Techniques and outcomes of laparoscopic surgery in gastroesophageal reflux disease

BACKGROUND: The purpose of this study is to report personal experience in laparoscopic antireflux surgery and to analyze the clinical and functional outcomes of this procedure, also in relation to the different techniques used. METHODS: From 1996 to 2000, 20 patients with gastroesophageal reflux disease associated with hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24 hrs-pH monitoring, endoscopic evidence of esophagitis and hiatal hernia, and defective lower esophageal sphincter. A Nissen fundoplication was performed in 13 patients with normal esophageal body motility, and a 270 degrees posterior fundoplication in seven patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 135 min and mean postoperative hospital stay 5 days. Operative morbidity was 15%. All the patients were completely cured of reflux symptoms; transient mild postoperative dysphagia occurred in two patients (10%). There was a significantly improvement of the results in postoperative esophageal manometry and 24 hrs-pH monitoring. CONCLUSIONS: This preliminary experience suggests that laparoscopic surgery represents a safe and effective procedure for the treatment of gastroesophageal reflux disease. Precise selection of patients and adequate surgical technique are essential.     

腹腔镜抗反流手术治疗胃食管反流病的总体疗效及手术指征选择

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

The laparoscopic surgical therapy of gastroesophageal reflux disease

Between January 1995 and February 1997 we performed 30 laparoscopic Nissen-Rossetti fundoplications and 3 laparotomic Nissen fundoplications. All patients were suffering from gastro-esophageal reflux disease (GERD) resistant to medical therapy, 19 patients were suffering also from hiatal hernia and 2 pz. were suffering from a para esophageal hernia. 1 patient had been previously treated with laparotomic Nissen fundoplication for GERD and hiatal hernia. Preoperative assessment included: oesophagogastroduodenoscopy (EGDS) with biopsies: 24-h pH-monitoring; 24-h manometry; barium swallow and DeMeester symptoms scoring. Mean operation time was 110 min. 1 pz. required conversion to laparotomy. 35% of pz. experienced mild grade dysphagia that resolved spontaneously in 4-8 weeks. Postoperative evaluation was performed in all patients 6 months after surgery. Overall results were characterised by a significant reduction of the symptoms score: mean score was reduced from 5.6/9 to 0/9. No signs of oesophagitis were seen at control EGDS. 24-h pH monitoring demonstrated a significant reduction of the total time at ph < 4 from a mean value of 28.2% preoperatively to 1.9% postoperatively. 24 h oesophageal manometry revealed a rise in lower oesophageal sphincter pressure from a mean of 11 mmHg preoperatively to a mean of 27 mmHg postoperatively. Our preliminary results demonstrate that laparoscopic Nissen-Rossetti fundoplication is a safe and effective procedure for gastro-oesophageal reflux disease but, sometimes, laparotomic technique can be considered in selected cases.     

腹腔镜手术治疗胃食管反流病的应用与评价

胃和十二指肠内容物反流人食管产生症状、体征或并发症时,称为胃食管反流病（gastroesophageal reflux disease,GERD）。GERD的并发症包括食管炎,消化性食管狭窄,食管溃疡及Bar．rett化生。因酸（碱）反流导致的食管黏膜破损称为反流性食管炎（reflux esophagitis,RE）。RE可导致一系列的临床症状如烧心感,反酸,胸骨后灼痛等,严重时可出现吞咽痛及大量出血、食管Barrett化生并导致食管癌的发生,因此,有必要给予重视。     

Quality of life for patients with gastroesophageal reflux disease

Surgical Endoscopy -     

腹腔镜Nissen胃底折叠术治疗胃食管返流病的长期效果

目的:评价腹腔镜Nissen胃底折叠术(laparoscopic Nissen fundoplication,LNF)治疗胃食管返流病的长期效果。方法:从MEDLINE、EMBASE、中国生物医学数据库(CBM)及Cochrane试验注册中心检索纳入了1991年到2007年10月发表的LNF治疗返流性食管炎的随机对照实验,并对纳入研究的方法学质量(随机方法、分配隐藏、盲法)进行评价,最后用Rev-Man4.2.9软件进行分析。结果:纳入4个随机对照实验(RCT),包括440例患者,纳入随访研究共387例。术后主观结果如满意度[OR0.5095%CI(0.25,1.00)]、术后抑酸药物的使用[OR0.4595%CI(0.08,2.53)]、返酸和烧心症状差异无统计学意义,吞咽困难LNF发生率高于传统胃底折叠术(conventional Nissen fundoplicationm,CNF)[OR4.1695%CI(1.51,11.50)]。客观结果如再手术率[OR1.7795%CI0.78,4.72)]、食管测压和24h pH检测两组间差异无统计学意义。结论:本研究中LNF治疗胃食管返流病的长期效果和传统胃底折叠术差异无统计学意义,但LNF术后吞咽困难发生率可能较高。     

