Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication

BACKGROUND: In the operative management of gastro-oesophageal reflux, a balance must be achieved between adequate control of reflux and excessive dysphagia. The ideal technique is not known. A randomized study was performed to determine whether laparoscopic anterior fundoplication is associated with a lower incidence of postoperative dysphagia than laparoscopic Nissen fundoplication, while achieving equivalent control of reflux. METHODS: Patients presenting for laparoscopic antireflux surgery were randomized to undergo either a Nissen fundoplication (n = 53) or an anterior 180 degrees hemifundoplication (n = 54). Patients were blinded to which procedure had been performed, and follow-up was obtained by a blinded independent investigator. Standardized clinical grading systems were used to assess dysphagia, heartburn and patient satisfaction 1, 3 and 6 months after operation. Objective measurement of lower oesophageal sphincter pressure, oesophageal emptying time, distal oesophageal acid exposure and endoscopic healing of oesophagitis was also performed. RESULTS: Operating time was similar for the two procedures (58 min for the Nissen procedure versus 60 min for anterior fundoplication). Resting and residual lower oesophageal sphincter pressures were lower following anterior fundoplication (29 versus 18 mmHg, and 13 versus 6 mmHg), and oesophageal emptying times were faster (92 versus 116 s). Acid exposure times and ability to heal oesophagitis were similar. At 3 months' follow-up clinical outcomes were similar for the two procedures. At 6 months, however, patients who had undergone anterior fundoplication experienced significantly less dysphagia for solid food and were more likely to be satisfied with the clinical outcome. CONCLUSION: Laparoscopic anterior fundoplication achieved equivalent control of reflux, more physiological postoperative manometry parameters, and an improved clinical outcome at 6 months. Continued follow-up remains necessary to confirm the long-term efficacy of the partial fundoplication procedure.     

Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease

BACKGROUND: The aim of this study was to compare laparoscopic and open Nissen fundoplication for gastro-oesophageal reflux disease in a randomized clinical trial. METHODS: Ninety-nine patients were randomized to either laparoscopic (52) or open (47) Nissen fundoplication. Patients with oesophageal dysmotility, those requiring a concurrent abdominal procedure and those who had undergone previous antireflux surgery were excluded. Independent assessment of dysphagia, heartburn and patients' satisfaction 1, 3, 6 and 12 months after surgery was performed using multiple standardized clinical grading systems. Objective measurement of oesophageal acid exposure and lower oesophageal sphincter pressure before and after surgery, and endoscopic assessment of postoperative anatomy, were performed. RESULTS: Operating time was longer in the laparoscopic group (median 82 versus 46 min). Postoperative pain, analgesic requirement, time to solid food intake, hospital stay and recovery time were reduced in the laparoscopic group. Perioperative outcomes, postoperative dysphagia, relief of heartburn and overall satisfaction were equally good at all follow-up intervals. Reduction in oesophageal acid exposure, increase in lower oesophageal sphincter tone and improvement in endoscopic appearances were the same for the two groups. CONCLUSION: The laparoscopic approach to Nissen fundoplication improved early postoperative recovery, with an equally good outcome up to 12 months.     

Meta-analysis of laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastro-oesophageal reflux disease based on randomized clinical trials

Background: Laparoscopic Nissen fundoplication (LNF) is the standard procedure for surgical management of gastro‐oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) is reported to be as effective as LNF but to be associated with a lower incidence of post‐operative dysphagia. This meta‐analysis was performed to compare the two techniques with respect to reflux control and associated complications, particularly dysphagia. Methods: Pubmed, Medline, Embase and The Cochrane Library were searched. Only randomized controlled trials (RCTs) comparing LNF and LTF were included. Outcomes evaluated were occurrences of heartburn and associated complications (e.g. dysphagia) and degree of patient's satisfaction at early (three to six months) and later (one to three years) post‐operative periods. Results: Of 939 patients in seven RCTs, 478 received LNF and 461 received LTF. For both groups, control of reflux was good and occurrence of heartburn were similar. A lower incidence of post‐operative dysphagia for both early and later post‐operative periods was observed for the LTF group. Patient's satisfaction following either procedure was similar. Conclusion: LNF and LTF are both safe and effective. LTF is truly associated with a lower occurrence of dysphagia. However, LTF is more likely than LNF to be associated with early surgical complications. On the whole, post‐surgical satisfaction ratios for the two groups were comparable.     

Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication

BACKGROUND: This double-blind, randomized study compared outcomes of laparoscopic Nissen total fundoplication and anterior partial fundoplication carried out by a single surgeon in a private practice. METHODS: All patients with proven gastro-oesophageal reflux disease, regardless of motility, presenting for laparoscopic antireflux surgery were randomized to either Nissen total or anterior partial fundoplication. Primary outcome measures were dysphagia and abolition of reflux. Secondary outcome measures were Visick scores, bloating, patient satisfaction and reoperation rate. RESULTS: Complete follow-up was available for 161 (98.8 per cent) of 163 patients (84 Nissen, 79 anterior). There were no differences in mean heartburn scores between groups. Recurrent reflux was observed in ten patients after anterior fundoplication, but none after the Nissen procedure. Dysphagia scores for both liquids and solids were lower after anterior fundoplication. Four patients had persistent troublesome dysphagia after Nissen fundoplication compared with none after anterior fundoplication. There were no differences between groups in postoperative bloating. The overall reoperation rate at 2 years was 7 per cent, all achieved laparoscopically. CONCLUSION: Nissen fundoplication cured reflux in all patients up to 2 years, but 5 per cent required revisional surgery. Recurrent reflux was more common after anterior fundoplication, but dysphagia was rare. Patient satisfaction was excellent in both groups. Revisional laparoscopic surgery was safe and usually successful.     

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     

Chronic dysphagia following laparoscopic fundoplication

BACKGROUND: Many surgeons practise tailored laparoscopic antireflux surgery in an attempt to prevent postoperative dysphagia. The aim of this study was to determine the effect of 360 degrees fundoplication (Nissen) or 270 degrees fundoplication (Toupet), and the influence of abnormal oesophageal peristalsis, upon postoperative dysphagia. METHODS: This was a cohort study from three tertiary referral centres, using dysphagia before laparoscopic fundoplication and 1 year after operation as the main outcome variable. Preoperative oesophageal manometry was performed on all patients. RESULTS: Some 761 patients underwent Nissen and 85 underwent Toupet fundoplication. Only 2 per cent reported severe postoperative dysphagia. There was a significant selection bias towards the Toupet operation for patients with abnormal oesophageal motility (P < 0.001). For patients whose oesophageal manometric findings were normal there was a significant improvement in dysphagia after Nissen fundoplication (P = 0.02), and no significant change following Toupet fundoplication. There was no significant change in the rate of dysphagia following either method of fundoplication amongst other subgroups in which oesophageal manometry was stratified as non-specific motor disorder, low-amplitude peristalsis, or aperistalsis. CONCLUSION: A tailored approach to the degree of fundoplication is unnecessary as patients with dysmotility suffer no more dysphagia after full laparoscopic Nissen fundoplication than those who have a partial Toupet wrap.     

Ten-year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180( degrees ) partial fundoplication

Background:

A randomized trial of laparoscopic Nissen fundoplication and anterior 180° partial fundoplication was undertaken to determine whether the anterior procedure might reduce the incidence of dysphagia and other adverse outcomes following surgery for gastro‐oesophageal reflux disease. This study evaluated clinical outcomes after 10 years.

Methods:

Some 107 patients were randomized to undergo laparoscopic Nissen or anterior 180° partial fundoplication. Ten‐year data were not available for 18 patients. Information was obtained from 89 patients (48 Nissen, 41 anterior fundoplication) using a standard clinical questionnaire that focused on symptoms of reflux, potential postoperative side‐effects and overall satisfaction with the outcome of surgery.

