Predicting patient dissatisfaction following laparoscopic Nissen fundoplication: an analysis of symptoms

Background

Nissen fundoplication is a well-established treatment for gastroesophageal reflux disease (GERD) with a high success rate and a long-lasting effect. However, the literature reports that a persistent, small group of patients is not fully satisfied with the outcome. Identifying this patient group preoperatively would prevent disappointment for both patients and surgeon. This has proven difficult since dissatisfaction was related to nondisease-related factors instead of typical symptoms of GERD or the objective findings of investigations. We studied our series of patients who underwent laparoscopic Nissen fundoplication to identify predictors of patient dissatisfaction and the impact of surgery on individual symptoms.

Methods

All consecutive private patients undergoing Nissen fundoplication were asked to complete a preoperative and postoperative questionnaire concerning symptoms, medication use, and satisfaction. Demographics, investigations, complications, and reinterventions were documented. A standard laparoscopic Nissen fundoplication was performed.

Results

Over an 11-year period 222 patients underwent surgery for GERD. The postoperative response rate to the questionnaire was 77.5 %, with dissatisfaction reported by 12.8 % of the patients. Of these dissatisfied patients, only 13.6 % had proven disease recurrence. Both satisfied and dissatisfied patients presented with an inconsistent pattern of symptoms. None of the preoperative symptoms and investigations or the patient’s age and gender was predictive of postoperative dissatisfaction. Only postoperative heartburn, regurgitation, and bloating significantly correlated with patient dissatisfaction.

Conclusion

Nissen fundoplication has a very high satisfaction rate overall. A small percentage of patients are not fully satisfied and dissatisfaction is associated with reported persistent symptoms and side effects of surgery rather than gender or preoperative symptom pattern, severity of esophagitis, or total 24 h esophageal acid exposure.     

Causes of dissatisfaction after laparoscopic fundoplication: the impact of new symptoms, recurrent symptoms, and the patient experience

Background

Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication.

Methods

All patients undergoing laparoscopic fundoplication in the authors’ series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from “very satisfying” to “very unsatisfying.” Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported.

Results

Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication.

Conclusions

Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time.     

Laparoendoscopic single site (LESS) vs. conventional laparoscopic fundoplication for GERD: is there a difference?

Background

This report details our experience with laparoendoscopic single site (LESS) fundoplication for GERD and provides a comparison to earlier contiguous patients undergoing conventional laparoscopic fundoplication.

Methods

With institutional review board approval, symptoms before and after LESS fundoplications and conventional laparoscopic fundoplications were scored by patients. Outcomes after 130 consecutive LESS fundoplications were compared to 130 contiguous consecutive outcomes after conventional laparoscopic fundoplications.

Results

Patients undergoing conventional laparoscopic vs. LESS fundoplication were very similar. There were no conversions to “open” operations and no notable complications with LESS fundoplication. Symptom reduction was broad and dramatic for patients undergoing LESS or conventional laparoscopic fundoplication; 96 % of patients who underwent LESS fundoplication scored their incision as ≥8 (1 = revolting to 10 = beautiful).

Conclusions

Relative to conventional laparoscopy, LESS surgery provides excellent resolution of symptoms without an apparent scar. In comparison to conventional laparoscopy, LESS fundoplication is as safe with similar symptom improvement and superior cosmesis.     

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

Background

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

Methods

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

Results

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

Conclusions

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.     

Early referral for 24-h esophageal pH monitoring may prevent unnecessary treatment with acid-reducing medications

Background

Gastroesophageal reflux disease (GERD) affects nearly 25 % of adults; however, an objective diagnosis is rarely established. We hypothesized that patients’ symptoms and response to acid-reducing therapy are poor predictors of the outcome of 24-h esophageal pH monitoring.

Methods

A review of 24-h esophageal pH monitoring studies performed at an ambulatory tertiary care center between 2004 and 2011 was performed. Demographics, type of GERD symptoms, and duration and response to acid-reducing medications before referral for pH monitoring were collected. DeMeester score, symptom sensitivity index (SSI), and symptom index (SI) were tabulated and compared with the patients’ symptoms and response to medical therapy.

