Comparison of patient-centered outcomes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernia

Background Patients undergoing laparoscopic Nissen fundoplication (LNF) with paraesophageal hernias (PEH) are not only older and less healthy than those with gastroesophageal reflux disease (GERD), but in addition the repair is more complicated. We evaluated whether outcomes relating to GERD symptoms and quality of life (QOL) were impacted by the presence of PEH. Methods Prospectively entered data from 149 patients (109 GERD and 40 PEH) were evaluated prior to and one year after LNF with standardized and validated symptoms scores. Scores for heartburn, dysphagia, disease-specific QOL (GERD-HRQL), and general health-related QOL (SF-12 physical and mental component scores) were compared between patients undergoing LNF for PEH or for GERD alone, at baseline and one year after surgery. p < 0.05 was considered statistically significant. Results Preoperative data for GERD-HRQL, heartburn, and dysphagia were available for 134 patients, with 96% one-year follow-up. SF-12 data were collected for 98 patients with 100% follow-up. PEH patients were older and had greater comorbidity. Preoperative GERD-HRQL and heartburn were significantly worse in the GERD group. One year after surgery, both GERD and PEH patients showed significant improvement in GERD-HRQL, heartburn and dysphagia scores, with no difference in any of these disease or symptom measures between the two study groups. Postoperative PCS and MCS scores showed improvement in GERD patients, while PEH patient scores remained at or below the population mean. Conclusions LNF is equally effective as an antireflux procedure in both GERD and PEH patients, prevents symptoms of reflux in PEH patients that have none preoperatively, and does not increase dysphagia in either group. Despite the increased complexity of the procedure, LNF provides an effective control of reflux symptoms in patients undergoing PEH repair. Supported by an unrestricted educational grant from Tyco Healthcare Canada     

Does laparoscopic Nissen fundoplication lead to chronic gastrointestinal dysfunction?

Background Laparoscopic Nissen fundoplication (LNF) efficiently controls the symptoms of gastroesophageal reflux disease (GERD); however, other nonspecific gastrointestinal (GI) symptoms have been reported following LNF. The aim of this study was to evaluate the long-term effects of LNF on nonspecific GI complaints. Methods The basis for this study is the prospective follow-up of 515 patients (mean age 46 ± 13 years) who underwent a LNF between 1992 and 1998. A questionnaire was designed to evaluate GERD symptoms (i.e., heartburn, epigastric pain, regurgitation, dysphagia, and fullness, score 0–60) and nonspecific GI symptoms (i.e., vomiting, diarrhea, constipation, and lack of appetite, score 0–48). Patients were assessed before surgery, at 6 months, 2 years, and 5 years after surgery. Results Laparoscopic Nissen fundoplication was associated with a significant decrease in both GERD and nonspecific GI symptoms score at 6 months and up to 5 years, in the whole group (p < 0.001). 360 patients (69.7%) had preoperative nonspecific GI symptoms and experienced a significant reduction in these symptoms following the surgery and lasting up to 5 years. The other 155 patients (30.3%) had no preoperative GI symptoms (GI symptoms score of 0). In this group, there was a small but statistically significant increase in GI symptoms score (p < 0.001). It was, however, clinically significant (defined as a score >12) in only 9.9% of the patients. Conclusions Laparoscopic Nissen fundoplication provides an efficient treatment of GERD up to 5 years, and in a majority of patients, it is not associated with any significant increase in nonspecific GI complaints. New nonspecific bowel symptoms can develop after LNF in some patients but are unlikely to be clinically significant. Presented to the Society of American Gastrointestinal Endoscopic Surgeons, Hollywood, Florida, April 2005     

Effective Nissen fundoplication length and bougie diameter size in young children undergoing laparoscopic Nissen fundoplication