Results:

There were no significant differences between the two groups with regard to reflux symptoms, dysphagia, abdominal bloating, ability to belch and overall satisfaction. Between 5 and 10 years after surgery, revisional surgery was required for reflux in two patients after anterior fundoplication. Two patients had revision after Nissen fundoplication, for reflux and recurrent hiatus hernia.

Conclusion:

Both laparoscopic anterior 180° partial and Nissen fundoplication are safe, effective and durable at 10 years' follow‐up. Most patients are satisfied with the clinical outcome. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication

HYPOTHESIS: Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind, randomized controlled trial. SETTING: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. PARTICIPANTS: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study. INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. RESULTS: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. CONCLUSIONS: At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.     

Comparison of laparoscopic and open Nissen fundoplication 2 years after operationrid=""

BACKGROUND: Laparoscopic operation has replaced the conventional open procedure in the treatment of gastroesophageal reflux disease (GERD) in spite of the fact that long-term results based on controlled clinical trials have been lacking. The objective of this study was to compare outcome, quality of life, and patient satisfaction after laparoscopic and open Nissen fundoplication in a community hospital setting with a 2-year follow-up. METHODS: Forty-two patients with GERD were randomized to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Outcome evaluation included reflux symptoms, gastrointestinal quality of life (GIQLI), and upper GI endoscopy. RESULTS: Esophagitis was cured among all patients in the LNF group and in 90% of the ONF group. There were two patients (10%) in both groups who had medicine-dependent recurrent reflux together with significant worsening in the GIQLI scores. One patient in the LNF group has been reoperated due to a suture granuloma in the left epigastric port. Two patients in the LNF group needed esophageal dilatation due to persistent dysphagia. GIQLI scores (scale, 0-144) were equally normalized in both groups. Overall, 90% in the LNF and 100% in the ONF group were either satisfied or very satisfied with the operation. There was only one patient (LNF) who would not choose to have the operation again. CONCLUSIONS: Laparoscopic and open Nissen fundoplication seem to be equally effective methods for improving reflux symptoms and quality of life, resulting in a high rate of satisfaction among patients with an intermediate follow-up period of 2 years.     

Five-year subjective and objective results of laparoscopic and conventional Nissen fundoplication: a randomized trial

OBJECTIVE: The purpose of this prospective study was to compare the subjective and objective outcome of laparoscopic (LNF) and conventional Nissen fundoplication (CNF) up to 5 years after surgery as obtained in a multicenter randomized controlled trial. SUMMARY OF BACKGROUND DATA: LNF is regarded as surgical treatment of first choice for refractory gastroesophageal reflux disease by many surgeons based on several short- and mid-term studies. The long-term efficacy of Nissen fundoplication, however, is still questioned as objective data gathered from prospective studies are lacking. METHODS: From 1997 to 1999, 177 patients were randomized to undergo LNF or CNF. Five years after surgery, all patients were requested to fill in questionnaires and to undergo esophageal manometry and 24-hour pH-metry. RESULTS: A total of 148 patients agreed to participate in the follow-up study: 79 patients after LNF and 69 after CNF. Of these, 97 patients (48 LNF, 49 CNF) consented to undergo esophageal manometry and 24-hour pH-metry. At 5 years follow-up, 20 patients had undergone reoperation: 12 after LNF (15%) and 8 after CNF (12%). There was no difference in subjective outcome, with overall satisfaction rates of 88% and 90%, respectively. Total esophageal acid exposure times (pH < 4) were 2.1% +/- 0.5% and 2.0% +/- 0.6%, respectively (P = 0.21). Antisecretory medication was taken daily in 14% and 16%, respectively (P = 0.29). There was no correlation between medication use and acid exposure and indices of symptom-reflux association (symptom index and symptom association probability). No significant differences between subjective and objective results at 3 to 6 months and results obtained at 5 years after surgery were found. CONCLUSIONS: The effects of LNF and CNF on general state of health and objective reflux control are sustained up to 5 years after surgery and the long-term results of LNF and CNF are comparable. A substantial minority of patients in both groups had a second antireflux operation or took antisecretory drugs, although the use of those medications did not appear to be related to abnormal esophageal acid exposure.     