Results

One hundred patients were included. Of all reported symptoms, only heartburn was more common in patients with positive DeMeester scores, but there were no correlations between any symptoms and SSI or SI scores. Sixty-nine percent of patients with esophageal symptoms had a positive DeMeester score compared with only 29 % of patients with extraesophageal symptoms (P < 0.01). Esophageal symptoms and endoscopic evidence of GERD significantly increased the likelihood of having a positive DeMeester score, but they had no influence on SSI or SI scores. There was no correlation between response to acid-reducing medications and DeMeester, SSI, or SI scores. A total of 536 person-years of acid-reducing medications were prescribed to the study population, of which 151 (28 %) were prescribed to patients who had a negative pH study.

Conclusions

Extraesophageal symptoms and response to empiric trials of acid-reducing medications are poor predictors of the presence of GERD and the DeMeester score is more likely to identify GERD in patients who met other empiric diagnostic criteria than SSI or SI. Early referral for 24-h esophageal pH monitoring may avoid lengthy periods of unnecessary medical therapy.     

Revision of failed traditional fundoplication using EsophyX® transoral fundoplication

Background

Laparoscopic revision of failed traditional fundoplication is difficult and involves risk of gastric, esophageal, and vagal nerve injury that is higher than that of the primary fundoplication. This study assessed feasibility and clinical outcomes of the transoral approach to revision of loose Nissen.

Methods

Between November 2009 and August 2011, a total of 11 patients underwent transoral repair as opposed to 70 patients who underwent laparoscopic or open revision of a failed fundoplication. Subjective and objective outcomes were evaluated with the GERD health-related quality of life (GERD-HRQL) questionnaire and the reflux symptom index (RSI) questionnaire and ambulatory pH testing. The competency of the new antireflux barrier was evaluated by endoscopy. Wilcoxon signed-rank test was used to compare pre- and postoperative variables.

Results

All 11 patients evidenced loosening of the Nissen fundoplication without evidence of hiatal failure. Mean age was 57 years, BMI was 25.1 kg/m², and 4 of 11 (36 %) were female. Indications for operation were abnormal pH-metry off PPIs (6), impedance/pH on PPIs (3), esophagitis (1), and evidence of free reflux on barium swallow (1). One patient developed a postoperative bleed requiring transfusion. Two patients had laparoscopic revision at 6 and 8 months after the transoral procedure. At a median follow-up of 14 (range = 6–28) months, 8/10 patients reported resolution of their primary symptoms. Eight patients had pH testing off PPIs both pre- and postoperatively; median % time with pH <4 improved by dropping from 8.1 % (21–4.8 %) to 0.6 % (13.4–0.01 %) (p = 0.008). Esophageal acid exposure normalized in 5/6 patients. Mean GERD-HRQL score improved significantly by dropping from 28.6 (10.6) preoperatively to 6.7 (6.1) post-TIF (p = 0.016). Mean RSI score improved more than 50 % in 5/7 patients.

Conclusion

Transoral revision of failed traditional fundoplication without herniation is technically feasible. It results in symptomatic and objective improvement of GERD without the risks of laparoscopic dissection for a majority of patients.     

Impact of Laparoscopic Sleeve Gastrectomy on Upper Gastrointestinal Symptoms

Background

Altered gastric anatomy following laparoscopic sleeve gastrectomy (LSG) is likely to induce upper gastrointestinal (GI) symptoms. Published studies, however, have focused mainly on gastroesophageal reflux disease (GERD). This study aims to evaluate LSG's impact on the prevalence of upper GI symptoms and to assess the effects of time from surgery, weight loss, and proton pump inhibitor (PPI) therapy.

Methods

The validated Rome III Criteria symptom questionnaire for upper GI symptoms, including quality of life items, has been self-administered to 97 patients who underwent LSG. Symptoms were analyzed either separately or altogether to classify patients in GERD or dyspepsia, subdivided in epigastric pain (EPS) and post-prandial distress (PDS) syndromes.

Results

Before LSG, 52.7 % of the patients were asymptomatic, 27.0 % had GERD, and 8.1 % had dyspepsia (2.7 % EPS, 5.4 % PDS). After a median follow-up of 13 months, 91.9 % of the patients complained of upper GI symptoms, the most prevalent being PDS (59.4 %). GERD prevalence did not differ before and after LSG. The only symptom strongly related to LSG was dysphagia (OR 4.7, 95 % CI 1.3–20.4, p?=?0.015), which was present in 19.7 % of the patients and mainly associated with PDS rather than GERD. GI symptoms, however, did not have a great impact on quality of life. Time from surgery, weight loss after surgery, as well as concomitant PPI, did not influence the symptoms.