Background/Purpose: Laparoscopic Nissen fundoplication (LNF) is utilized in the management of symptomatic gastroesophageal reflux disease (GERD) in children. An effective length of fundoplication and bougie size has never been established in infants and children requiring LNF for GERD. To determine this effective fundoplication length and appropriate bougie size, we analyzed all patients less than 15 kg undergoing LNF for GERD over a 2-year period. Methods: Data recovered retrospectively included age, weight, gender, need for gastrostomy, length of postoperative hospitalization, operating time, bougie size, and fundoplication length. Results: One hundred patients weighed less than 15 kg (mean, 7.23 kg). Mean operating time was 95 minutes (range, 31 minutes to 159 minutes). Gastrostomies were placed in 32 patients. Postoperative hospitalization averaged 1.8 days for elective LNF. Fundoplication length was measured in each patient and averaged 2.06 cm. Bougie size varied from 22F to 42F, and the size utilized was based on the patient's weight. There were no instances of dysphagia or the need for esophageal dilatation postoperatively. Two patients have been seen for recurrent symptoms. One patient has required a second LNF, and the other has a normal upper gastrointestinal study and pH study. Conclusion: This study of LNF in small children has shown that resolution of GERD symptoms in most patients can be accomplished with an average fundoplication length of approximately 2 cm and a graduated bougie size relative to the patient's weight.     

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.     

Laparoscopic fundoplication: A 10-year learning curve

Background Laparoscopic Nissen fundoplication (LNF) has become the most common surgical treatment for gastroesophageal reflux disease (GERD). Controversies still exist regarding the operative technique and the durability of the procedure. Methods A retrospective study of 808 patients undergoing 838 LNF for GERD at a tertiary referral center was undertaken. Demographic, perioperative, and follow-up data had been entered onto the unit database. Results During a median follow-up period of 60 months (range, 2–120 months), heartburn decreased to 3% of the patients (19/645) and regurgitation to 2% (11/582) (p < 0.01). Respiratory symptoms improved in 69 (85%) of 81 patients (p < 0.01). The incidence of postoperative dysphagia was unaffected by the use of an intraesophageal bougie (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.82–1.64; p = 0.41) or division of the short gastric vessels (OR, 0.84; 95% CI, 0.42–1.07; p = 0.72). In the immediate postoperative period, the incidence of abdominal symptoms increased by 10% (p < 0.01) and dysphagia by 16% (p < 0.01). After 10 postoperative years, only 3% (30/484) were found to have abdominal symptoms, whereas the incidence of dysphagia declined to zero. Conclusion The findings show that LNF is a safe and effective procedure with long-term durability. Abdominal symptoms and dysphagia are the principal postoperative complaints, which improve with time. Personal preference should dictate the use of a bougie, division of the short gastric vessels, or both.     

A budget impact analysis of a magnetic sphincter augmentation device for the treatment of medication-refractory mechanical gastroesophageal reflux disease: a United States payer perspective

Medication-refractory gastroesophageal reflux disease (GERD) is sometimes treated with laparoscopic Nissen fundoplication (LNF); however, this is a non-reversible procedure associated with important side effects and the need for repeat surgery. Removable magnetic sphincter augmentation (MSA) devices are an alternative, effective, and safe treatment option for such patients who have some lower esophageal sphincter function. The objective of this study was to assess the economic impact of introducing MSA technology (i.e., LINX Reflux Management System) into current practice from a US-payer perspective. An economic budget impact model was developed over a 1-year time horizon that compared current treatment of GERD patients who are medically managed (but refractory) or receiving LNF to future treatment of GERD patients that included a mix of patients treated with medical management only, LNF, or MSA. Resources included within the analyses were index procedures (inpatient and outpatient use), reoperations (revisions and removals), readmissions, healthcare visits, diagnostic tests, procedures, and medications. Medicare payment rates were typically used to inform unit costs. Assuming a hypothetical commercial insurance population of 1 million members, the base-case analysis estimated a net cost savings of $111,367 with introduction of the MSA. This translates to a savings of $0.01 per member per month. Results were largely driven by avoided inpatient procedures with use of the MSA device. Alternative analyses exploring the potential impact of increasing surgical volumes predicted that results would remain cost saving if the proportion of MSA market share taken from LNF was ≥ 90%. This study predicts that the introduction of the MSA device would lead to favorable budget impact results for the treatment of medication-refractory mechanical GERD for commercial payers. Future analyses will benefit from inclusion of middle-ground treatments as well as longer time horizons.     