Prospective randomized trial of Nissen fundoplication and Angelchik prosthesis in the surgical treatment of medically refractory gastro-oesophageal reflux disease

Fifty patients with gastro-oesophageal reflux disease refractory to multiple courses of medical therapy were entered into a prospective randomized trial comparing Nissen fundoplication with the Angelchick prosthesis as a primary surgical procedure. The two groups were matched for age, sex, duration of symptoms before surgery, type of medical therapy, pattern of symptom presentation, endoscopic grade of oesophageal inflammation, manometric lower oesophageal pressure and 24-h pH profile. Twenty-five patients were randomized to each of the Nissen fundoplication and Angelchik prosthesis groups. Operation time and hospital stay were similar in both groups. Persistent dysphagia was reported in five of the patients with an Angelchik prosthesis compared with none in the Nissen fundoplication group. Three prostheses were removed because of severe dysphagia while no Nissen fundoplication required revision. No patient with preoperative dysphagia because of stricture reported swallowing difficulties after operation. At clinical assessment at 3, 6, 12 and 24 months after operation, 85-88 per cent of the patients having a Nissen fundoplication were graded Visick 1 or 2 compared with 60-72 per cent of patients in the Angelchik group.     

Gastroesophageal disease and nausea: does fundoplication help or hurt?

HYPOTHESIS: Nausea associated with gastroesophageal reflux disease is cured by laparoscopic Nissen fundoplication (LNF). DESIGN: Prospective cohort study of unselected patients who underwent LNF from January 1, 1995, through March 31, 1999. Patients were followed up by a physician for 6 to 36 months. SETTING: A large community teaching hospital. PATIENTS: One hundred consecutive patients with gastroesophageal reflux disease who underwent LNF; all patients were followed up. Patients were grouped according to the presence (group A, n = 33) or absence (group B, n = 67) of preoperative nausea. Interventions were LNF, esophageal manometry, 24-hour pH monitoring, and nuclear gastric emptying studies. MAIN OUTCOME MEASURES: Resolution of symptoms after LNF. RESULTS: Nausea was the most common atypical symptom of gastroesophageal reflux disease, occurring in 33 patients (33%). There were no differences in esophageal manometry or 24-hour pH results between groups. There was a female preponderance in group A (55% vs 33%; P = .003). Patients in group A had a higher prevalence of preoperative dysphagia (P = .02). Patients with persistent postoperative nausea had a higher prevalence of cough (P = .003) and dysphagia (P = .009). The LNF was more effective in reducing heartburn (95% reduction) and regurgitation (95% reduction) than cough and dysphagia (60% reduction). There was a 79% reduction in the number of patients with nausea (33 to 7; P<.001). CONCLUSION: Laparoscopic Nissen fundoplication is effective in eliminating nausea associated with gastroesophageal reflux disease and is not contraindicated in these patients.     

Dysphagia and clinical outcome after laparoscopic Nissen or Rossetti fundoplication: sequential prospective study

Laparoscopic fundoplication represents the most widely used operation in the surgical treatment of gastroesophageal reflux disease (GERD). Besides being operator-dependent, the clinical outcome (efficacy and side-effects) seems also to be dependent on the specific surgical technique. In this prospective trial we compared the results of two groups of patients who were submitted sequentially to the Rossetti or Nissen fundoplication procedure. Dysphagia, other side effects, and clinical outcome were evaluated early after surgery and at 6 and 12 months after the operation. Although both procedures were clinically effective, there was a significant trend toward less postoperative dysphagia in the Nissen group. In these patients the incidence of early dysphagia was significantly lower than that observed in those submitted to the Rossetti fundoplication. In addition, Nissen patients experienced a significantly smaller number of days with dysphagia. One year after surgery, however, the two procedures proved equally successful without any significant difference in dysphagia incidence. Complete fundic mobilization should therefore be advised to reduce the incidence of early troublesome dysphagia.     