Conclusions

After a median follow-up of 13 months, PDS-like dyspepsia, rather than GERD, was the main complaint, both poorly responding to PPI therapy. A longer follow-up will be necessary to evaluate their future persistency.     

Outcome of Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease in Non-responders to Proton Pump Inhibitors

Background

Gastroesophageal reflux disease (GERD) is a common public health problem. Medical treatment remains the first line of treatment of GERD. Failure of medical treatment may occur in up to 45 % of GERD patients. This study aims to evaluate the outcome of laparoscopic Nissen fundoplication (LNF) as a means of antireflux surgery in patients with poor response to anti-reflux medication.

Patients and Methods

This is a prospective study of patients who underwent LNF in the period between January 2000 and December 2010 in the Gastrointestinal Surgical Center, Mansoura University, Egypt. Patients were assessed preoperatively and postoperatively, after 1 year, by clinical examination, esophagogastroscope, barium esophagography, esophageal manometry and 24-h pH monitoring. Patient satisfaction after surgery was also graded through a questionnaire.

Results

The study population was 370 patients. 296 patients were good responders to proton pump inhibitors (PPI) while 74 patients were PPI non-responders. Preoperatively, atypical reflux symptoms were significantly more in PPI non-responders (P?=?0.006). On follow-up, PPI responders significantly reported relief of heartburn (P?=?0.01) and regurgitation (P?=?0.04). Patient satisfaction was more in PPI responders (P?=?0.04). Both groups were comparable regarding anatomical and functional assessment. Integrity of the wrap was higher in PPI responders (P?=?0.04).

Conclusion

PPI non-responders should not be precluded from LNF. Thorough assessment is mandatory to confirm GERD diagnosis. A substantial proportion of PPI failures show good response to LNF but significantly than clinical response in PPI responders. Increased likelihood of poor outcome after surgery should be discussed with the patient.     

Revisional laparoscopic antireflux surgery after unsuccessful endoscopic fundoplication

Background

Transoral incisionless fundoplication (TIF), a novel endoscopic procedure for treating gastroesophageal reflux disease (GERD), currently is under evaluation. In case of treatment failure, subsequent revisional laparoscopic antireflux surgery (rLARS) may be required. This study aimed to evaluate the feasibility, safety, and outcomes of revisional antireflux surgery after previous endoscopic fundoplication.

Methods

Chronic GERD patients who underwent rLARS after a previous TIF procedure were included in the study. Pre- and postoperative assessment included GERD-related quality-of-life scores, proton pump inhibitor (PPI) usage, 24-h pH-metry, upper gastrointestinal endoscopy, and registration of adverse events.

Results

Revisional laparoscopic Nissen fundoplication was feasible for all 15 patients included in the study without conversions to open surgery. Acid exposure of the distal esophagus improved significantly after rLARS, and esophagitis, PPI usage, and hiatal hernia decreased. Quality of life did not improve significantly after rLARS, and 33 % of the patients experienced dysphagia.

Conclusion

Revisional laparoscopic Nissen fundoplication was feasible and safe after unsuccessful endoscopic fundoplication, resulting in objective reflux control at the cost of a relatively high rate of dysphagia.     

Medically refractory gastroesophageal reflux disease in the obese: what is the best surgical approach?

Background

Obesity is a recognized risk factor for gastroesophageal reflux disease (GERD). Traditional antireflux surgery (fundoplication) may not be appropriate in the morbidly obese, especially when other effective alternatives exist (bariatric surgery).

Methods

A 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were randomly selected and emailed a link to an online survey.

Results

A total of 550 surgeons were contacted via email, and 92 (17 %) completed the survey. Of the respondents, 88 % perform laparoscopic antireflux surgery, 63 % perform bariatric surgery, and 59 % perform both. Overall, 77 % completed a minimally invasive surgery fellowship. In response to the question “Would you perform a laparoscopic fundoplication in a patient with medically refractory GERD and a BMI of ‘X’?” surgeons were less likely to offer fundoplication at a higher body mass index (BMI). The majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), followed by laparoscopic sleeve gastrectomy (6 %). Many had a morbidly obese patient with a primary surgical indication of GERD denied a bariatric procedure by their insurance company (57 %), and 35 % of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Respondents uniformly felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %).