Significant weight loss after laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication (LNF) has evolved as a gold standard in antireflux surgery. However, the association between body weight and gastroesophageal reflux disease (GERD) is still unclear, and no data are available concerning the effect of fundoplication on body weight. We present the first report elucidating the impact of LNF on body weight in GERD patients with special emphasis on patients quality of life.Methods From July 2000 to March 2003, LNF was carried out in 213 patients (85 women and 128 men) after thorough preoperative examination including clinical interview with standardized assessment of symptoms and quality of life (QoL), endosocopy, barium swallow, 24-h pH-metry, and manometry. Follow-up investigations were performed 3 and 12 months after LNF obtainable from 209 patients (98.1%) and 154 patients (72.3%), respectively.Results The mean body mass index (BMI) decreased significantly after LNF (27.6 ± 5.6 kg/m² before LNF vs 26.0 ± 3.8 kg/m² after LNF, p < 0.001). Twelve months after LNF, neither a tendency toward a renewed increase nor a further decrease in BMI was observable. The average body weight loss was 3.9 kg. BMI reduction was higher in women than in men (p < 0.002), and obese patients lost more weight than lean patients (p < 0.001). There was no association between BMI reduction and dysphagia. Plasma cholesterol and triglyceride levels did not change after LNF. The mean general score of the Gastrointestinal Quality of Life Index markedly improved (90.1 ± 21.3 before LNF vs 118.0 ± 16.2 after LNF, p < 0.01), as did the GERD-Health Related Quality of Life Index (21.9 ± 6.4 before LNF vs 3.5 ± 2.7 after LNF, p < 0.001). However, there was no association between changes in BMI and QoL.Conclusion LNF leads to significant and persistent body weight loss.     

Ineffective Esophageal Motility in Patients with GERD is no Contraindication for Nissen Fundoplication

Background

Patients with preoperative ineffective esophageal motility (IEM) are thought to be at increased risk for postoperative dysphagia leading to the recommendations for tailoring or avoiding anti-reflux surgery in these patients. The aim of this study was to evaluate if IEM has an influence on postoperative outcome after laparoscopic Nissen fundoplication (LNF).

Methods

Seventy-two consecutive patients with IEM underwent LNF and were case-matched with 72 patients without IEM based on sex, age, BMI, HH size, total pH percentage time, total number of reflux episodes and the presence of BE. Standardized interview assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake, GERD-health-related-quality-of-life (GERD-HRQL), alimentary satisfaction and patients’ overall satisfaction was evaluated.

Results

Although a higher rate of preoperative dysphagia was observed in patients with IEM (29% IEM vs. 11% no IEM, p = 0.007), there was no significant difference in rates of dysphagia postoperatively (2 IEM vs. 1 no IEM, p = 0.559). Furthermore, no distinction was found in the postoperative outcome regarding symptom relief, quality of life, gas bloating syndrome, ability to belch and/or vomit or revision surgery between the two groups.

Conclusion

Although preoperative IEM has an influence on GERD presentation, it has no effect on postoperative outcome after LNF. IEM should not be a cause for avoiding LNF, as is has been shown as the most effective and safe anti-reflux treatment.

     

Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease (GERD)

Background: A prospective study was conducted to evaluate the physiologic and clinical consequences of laparoscopic Nissen fundoplication (LNF), using strict indications for surgery. Methods: From 1992 to 1997, 50 patients underwent LNF. Indications for operative treatment were either failure of conservative treatment or foresight to see long-term use of strong acid suppressive therapy. Patients were evaluated by barium esophagogastric study (BES), esophagoscopy, 24-h pH monitoring (pHM), stationary esophageal manometry, gastric-emptying studies (GES), pancreatic polypeptide stimulation test (PPT) and clinical evaluation using questionnaires. Results: Perioperative complications necessitated conversion to laparatomy in two cases, and there was no mortality. Severe dysphagia resulted in reoperation in two patients. The average maximum lower esophageal sphincter pressure (MLESP) increased from 6.1 mmHg to 12.7 mmHg. Endoscopy showed improved grading of the esophagitis, and the total percentage of pH less than 4 during 24 h decreased from a mean of 9.2 to 0.95. Three patients demonstrated impaired PPTs postoperatively; two had (mild) diarrhea. The overall success rate after the operation was 90%. Conclusions: The results of LNF in a limited number of patients with severe and/or resistant gastroesophageal reflux disease (GERD) receiving continuous medical treatment with proton pump inhibitors (PPIs) on a maintenance base are comparable with LNF results in centers with a more liberal policy concerning indications for LNF surgery. Received: 15 September 1997/Accepted: 12 October 1997     

Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive value of preoperative assessment

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has established itself as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). There are, however, few available data on the assessment of long-term failures after LNF. METHODS: We sought to clarify the mechanisms of failure among a group of patients who reported suboptimal results after LNF. In addition, we attempted to identify specific elements in the preoperative evaluation of GERD patients that might herald a predisposition to anatomical or physiological failure. RESULTS: One hundred and thirty-one consecutive patients who underwent LNF by a single surgeon were analyzed to identify reasons for surgical failure. Fourteen patients (10.6%) comprised the failure group. Detailed independent statistical analysis identified a hiatus hernia greater than 3 cm at operation (P = 0.003), abnormal preoperative pH analysis in the upright position (P = 0.039), failure to respond to proton pump inhibition preoperatively (P = 0.015), and a preoperative psychiatric history (P = 0.0012) as predictors of subsequent failure. CONCLUSIONS: In patients who do not respond to proton pump inhibition preoperatively, the evaluating surgeon should be circumspect in advocating antireflux surgery. A detailed assessment of underlying psychiatric or psychological symptoms must also be made. If a large (>3 cm approximately) hiatus hernia is identified or there is abnormal pH analysis in the upright position preoperatively, the surgeon should be guarded about the long-term outcome, and patients should be advised accordingly.     

Endoluminal gastroplasty: a new treatment for gastroesophageal reflux disease

Initial studies demonstrate that EndoCinch is safe and may be an effective outpatient procedure. Symptom improvement, reduction in medication requirements, and ultrasound evidence of muscle hypertrophy are encouraging. The durability of these benefits remains in question. Seventeen percent of patients require a repeat gastroplication to achieve a satisfactory result and some elect to undergo laparoscopic Nissen fundoplication. Additional investigations are required to assess the number and location of the plications for optimal patient outcome. Prospective randomized studies comparing ELGP to medical and surgical treatments of GERD may be appropriate after device refinements. Of additional importance is the possibility of a cure with an ELGP. Patients who are self-medicated or noncompliant often are willing to seek consultation if a noninvasive curative procedure is available. One third of these patients have advanced disease and are treated best with surgery rather than an ELGP; thus, surgeons should be involved with ELGP for GERD control.     

Laparoscopic fundoplication

BACKGROUND: The effectiveness of laparoscopic Nissen fundoplication (LNF) was assessed in patients with chronic gastroesophageal reflux disease (GERD) using pH study and different quality-of-life indexes. We correlated both types of data and hypothesised that improvement in quality of life following LNF does not necessarily correlate with improvement in pH values. METHODS: Seventy patients presenting with typical symptoms of GERD (14 with Barrett's esophagus) underwent LNF between May 1997 and December 2000. All patients were evaluated both prior to and 3 months after surgery using 24-h pH study, endoscopy, and a validated quality-of-life questionnaire. RESULTS: Following LNF, reflux was reduced to normal in all but six patients. Howevers despite persistent reflux, the Gastrointestinal Quality of Life Index (GQLI), of these six patients improved postoperatively from 79.5 +/- 12.2 to 111.7 +/- 8.3. These results correlate with those of patients who had normal postoperative pH studies-namely, 88.5 +/- 19.3 to 112 +/- 16.7. There was no difference in quality-of-life improvement between patients with Barrett's esophagus and those without it. CONCLUSION: There is only a weak correlation between quality-of-life assessment and pH study. Because the patient's quality of life is likely to improve following LNF, an objective means parameter of assessing the effectiveness of antireflux surgery, such as pH study or endoscopy, is recommended.     