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux

BACKGROUND: Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial. METHODS: Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment. RESULTS: At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003). CONCLUSION: LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.     

A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair.

HYPOTHESIS: The technique used for repair of the esophageal hiatus during laparoscopic Nissen fundoplication can influence the likelihood of postoperative dysphagia. DESIGN: A prospective double-blind randomized control trial. SETTING: A university teaching hospital. PARTICIPANTS: A total of 102 patients with proven gastroesophageal reflux disease, undergoing a laparoscopic Nissen fundoplication were randomized to undergo fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Patients were excluded for the following reasons: they had esophageal motility disorders, required a concurrent abdominal procedure, had undergone previous antireflux surgery, or had very large hiatus hernias. INTERVENTIONS: Laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, patient satisfaction, and other symptoms 1, 3, and 6 months following surgery, using multiple standardized clinical grading systems. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, distal esophageal acid exposure, and endoscopic assessment of postoperative anatomy and esophageal mucosa. RESULTS: Symptoms of postoperative dysphagia, relief of heartburn, and overall satisfaction 6 months after surgery were not influenced by the hiatal repair technique. However, to achieve a similar incidence of dysphagia, more patients who initially underwent posterior hiatal repair required a second surgical procedure (6 vs 0 patients). The hiatal repair technique did not affect the likelihood of early postoperative paraesophageal herniation. CONCLUSION: Anterior suturing of the hiatus appears to be at least as good in the short-term as posterior suturing as a method of narrowing the hiatus during laparoscopic Nissen fundoplication.     

Single center prospective randomized trial of laparoscopic Nissen versus anterior 90° fundoplication

Although Nissen fundoplication is a very effective treatment for gastroesophageal reflux, it is associated with a small incidence of troublesome postoperative side effects. To prevent this, progressive modification of surgical techniques has led to the development of an anterior 90° fundoplication. We undertook a prospective randomized trial to compare this procedure with Nissen fundoplication to determine whether it would achieve a better clinical outcome. Patients presenting to a single center for primary laparoscopic antireflux surgery were randomized to undergo either an anterior 90° fundoplication (n=40) or a Nissen fundoplication without division of the short gastric vessels (n=39). Clinical questionnaires were used to assess outcome at 1 month, 3–6 months, and 12 months. Both patients and the clinical interviewer were masked as to which procedure was performed. Follow-up with endoscopy, esophageal manometry, and pH monitoring was also undertaken. Operating time was similar for the two procedures (60 minutes for anterior vs. 55 minutes for Nissen fundoplication). Early postoperative complications were more common after Nissen fundoplication (18% vs. 5%). Two patients underwent laparoscopic reoperation for recurrent reflux after anterior 90° fundoplication, and four underwent laparoscopic reoperation after Nissen fundoplication (dysphagia, 3 patients; acute hiatus hernia, 1 patient). One year after surgery, dysphagia and other wind-related side effects were less common after anterior 90° fundoplication. Control of reflux symptoms and satisfaction with the overall outcome was similar for the two procedures. Anterior 90° fundoplication is followed by fewer side effects than Nissen fundoplication. This advantage is offset by a greater likelihood of reflux recurrence. However, this does not diminish patient satisfaction. Financial support for this study was provided from a project grant (no. 157986) from the National Heath and Medical Research Council of Australia (to D.I.W. and G.G.J.).     

The outcomes of laparoscopic fundoplication for gastro-oesophageal reflux disease. Long term results

