A national survey was undertaken by the Italian Society for Laparoscopic Surgery to investigate the prevalence, indications, conversion rate, mortality, morbidity, and early results of laparoscopic antireflux surgery. Methods: Beginning on January 1, 1996, all of the centers taking part in this study were asked to complete a questionnaire on each patient. The questionnaire was divided into four parts and covered such areas as indications for surgery and preoperative workup, type of operation performed and certain aspects of the surgical technique, conversions and their causes, intraoperative and postoperative complications (within 4 weeks), and details of the postoperative course. The last part of the questionnaire focused on the follow-up period and was designed to gather data on recurrence of preoperative symptoms, postoperative symptoms (dysphagia, gas bloat), and postoperative test findings. Results: As of June 30 1998, 21 centers were taking part in the study and 621 patients were enrolled, with a median of 27 patients per center (less than one patient/month). The most popular technique was the Nissen-Rossetti (52%), followed by the Nissen (33%) and Toupet procedures (13%). Other techniques, such as the Dor and Lortat-Jacob, were used in the remainder of cases. Patients who received a Toupet procedure had a higher incidence of defective peristalsis (p < 0.05). The conversion rate to open surgery was 2.9%. The most common causes of conversion were inability to reduce the hiatus hernia or distal esophagus in the abdomen and adhesions from previous surgery. Perforation of the stomach and esophagus occurred in <1% of patients. Mortality was nil. Postoperative complications were observed in 7.3% of cases. The most common complication was acute dysphagia (19 patients), which required reoperation in 10 patients. No differences in the incidence of acute dysphagia were found for the different surgical techniques employed. Follow-up data were obtained for 319 patients (53%): 91.5% of the patients remained GERD symptom–free; severe esophagitis (grade 2–3) healed in 95% of the patients; lower esophageal sphincter (LES) manometric characteristics (pressure, abdominal length, and overall length) improved significantly after surgery (p < 0.005); and acid exposure of the distal esophagus decreased. Conclusions: Laparoscopic antireflux surgery has no mortality and a low morbidity. Symptoms and esophagitis are resolved in >90% of patients. Despite these favorable results, however, this type of surgery is not yet as widely employed in Italy as in other countries. Received: 12 February 1999/Accepted: 8 June 1999     

Day-case laparoscopic Nissen fundoplication

Introduction   Nissen fundoplication has been performed laparoscopically for over 15 years, being associated with shorter hospital stay and fewer complications than conventional open surgery with good long-term outcomes. Day-case laparoscopic Nissen fundoplication (LNF) is rarely performed in the UK and most series in the literature report length of stay >2 days. Methods   The objective of this study was to examine the safety and efficacy of day-case LNF. The clinical records of all patients undergoing LNF under the care of three surgeons in a district general hospital (DGH) during a 5-year period (January 2003 to December 2007) were reviewed to examine length of stay, complications, length of procedure, grade of operating surgeon and symptoms on follow-up. Results   One hundred thirteen day-case LNFs were recorded in this series. Day-case LNF patients had median age of 45 years (range 20–68 years, 65% (64.6%) male) and 98% were American Society of Anesthesiologists (ASA) grade I or II. Twenty-one cases (19%) were performed by higher surgical trainees. Median operative time was 54 minnutes (range 25–120 min). Only one perioperative complication (port-site bleed) occurred, treated without prolonging length of stay. The proportion of all LNF performed as day cases increased from 8% to 52% during the study period. Median operative time has significantly reduced from the first 20 consecutive LNF cases to the latest 20 cases [65 min (range 40–120 min) versus 48 min (range 25–72 min); p = 0.037]. At follow-up (median 7 weeks, range 2–31 weeks) 82% of patients had improvement in all presenting symptoms. Eight patients had postoperative complications [wound infection (n = 2), persistent regurgitation requiring laparoscopic division of a gastric band adhesion (n = 1), dysphagia (n = 5 with two patients requiring redo partial fundoplication and one patient requiring dilatation) and there were no conversions to open surgery. Conclusion   Day-case LNF is safe and effective for treating selected patients with gastroesophageal reflux disease (GERD) in a DGH. The proportion of day-case LNFs is increasing in our unit. Half of the LNFs in a DGH can be done as day cases. Experience is associated with a significant reduction in operative time.     

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).     