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

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

Long-term outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder

A strong link exists between gastroesophageal reflux disease (GERD) and airway diseases. Surgical therapy has been recommended as it is more effective than medical therapy in the short term, but there is little data on the effectiveness of surgery long-term. We analyzed the long-term response of GERD-related airway disease after laparoscopic anti-reflux surgery (LARS). Methods In 2004, we contacted 128 patients with airway symptoms and GERD who underwent laparoscopic antireflux surgery (LARS) between 12/1993 and 12/2002. At median follow-up of 53 months (19–110 mo) we studied the effects on symptoms, esophageal acid exposure, and medication use and we analyzed the data to determine predictors of successful resolution of airway symptoms. Results Cough, hoarseness, wheezing, sore throat, and dyspnea improved in 65-75% of patients. Heartburn improved in 91 % (105/116) of patients and regurgitation in 92% (90/98). The response rate for airway symptoms was the same in patients with and without heartburn. Almost every patient took proton pump inhibitors (PPIs) preoperatively (99%, 127/128) and 61% (n = 78) were taking double or triple dose. Postoperatively, 33% (n = 45) of patients were using daily anti-acid therapy but no one was on double dose. The only factor that predicted a successful surgical outcome was the presence of abnormal reflux in the pharynx as determined by 24-hour pharyngeal pH monitoring. One hundred eleven (87%) patients rated their results as excellent (n = 78, 57%) or good (n = 33, 24%). Conclusion LARS provides an effective and durable barrier to reflux, and in so doing improves GERD-related airway symptoms in ∼70% of patients and improves typical GERD symptoms in ∼90% of patients. Pharyngeal pH monitoring identifies those patients more likely to benefit from LARS, but better diagnostic tools are needed to improve the response of airway symptoms to that of typical esophageal symptoms.     

Assessment and management of gastroesophageal reflux disease following bariatric surgery

Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.     

Trends in surgery for gastroesophageal reflux disease: the effect of laparoscopic surgery on utilization

BACKGROUND: In addition to substituting for open surgery, minimally invasive surgery may lower thresholds for intervention and thus increase overall utilization rates. The degree to which laparoscopy may have lowered the threshold for elective anti-reflux surgery is unknown. METHODS: Using the Uniform Hospital Discharge Dataset and ICD-9 procedure and diagnosis codes, we identified all laparoscopic and open anti-reflux procedures performed on adults in Massachusetts, New Hampshire, and Vermont for each year from 1993 to 1998. We then examined secular trends and regional variation in the use of laparoscopic and open anti-reflux surgery. RESULTS: The population-based rate of anti-reflux surgery more than doubled between 1993 (4.8 per 100,000) and 1998 (11.7 per 100,000). Laparoscopic anti-reflux procedures increased more than 6-fold between 1993 and 1998, from 1.2 to 8.9 procedures per 100,000 adults, with accompanying declines in overall length of stay and mortality. However, the number of open anti-reflux procedures decreased only modestly (22%) over this time period. In the year hospitals performed their first laparoscopic anti-reflux operation, procedure rates nearly tripled, on average, and then increased slowly in subsequent years. In 1997 and 1998, rates of anti-reflux surgery varied nearly 5-fold across hospital referral regions, ranging from 5.4 to 24.5 per 100,000. CONCLUSIONS: With the growth of minimally invasive surgery, rates of anti-reflux surgery have increased substantially, with wide regional variation in intervention rates. Further research is needed to determine the appropriate threshold for surgical treatment in patients with gastroesophageal reflux.     

The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children

Background The benefits of surgery for gastroesophageal reflux disease (GERD) in infants and children have been questioned in the recent literature. The goal of this review was to determine the best current practice for the diagnosis and management of this disease. Methods The literature was reviewed for all recent English language publications on the management of GERD in 8- to 10-year-old patients. Results In infants and children, GERD has multiple etiologies, and an understanding of these is important for determining which patients are the best surgical candidates. Proton pump inhibitors (PPIs) have become the mainstay of current treatment for primary GERD. Although laparoscopic surgery appears to be better than open surgery, there remains some morbidity and complications that careful patient selection can minimize. Conclusion Surgery for GERD should be performed only after failure of medical management or for specific problems that mandate it.     