Conclusion

When surgical treatment of GERD is indicated in an obese patient, bariatric surgery is the optimal approach, in the opinion of surgeons responding to our survey. Unfortunately, third-party payers often decline to provide benefits for a bariatric procedure for this indication. Additional data is necessary to confirm our belief that the opinions elicited through this survey are consistent with the standard of care as defined by the medical community.     

Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications

Background

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.

Methods

This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).

Results

Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and “atypical” extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.

Conclusions

Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.     

Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis

Background

Medical, endoscopic, and open/laparoscopic surgical methods are used to treat gastroesophageal reflux disease (GERD). This study aimed to perform a systematic review of randomized controlled trials comparing medical and surgical treatments of GERD in adult patients.

Methods

For the study, MEDLINE and EMBASE (1980–2012) were searched. Two reviewers independently assessed methodologic aspects and extracted data from eligible studies, focusing on patient-relevant outcomes. The primary outcomes were health-related and GERD-specific quality-of-life aspects. Standardized mean differences (SMDs) between treatment groups were calculated and combined using random-effect meta-analysis.

Results

The study identified 11 publications reporting on 7 trials comparing surgical (open or laparoscopic) and medical treatment of GERD. Meta-analysis of both quality-of-life aspects showed a pooled-effect estimate in favor of fundoplication (SMD 0.18; 95 % confidence interval [CI] 0.01–0.35; SMD 0.33; 95 % CI 0.13–0.54). Heartburn and regurgitation were less frequent after surgical intervention. However, a considerable proportion of patients still needed antireflux medication after fundoplication. Nevertheless, the surgical patients were significantly more satisfied with their symptom control and showed higher satisfaction with the treatment received.

Conclusions

This systematic review showed that surgical management of GERD is more effective than medical management with respect to patient-relevant outcomes in the short and medium term. However, long-term studies still are needed to determine whether antireflux surgery is an equivalent alternative to lifelong medical treatment.     

Long-term outcomes of reintervention for failed fundoplication: redo fundoplication versus Roux-en-Y reconstruction

Background

Redo fundoplication (RF) is the mainstay of treatment for failed fundoplication. A subset of patients with failed fundoplication requires Roux-en-Y reconstruction (RNY) for symptom relief. The aim of this study was to compare the long-term subjective outcomes between RF and RNY in patients with failed fundoplication.

Methods

After Institutional Board Review approval, retrospective review of a prospective database identified 119 RF (mean = 54.1 years, 78 women) and 64 RNY (mean = 54.8 years, 35 women) patients who underwent reoperative surgery between December 2003 and September 2009. Data variables analyzed included demographics, esophageal manometry, 24-h pH study, type of procedure, perioperative findings, complications, pre- and postoperative symptom (heartburn, regurgitation, dysphagia, and chest pain) scores (scale 0–3), and patient satisfaction score (scale 1–10). Patients with grade 2 and 3 scores were considered to have significant symptoms.

Results

Patients who underwent RNY had a significantly higher body mass index, higher mean number of risk factors, and higher preoperative severity of heartburn and regurgitation compared to the RF group. Of the 183 patients, long-term (>3 years) follow-up was available for 132 (89 RF and 43 RNY) patients. Symptom severity significantly improved after both procedures, with the exception of dysphagia in the RNY group. Overall, there was no significant difference in patients’ satisfaction between the RF and RNY groups. In subset analysis, patients with morbid obesity, esophageal dysmotility, or ≥4 risk factors have better satisfaction with RNY compared to RF (p = 0.027, 0.031, and 0.045, respectively).

Conclusions

RF and RNY have equally good patient satisfaction at 3 years follow-up. RNY may have improved outcomes in patients who are morbid obese, have esophageal dysmotility, or have four or more risk factors.     

Influence of wrap length on the effectiveness of Nissen and Toupet fundoplications: 5-year results of prospective, randomized study

Background

Long-term results in antireflux surgery may depend on fundoplication type and wrap length. We compared the outcome of two different wrap lengths among the patients undergoing partial or total fundoplications. This study is the next part of a prospective 5-year follow-up assessment.

Methods

A total of 153 patients were randomized to Nissen or Toupet 1.5- or 3-cm wrap laparoscopic fundoplication. The primary endpoint—treatment failure rate was defined as a recurrent GERD or persistent dysphagia. Intensity of heartburn, dysphagia, gas-bloating, presence of esophagitis were assessed as a secondary outcome at 1-year and 5-year follow-up.