Patterns of success and failure with laparoscopic Toupet fundoplication

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

Recurrence after laparoscopic and open Nissen fundoplication

Background: Laparoscopic Nissen fundoplication as treatment for gastroesophageal reflux disease (GERD) in adults has a reported recurrence rate of 2–17%. We investigated the rates and mechanisms of failure after laparoscopic Nissen fundoplication in children. Methods: All patients who underwent a laparoscopic Nissen fundoplication for GERD and who subsequently required a redo Nissen were reviewed (n = 15). The control group consisted of the most recent 15 patients who developed recurrent GER after an open Nissen, fundoplication. Results: Between 1994 and 2000, laparoscopic Nissen fundoplication was performed in 179 patients. Fifteen patients (8.7%) underwent revision. The mechanisms of failure were herniation in four patients, wrap dehiscence in four, a too-short wrap in three, a loosened wrap in two, and other reasons in two. The reoperation was performed laparoscopically in five patients (33%). The failure mechanisms were different in the open patients: eight were due to slipped wraps; three to dehiscences; and two to herniations. Conclusion: The failure rate after laparoscopic Nissen is acceptably low. A redo laparoscopic Nissen can be performed safely after an initial laparoscopic approach.     

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease

Background It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients.Methods From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 ± 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 ± 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients’ satisfaction with surgery. The data of a complete 5-year follow-up are available.Results There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients’ satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 ± 11.6 points/EGD-negative vs 93.8 ± 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 ± 8.5 for EGD-negative vs 120.9 ± 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 ± 8.5).Conclusion We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.Poster presented at the 11th International Congress of the European Association for Endoscopic Surgery, Glasgow, 2003     

Ambulatory laparoscopic fundoplication

Background: Increasingly larger series of laparoscopic fundoplications (LF) are being reported. A well-documented advantage of the laparoscopic approach is shortened hospital stay. Most centers report typical lengths of stay (LOS) for LF of 2–3 days. Our success with LF with a LOS of 1 day led to an attempt at performing LF on an ambulatory basis. Methods: Sixty-one consecutive patients with appropriate criteria for LF underwent surgery at our institution. Patients were counseled by the authors as to the usual postop course and progression of diet. All patients received preemptive analgesia (PEA) consisting of perioperative ketorolac and preincisional local infiltration with bupivicaine. Anesthetic management included induction with propofol, high-dose inhalational anesthetics, minimizing administration of parenteral narcotics, and avoidance of reversal of neuromuscular blockade. Immediate postop pain management included parenteral ketorolac and oral hydro- or oxycodone. All patients were given oral fluids and soft solids after transfer from the recovery room to the postoperative observation unit. Two patients were excluded from ambulatory consideration due to excessive driving distance from our hospital. Another two were hospitalized for observation after experiencing intraoperative technical problems. Results: Of 57 patients in whom same-day discharge was attempted, there were three failures requiring overnight hospitalization: All were due to pain and nausea; one patient also suffered transient urinary retention. There were no adverse outcomes related to early discharge, and there were no readmissions. One patient returned to the emergency room after delayed development of urinary retention. Median time from conclusion of operation to discharge was less than 5 h. No patients expressed dissatisfaction with early discharge on follow-up interview. Conclusions: LF can be safely performed as an ambulatory procedure. Analgesic and anesthetic management should be tailored to minimize nausea and provide adequate pain control. Received: 1 April 1996/Accepted: 29 May 1997     

Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective?

Background: The elderly have prevalence rates and clinical features of gastroesophageal reflux disease (GERD) similar to those in younger individuals, but the role of laparoscopic antireflux surgery (LARS) in the elderly has not been clearly established. The purpose of this study was to determine if the results of LARS in the elderly are comparable with those in younger patients. Methods: All patients undergoing LARS for GERD at the Washington University Medical Center were entered prospectively into a computerized database. Between May 1992 and June 1998, 339 patients underwent LARS and were divided into two groups based on age: nonelderly (ages, 18–64 years; n= 303) and elderly (age, ≥65 years; n = 36). Data were expressed as mean ± standard deviation (SD) and statistical analysis was performed. Results: Elderly patients had a higher American Society of Anesthesiology (ASA) score (2.3 ± 1.5) and a longer hospital stay (2.1 ± 0.2 days) than the younger group (ASA, 1.9 ± 0.5; hospital stay, 1.6 ± 0.9 days; p < 0.001). Operation times averaged 154 ± 68 min in the elderly compared with 134 ± 49 min in the nonelderly (p= NS). Grade I complications occurred significantly more frequently in the elderly (13.9%) than in the nonelderly (2.6%), but the incidence of grade II complications was similar between the groups (elderly 2.8% vs nonelderly 2.7%). There were no grade III complications in either group, but there was one death in the nonelderly group. At follow-up ranging to 81 months (median, 27 months), the two groups had similar low incidences of heartburn and dysphagia. Anatomic failures of LARS developed in 19 nonelderly patients (6.2%) compared with 2 elderly patients (5.5%; p= NS). Conclusions: As shown in this study, LARS is safe and effective in elderly patients with GERD. Age older than 65 years should not be a contraindication to laparoscopic antireflux surgery in properly selected patients. Received: 3 March 1999/Accepted: 2 April 1999     

Are esophagocrural sutures needed during laparoscopic fundoplication: A prospective randomized trial

Purpose

Historically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures.

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.     