Quality of life after antireflux surgery compared with nonoperative management for severe gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease significantly affects a patient's quality of life (QOL). Laparoscopic fundoplication offers an alternative to medical therapy, but few studies have compared outcomes. Our objective was to examine QOL scores in gastroesophageal reflux disease patients treated medically and surgically. STUDY DESIGN: We undertook a retrospective analysis of patients undergoing surgical or medical treatment for gastroesophageal reflux disease over a 1-year period (August 1997 to August 1998). Followup QOL was measured using the Short-Form 36, and heartburn severity was measured using the Health Related Quality of Life scale (a disease-specific instrument with a best score of 0 and a worst score of 45). RESULTS: Laparoscopic fundoplication was undertaken in 120 patients with a median age of 47 years (range 17 to 80 years). The medical cohort included 51 patients selected from the gastroenterology clinic with a median age of 48 years (range 17 to 82 years). Duration of heartburn was not significantly different, with 40 (78.4%) of the 51 medical and 98 (81.7%) of the 120 surgical patients having had symptoms for longer than 12 months. There were no operative deaths. There were 12 complications (esophageal perforation 1, pneumothorax 2, pneumonia 1, pulmonary embolus 3, other/miscellaneous 5). Mean length of stay was 1.6 days, time to oral intake 1.2 days, and return to normal activity 4.2 weeks. Routine followup was available in 118 surgical and 47 medical patients. The medical cohort had increased (p < 0.05) symptoms of heartburn (43% versus 19%), waterbrash (26% versus 8%), and regurgitation (30% versus 8%) and greater requirement for proton pump inhibitors (74% versus 19%) and propulsid (19% versus 3%) over the surgical group. Detailed outcomes were available in 101 surgical and 37 medical patients. Mean (+/-SE) Health Related Quality of Life scores were better (p < 0.05) in the surgical group (4+/-0.6 versus 21+/-1.4). More of the medical patients were dissatisfied (21.6% versus 5.9%). Short-Form 36 scores at followup were better (p < 0.05) in six of eight domains for surgical patients. CONCLUSION: Heartburn scores and global QOL scores were superior after laparoscopic fundoplication compared with medical management in this patient population. Laparoscopic fundoplication should be considered for patients who are dissatisfied with medical treatment.     

Laparoscopic surgery for gastroesophageal reflux disease during the first year of life

BACKGROUND: Very few children need gastroesophageal antireflux surgery during their first year of life; hence, no series has been published so far. The authors report their experience in 3 centers. METHODS: From January 1993 to December 1998, 36 infants between 23 days and 13 months of age, suffering from gastroesophageal reflux disease (GERD), underwent surgery by a laparoscopic approach. The patients' weights ranged from 2.4 to 8.5 kg. Preoperative diagnostic studies included esophagograms, manometries, endoscopies, and pH-metries. Fifteen babies (41.6%) had associated anomalies, and 10 (27.7%) were neurologically impaired. Thirty-six laparoscopic fundoplications were performed according to either Toupet's procedure (17 of 36), Rossetti's (10 of 36), Nissen's (8 of 36) or Lortat-Jacob's (1 of 36). Four infants previously had undergone a gastrostomy, whereas 6 needed one during the antireflux procedure. RESULTS: There was no mortality in our series. Three infants (8.3%) had an intraoperative complication: 1 lesion of a diaphragmatic vessel, 1 pneumothorax, and 1 case of severe hiatal hernia requiring conversion to open surgery. During the median follow-up of 22 months, 4 redo procedures were performed (11.1%). CONCLUSIONS: This experience shows the feasibility of laparoscopic fundoplication even in children below 1 year of age. An accurate preoperative diagnostic study is mandatory, because 50% of these patients presented associated anomalies. A long and accurate follow-up is necessary to evaluate long-term results and detect possible complications, which can occur as late as 1 year after surgery. In addition, we believe that redo antireflux surgery is possible by the laparoscopic approach without major difficulties, based on our larger experience with older children.     

Quality of life measurement in the management of gastroesophageal reflux disease

QOL measurement is being reported with increasing frequency in the surgical literature. The authors have found, as have others, that the use ofa generic instrument such as the SF36 in combination with a disease-specific instrument will provide the most comprehensive information. GERD isa significant health problem that primarily affects the QOL of a large segment of the population. New therapies for GERD continue to be developed and introduced into clinical practice. QOL assessment should bean important part of the evaluation of these new therapies.     

Minimally invasive surgery for gastroesophageal reflux disease

: The goal of this study was to determine if the outcome of antireflux surgery can be improved by: (1) conducting a careful preoperative workup to characterize gastroesophageal reflux disease (GERD) in the individual patient; and (2) tailoring the operation to the results of the preoperative function tests. : Sixty-eight patients had operations for GERD by minimally invasive techniques. : A Rossetti fundoplication was performed in 22 patients. Sixty-eight percent became asymptomatic. Twenty-seven percent developed dysphagia or gas bloat. Thirty-five patients had a Nissen fundoplication. Ninety-one percent are asymptomatic. Eleven patients with severe abnormalities of esophageal peristalsis underwent a Guarner fundoplication with relief of symptoms in 82% of patients. No patients in the Nissen or Guarner group developed postoperative persistent dysphagia or gas bloat. A pyloromyotomy was performed in 3 patients because of severe delayed gastric emptying. : Minimally invasive surgery for GERD gives good-to-excellent results even in patients with abnormal esophageal body function, provided that the operation is tailored to the individual patient based on the results of the preoperative function tests.