Results

At 5-year follow-up, data were collected from 129 (85 %) patients. At 1-year follow-up, 17 (11 %) treatment failures were detected. At the end of the fifth year, the numbers reached 23 (15 %). The failures were more common in the 1.5-cm Toupet (25 %) and the 3-cm Nissen group (18.2 %). The significant difference in failure rates was found between 1.5-cm and 3-cm Toupet groups (P < 0.05). Dysphagia remained low during the follow-up in all of the groups. The prevalence of higher scores of heartburn after 5 years was detected in Nissen 1.5-cm group (20.8 %). The lowest scores were observed in Toupet 3-cm group. Bloating symptoms were more prevalent among Nissen and Toupet 3-cm group patients at 5-year follow-up. At the end of the fifth year, the prevalence of esophagitis was lower in Nissen 1.5-cm (19.3 %) and Toupet 3-cm (13.3 %) groups. The highest prevalence of esophagitis—32.4 %—was found in Toupet 1.5-cm group.

Conclusions

Nissen and Toupet fundoplication achieved sufficient control of reflux with success rate of 85 % at 5-year follow-up. There were no significant differences in the postoperative dysphagia, esophagitis, and bloating rates. However, the distribution of treatment failures leads us to conclude that 1.5-cm wrap length is insufficient in cases of posterior partial fundoplication.     

Endoscopic Evaluation of Laparoscopic Nissen Fundoplication: 89 % Success Rate 10 Years After Surgery

Background

The surgical outcome of fundoplication can be evaluated by means of esophagogastroduodenoscopy (EGDS). The literature reveals only one prior long-term follow-up series with endoscopic evaluation of the fundoplication wraps after laparoscopic Nissen fundoplication (LNF). The results achieved at a university clinic showed LNF to be more durable than open fundoplication (ONF). Previously, in our community-based hospital, the results of ONF were somewhat poorer than those achieved at a university clinic. The objective of the present study was to describe the long-term results of LNF in our hospital as regards surgical and symptomatic outcomes.

Methods

In 1997–1999, 107 LNFs were performed in our hospital. A questionnaire with symptom evaluation was mailed to all patients. The patients who agreed to participate were interviewed and underwent EGDS.

Results

Of the 107 patients, 64 (59.8 %) participated in the study (40 men, mean age 61.9 years, range 28–85 years). The mean follow-up time was 9.8 years. Seven endoscopic examinations (10.9 %) showed a defective fundic wrap; three of the patients had undergone reoperation. Fifty-eight (90.6 %) patients had no or minimal heartburn and 61 (95.3 %) had no or minimal regurgitation. Twenty-three (35.9 %) patients had moderate or severe dysphagia, and 43 (67.2 %) patients had moderate or severe flatulence. Fifty-seven (89.1 %) patients would have opted for surgery again.

Conclusions

This study contributes to the previous notion that LNF is associated with fewer surgical failures than ONF. Our results indicate that LNF can well be performed in a community-based hospital with acceptable long-term results.     

Electrical stimulation therapy of the lower esophageal sphincter is successful in treating GERD: final results of open-label prospective trial

Background

Electrical stimulation of the lower esophageal sphincter (LES) improves LES pressure without interfering with LES relaxation. The aim of this open-label pilot trial was to evaluate the safety and efficacy of long-term LES stimulation using a permanently implanted LES stimulator in patients with gastroesophageal reflux disease (GERD).

Methods

GERD patients who were at least partially responsive to proton pump inhibitors (PPI) with abnormal esophageal pH, hiatal hernia ≤3 cm, and esophagitis ≤LA grade C were included. Bipolar stitch electrodes were placed in the LES and an IPG was placed in a subcutaneous pocket. Electrical stimulation was delivered at 20 Hz, 215 μs, 3–8 mA in 30 min sessions. The number and timing of sessions was tailored to each patient’s GERD profile. Patients were evaluated using GERD-HRQL, daily symptom and medication diaries, SF-12, esophageal pH, and high-resolution manometry.