Immediate and delayed effects of laparoscopic Nissen fundoplication on pulmonary function

Background: An effort was made to assess the respiratory outcomes of laparoscopic Nissen fundoplication (LNF). Methods: Prospective follow-up of 69 patients undergoing LNF for gastroesophageal reflux disease. Outcomes included pulmonary function testing, 24-h pH recording, esophageal manometry, and symptom assessment. Results: There was an improvement (p < 0.0001) in heartburn and cough scores. There was a significant fall in spirometry (p < 0001), diffusing capacity (p < 0.0001), and respiratory muscle strength (p < 0.0001) 36 h after surgery, which had returned to baseline by 1 month. At 6 months, the patients (n= 16) with impaired preoperative diffusing capacity showed improvement (17.8 ± 3.7 to 19.8 ± 4.6 ml/min/mmHg, p= 0.0245). Conclusion: Patients undergoing LNF have impaired gas exchange before surgery which tends to improve 6 months after surgery. There is an early reversible impairment in respiratory function due to diaphragm dysfunction. Patients with a preoperative 1-s forced expired volume > 1.5, or 50% predicted, are unlikely to develop signficant early respiratory complication. Received: 22 April 1996/Accepted: 9 July 1996     

Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn

Background: Heartburn and gastroesophageal reflux disease (GERD) affects approximately 25–50% of morbidly obese patients. Although objective physiologic testing has been reported extensively in patients following Nissen fundoplication, there are no previous reports of such testing in morbidly obese patients. A life-saving surgical alternative for the morbidly obese patient is gastric bypass surgery, which usually improves heartburn symptoms in addition to many serious health conditions such as diabetes, hypertension, and sleep apnea. We hypothesized that, in morbidly obese patients, gastric bypass surgery would be as effective as Nissen fundoplication in reducing both heartburn symptoms and esophageal acid exposure, as reflected by the DeMeester score. Methods: Between 1995 and 2000, all patients undergoing laparoscopic Nissen fundoplication (LN) and laparoscopic gastric bypass (LGB) in our practice underwent preoperative and postoperative esophageal physiologic testing. Patients were included in this study that were morbidly obese and had significant heartburn symptoms or objective evidence of acid reflux, and had repeat esophageal physiologic testing after either LN or LGB. Data were obtained through retrospective review of prospectively collected data. Results: Twelve patients met the inclusion criteria: six patients who had LN and six who had LGB. The mean body mass index (BMI) was 55 kg/m² in the LGB group and 39.8 in the LN group. After surgery, the mean DeMeester score decreased from 64.3 to 2.8 in the LN group (p = 0.01) and from 34.7 to 5.7 in the LGB group (p = 0.1). Both groups mean postoperative DeMeester scores were normal after surgery, and there was no significant difference between the two groups (p = 0.3). Both groups experienced a significant improvement in heartburn symptoms postoperatively. The mean preoperative symptom score improved from 3.5 to 0.5 in the LN group (p = 0.01) and from 2.2 to 0.2 in the LGB group (p = 0.003). There was no difference in the mean postoperative symptom scores between the groups (p = 0.35). After surgery, mean LES resting pressures increased from 12.9 to 35.5 (p = 0.003) in the LN group and from 23.6 to 29.7 (p = 0.45) in the LGB group. There were no complications in either group. Conclusion: Results of this study show that laparoscopic gastric bypass and laparoscopic Nissen fundoplication are both effective in treating heartburn symptoms and objective acid reflux in morbidly obese patients. The health benefits of weight loss after laparoscopic gastric bypass should make this operation the procedure of choice in the morbidly obese patient with heartburn.     

Pledgeted mattress sutures reduce recurrent reflux after laparoscopic Nissen fundoplication

Introduction

In response to a perceived increase in the incidence of recurrent reflux after adopting the laparoscopic Nissen fundoplication, we adjusted our technique to include the use of pledgeted, horizontal mattress sutures for crural closure and wrap construction.

Methods

We assessed the impact of this technical modification in children who underwent laparoscopic fundoplication between 1997 and 2007 at a large children's hospital. The medical history, indications, technical details, and outcomes were reviewed. Differences between groups were assessed with χ², logistic regression, and Kaplan-Meier analysis.

Results

A total of 384 subjects were identified. Neurologic deficits were present in 77%. The crural closure and wrap were constructed with simple sutures in 226 and with pledgeted, horizontal mattress sutures in 158. The cumulative incidences of recurrent reflux, gagging/retching, wrap failure on imaging studies, and reoperation were significantly greater with the use of simple sutures (P < .01, .03, < .01, and < .01, respectively). Kaplan-Meier analysis confirmed a significant difference in the probability of recurrent reflux with simple sutures despite a significant difference in postoperative follow-up. Operative time was the same with both methods.

Conclusions

The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication may reduce the incidence of recurrent reflux.