Impact of laparoscopic Nissen’s fundoplication on response of disease specific symptoms and quality of life

The aim of this study is to establish responsiveness of gastroesophageal reflux disease (GERD) symptom score, quality of life SF-36 score in GERD with relation to oesophageal manometry and upper gastrointestinal endoscopy following laparoscopic Nissen’s fundoplication (LNF). Interventional prospective study was done enrolling 77 patients of GERD who respond to proton pump inhibitor (PPI) and have undergone LNF, strict diagnostic criteria were followed with GERD score, upper gastrointestinal endoscopy, oesophageal manometry, and endoscopically negative patients have further undergone 24-h pH study. Follow-up was done at 12 and 24 months by GERD score, SF-36 score, endoscopy, oesophageal manometry. GERD score shows significant difference in pre-operative and post-operative score with P value <0.001 except dysphagia. Post-LNF improvement in GERD score is consistent with improvement in lower oesophageal sphincter (LES) pressure at 12 months. All dimensions in quality of life SF-36 show significant difference in pre-operative and post-operative score at 12 months with P value <0.001. Results are consistent at 24 months. Oesophagitis was decreased from 40.2 to 11.6 % as well as it showed down grading on endoscopy in post-operative period. Out of three patients of complete disruption of wrap, two patients underwent redo surgery and showed improvement. In properly diagnosed PPI respondent patients by GERD score, LNF has got improvement in GERD score, quality of life in all dimensions of SF-36 score in relation to improvement with LES pressure and oesophagitis.     

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.     

Evaluation of supplemental cautery during endoluminal gastroplication for the treatment of gastroesophageal reflux disease

Background  Endoscopic suture plications at the cardia decreased gastroesophageal reflux disease (GERD) symptoms in short-term studies. Pull-through of submucosal sutures may lead to loss of efficacy. The application of cautery on mucosal surfaces may promote tissue adherence. This study aimed to compare the efficacy of endoluminal gastroplication (ELGP) using Endocinch with and without adjuvant cautery. Methods  Vertical plications were created using ELGP. Patients were randomized to either ELGP alone or ELGP with an adjuvant bicap cautery. Patients were blinded to their randomization category and encouraged to take antisecretory medications if needed. Heartburn was scored on a scale of 0 (none), 1 (occasional), 2 (frequent), or 3 (daily). Patients undergoing a second antireflux procedure during the follow-up period were considered study failures and scored 3. Results  Of the 18 patients enrolled in the study, 1 was lost to follow-up evaluation at 12 months and 2 could not be followed up at 24 months. The cautery group included 10 patients (9 men) with a mean age of 53.2 years. The group without cautery consisted of 8 patients (5 men) with a mean age of 50.4 years. The use of ELGP with cautery resulted in a trend toward greater improvement in several parameters (heartburn score, total percentage of time that pH was less than 4, and medication use) at 12 months than ELGP without cautery. These trends were not seen at 24 months, when all but 1 patient had ongoing symptoms, used daily proton pump inhibitor/H2-blocker, or went on to undergo a second antireflux procedure (2 Nissen and 3 Enteryx). Conclusions  Cautery numerically improved plication persistence, decreased esophageal acid exposure, and improved symptoms at 1 year compared with sutures alone. Little or no long-term efficacy of ELGP with or without cautery was observed after 2 years of follow-up evaluation.     

Outcome of laparoscopic Nissen fundoplication in patients with body mass index ≥35

Background To date, few studies have examined the effect of morbid obesity on the outcome of laparoscopic antireflux surgery and results have been conflicting. The aim of this work was to study the outcome of laparoscopic Nissen fundoplication (LNF) in patients with body mass index (BMI) ≥ 35. Methods We prospectively followed 70 patients (15 men, 55 women) with a proven diagnosis of gastroesophageal reflux disease (GERD) and a mean BMI of 38.4 ± 0.5 (range, 35–51) who underwent LNF. All patients underwent 24-h pH study, esophageal manometry, upper gastrointestinal (GI) endoscopy, and GERD symptom score before and 6 months after LNF. Surgical outcomes were compared to those of 70 sequential nonobese patients (BMI < 30) who also underwent LNF. Results LNF was completed laparoscopically in 69 of 70 patients in the morbidly obese (MO) group and in all 70 patients in the normal-weight (NW) group. The mean operative time for the MO group was not significantly longer than that for the NW group (55.9 ± 2.3 min vs 50.0 ± 2.1 min), but the mean length of stay was significantly longer (3.17 ± 0.2 days vs 2.2 ± 0.1 days, p < 0.0001) in the MO group. There was one postoperative complication (a transhiatal herniation of the stomach) in the morbidly obese group. In both patient groups, LNF resulted in a significant increase in lower esophageal sphincter (LES) pressures. This was associated with a significant decrease in percent acid reflux in 24-h testing and a significant improvement in GERD symptom score in both groups, although patients in the MO group had a significantly higher mean reflux symptom score after surgery than did those in the NW group. After a mean follow-up of 41.6 ± 2.9 months, one patient in the MO group required reoperation and one proton pump inhibitor therapy (PRN PPI), as required. Conclusions Morbid obesity does not adversely affect the outcome of LNF. The conversion rate is low when performed by an experienced surgeon. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Los Angeles, CA, USA, 12–15 March 2003     