INTRODUCTION: The aim of this study was to evaluate the long term efficacy of laparoscopic treatment of gastroesophageal reflux disease (GERD). PATIENT AND METHODS: Between 1(st) January 1992 and 31 December 1996, 161 patients underwent complete or partial laparoscopic fundoplication for a symptomatic GERD. One hundred and twenty three patients were submitted to Nissen-Rossetti fundoplication, 26 patients to Nissen fundoplication and 12 patients to a partial posterior Toupet fundoplication.141 patients were evaluated at 3 months, 2-years and 5-years. Since undergoing the operation, four patients died of unrelated causes, 16 patients could not be contacted for follow up (10%). pH monitoring and oesophageal manometry were performed preoperatively and at 3 months postoperatively. The patients were evaluated 2 and 5-years after surgery by specific phone questionnaire. RESULTS: There was no mortality, the morbidity rate was 1.2% and the conversion rate was 5%. Incidence of dysphagia 3 months after surgery was 23.4%, and 5-years after 12%; 12% of patients had recurrent symptoms at 5 years. CONCLUSION: The overall satisfaction rate at 5 years was 91.4%. Nissen-Rossetti fundoplication seems to have better results at 5-years regarding postoperative dysphagia and symptoms recurrence.     

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. Methods A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. Results In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 ± 5.2 mmHg (range, 6.0–30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% ± 8.3% (range, 70–100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett’s progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1–46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. Conclusion The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360° fundoplication should not be contraindicated for patients with severe esophageal dysmotility.     

腹腔镜Nissen与Toupet胃底折叠术式治疗胃食管反流病疗效比较的Meta分析

目的比较腹腔镜Nissen手术与Toupet手术在治疗胃食管反流病的疗效以及术后并发症的发生率。方法通过Pubmed,Medline,Embase以及Cochrane图书馆数据库进行文献检索,用Nissen,Toupet,fundoplication[Mesh]为关键词,仅将比较腹腔镜Nissen以及Toupet两种手术方式的随机对照研究纳入本研究,分别统计两组患者在术后早期（3-6个月）以及术后晚期（1。3年）的烧心、反酸、吞咽困难、胸痛、腹胀、不能打嗝、腹泻、术后早期并发症的发生率及满意度等。结果在纳入本研究的7个随机对照研究总计939例患者中．腹腔镜Nissen手术478例,腹腔镜Toupet手术461例。两组患者的反流症状均得到了良好的控制．术后烧心的发生率差异无统计学意义（DR：1．01,95％CI：0．48。2．13,P=0．97）。尽管Toupet组在术后早期及晚期吞咽困难的发生率显著低于Nissen组（OR=3．34,95％CI：2．22-5．02,P〈0．01）,但前者术后早期并发症的发生率显著高于后者（OR=O．31,95％CI：0．11-0．93,P=0．04）;而两组患者术后远期满意度差异无统计学意义（OR=0．98,95％CI：0．61-1．56。P=0．92）。结论腹腔镜Nissen及Toupet手术均为安全有效的手术方式。选择哪种术式可根据患者情况及外科医生自身技术和经验而定。     

Nissen vs toupet laparoscopic fundoplication

BACKGROUND: Nissen fundoplication (360 degrees ) is the standard operation for the surgical management of gastroesophageal reflux disease (GERD). To avoid postoperative dysphagia, it has been proposed that antireflux surgery be tailored according to the degree of preexisting esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and the Toupet procedure (270 degrees ) has been recommended for these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques in terms of reflux control and complication rate (dysphagia). Our objective was to determine the impact of preoperative esophageal motility on the clinical and objective outcome, following Toupet vs Nissen fundoplication and to evaluate the success rate of these procedures. METHODS: From May 1999 until May 2000, 200 patients with GERD were included in a prospective randomized study. After preoperative examinations (clinical interview, endoscopy, 24-h pH study and esophageal manometry), 100 patients underwent either a laparoscopic Nissen (50 with and 50 without motility disorders), or a Toupet procedure (50 with and 50 without motility disorders). Postoperative follow-up after 4 months included clinical interview, endoscopy, 24-h pH study and esophageal manometry. RESULTS: Interviews showed that 88% (Nissen) and 90% (Toupet) of the patients, respectively, were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication than after a Toupet (30 vs 11, p <0.001) and did not correlate with preoperative motility. In terms of reflux control, the Toupet proved to be as effective as the Nissen procedure. CONCLUSION: Tailoring antireflux surgery to esophageal motility is not indicated, since motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation because it has a lower rate of dysphagia and is as effective as the Nissen fundoplication in controlling reflux.