Results

24 patients (mean age = 53 years, SD = 12 years; 14 men) were implanted; 23 completed their 6-month evaluation. Median GERD-HRQL scores at 6 months was 2.0 (IQR = 0–5.5) and was significantly better than both baseline on-PPI [9.0 (range = 6.0–10.0); p < 0.001] and off-PPI [23 (21–25); p < 0.001] GERD-HRQL. Median%  24-h esophageal pH < 4.0 at baseline was 10.1 and improved to 5.1 at 6 months (p < 0.001). At their 6-month follow-up, 91 % (21/23) of the patients were off PPI and had significantly better median GERD-HRQL on LES stimulation compared to their on-PPI GERD-HRQL at baseline (9.0 vs. 2.0; p < 0.001). There were no unanticipated implantation- or stimulation-related adverse events or untoward sensation due to stimulation. There were no reports of treatment-related dysphagia, and manometric swallow was also unaffected.

Conclusions

Electrical stimulation of the LES is safe and effective for treating GERD. There is a significant and sustained improvement in GERD symptoms, esophageal pH, and reduction in PPI usage without any side effects with the therapy. Furthermore, the therapy can be optimized to address an individual patient’s disease.     

Transoral incisionless fundoplication for treatment of gastroesophageal reflux disease in clinical practice

Background

Transoral incisionless fundoplication is a recently introduced endoluminal technique for the treatment of gastroesophageal reflux disease (GERD). The objective of this study was to determine outcomes in chronic GERD patients who were referred for surgical management.

Methods

A cohort of 38 patients underwent transoral incisionless fundoplication (TIF) in a tertiary care setting. Pre- and post-procedure assessment included GERD-related quality of life questionnaires, proton pump inhibitor (PPI) usage, 24-h pH measurements, upper gastrointestinal endoscopy, esophageal manometry, and registration of adverse events. Duration of follow-up was 36?months.

Results

Gastroesophageal valves were constructed of 4?cm (range, 4–6) in length and 220° (range, 180–240) in circumference. One serious adverse event occurred, consisting of intraluminal bleeding at a fastener site. Hiatal hernia was completely reduced in 56?% and esophagitis was cured in 47?% of patients. Postprocedure esophageal acid exposure did not significantly improve (p?>?0.05). At 36 (range, 29–41) months follow-up 14 patients (36?%) had undergone revisional laparoscopic fundoplication. Quality of life scores of the remaining cohort showed significant improvement (p?<?0.0001) and daily use of antisecretory medication was discontinued by 74?%.

Conclusions

Endoluminal fundoplication improved quality of life and reduced the need for PPIs in only a subgroup of patients at 3?years follow-up. The amount of patients requiring additional medication and revisional surgery was high.     

Short-term safety and symptomatic outcomes of transoral incisionless fundoplication with or without hiatal hernia repair in patients with chronic gastroesophageal reflux disease

Background

A retrospective community-based study evaluated the safety and symptomatic outcomes of the transoral incisionless fundoplication (TIF) procedure with or without hiatal hernia repair (HHR) in patients with chronic gastroesophageal reflux disease (GERD).

Materials and methods

Forty-eight patients underwent TIF using EsophyX (EndoGastric Solutions, Redmond, WA) in 3 community hospitals. Patients who presented with a hiatal hernia 3 cm or more in the greatest transverse diameter underwent laparoscopic HHR before TIF.

Results

Forty-two patients completed follow-up assessment at a median of 6 (range 1–11) months. Laparoscopic HHR was performed in 18 (43%) patients before TIF. There were no long-term postoperative complications. GERD-health related quality of life scores indicated heartburn elimination in 63% of patients. The need for daily proton pump inhibitor (PPI) therapy was eliminated in 76% of patients. Atypical symptom relief measured by the median reflux symptom index score reduction was significant (5 [0–47] vs 22 [2–42] on PPIs, P < .001).

Conclusions

Our results support the safety and symptomatic improvement of TIF with or without laparoscopic HHR. The patients' symptoms were significantly improved, and PPI use was significantly reduced.     

Laparoscopic Total Fundoplication for Gastroesophageal Reflux Disease. How I Do It

Introduction

A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD).

Discussion

Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis.

Conclusion

This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.     

Gastrointestinal symptoms and patient satisfaction more than 1?year after laparoscopic Nissen fundoplication

Background  

Symptoms from poorly controlled gastroesophageal reflux disease (GERD) such as heartburn and regurgitation often resolve after laparoscopic Nissen fundoplication. Unfortunately, new gastrointestinal symptoms such as bloating may occur for some patients. Accurate data regarding the gastrointestinal symptoms experienced by patients who have had a laparoscopic fundoplication may help patients to make more informed decisions about pursuing surgery for their reflux disease.