腹腔镜Nissen胃底折叠术治疗胃食管反流病

目的 探讨腹腔镜Nissen胃底折叠术治疗胃食管反流病的效果.方法 对近2年来收治的109例胃食管反流病实施腹腔镜Nissen胃底折叠术患者的临床资料进行回顾性分析.结果 108例成功完成手术.1例因难以控制的脾上极胃短血管出血而中转开腹.手术用时30-245(平均68.1)min,术中出血5～450(平均30.0)mL;术后住院天数2～8(平均4.2)天.术后102例获3～27个月的随访,7例失访.随访患者中99例(97.1%)反酸、烧心等消化道症状基本消失,2例(2.0%)明显缓解,1例(0.9%)无效.术后2例出现较严重的吞咽困难,1例严重上腹胀气,2例腹泻,1例出现术后食管裂孔疝.结论 腹腔镜Nissen胃底折叠术是治疗胃食管反流病的一种微创、安全、有效的治疗方法.     

Laparoscopic versus open fundoplication in infants

BACKGROUND: Laparoscopic esophagogastric fundoplication is an effective treatment for severe gastroesophageal reflux disease (GERD), although its role in the very young is still largely undetermined. We review our surgical outcome in infants with severe GERD, comparing laparoscopic (LNF) with open (ONF) Nissen fundoplication. METHODS: This study reviewed 55 consecutive Nissen fundoplications performed for GERD on infants less than 1 year old at our institution between January 1996 and June 2000. The follow-up period for LNF averaged 14.2 months (range, 3.3-42 months), as compared with 16.5 months (range, 1-37.1 months) for ONF (p was not significant, t-test). Surgical outcome was compared in terms of the following parameters: average operative time, times to initiation and completion of feeding schedule, postoperative complications, and recurrence rates. RESULTS: For the study, 53 infants were divided into two groups: LNF (n = 39; 73.6%) and ONF (n = 14; 26.4%). The average operating time for LNF was 120 +/- 24 min (range, 60-195 min), as compared with 91 +/- 21 min (range, 60-135 min) for ONF (p < 0.05, t-test). Time to initiation of postoperative feeding schedule was 1.3 +/- 0.3 days for LNF, as compared with 3 +/- 0.9 days for ONF (p < 0.05, t-test). Full feedings were reached in 1.7 +/- 0.6 days for LNF, as compared with 1.3 +/- 0.9 for ONF (p was not significant, t-test). During the short-term follow-up period, recurrent reflux developed in 2/14 ONF patients (14.3%) as compared with 1/39 LNF patients (2.6%) (p < 0.05). CONCLUSIONS: We conclude that in addition to sparing infants the morbidity of celiotomy, laparoscopic Nissen fundoplication had a surgical outcome comparable to that of traditional open fundoplication in infants with severe GERD. Importantly, resumption of goal nutritional regimens was equally efficient in both groups.     

Laparoscopic Nissen fundoplication: two-year comprehensive follow-up of a technique of minimal paraesophageal dissection.

OBJECTIVE: To provide a comprehensive follow-up of 381 patients after laparoscopic Nissen fundoplication (LNF) using a technique of minimal paraesophageal dissection. METHODS: Patients underwent a 24-hour pH recording, esophageal manometry, and symptom score assessment for six symptoms of gastroesophageal reflux disease preoperatively. To date, 260 patients have undergone repeat studies at 6 months and 108 patients at 2 years. RESULTS: LNF was associated with a significant (p < 0.0001) increase in the lower esophageal sphincter (LES) pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours and symptom score 6 and 24 months after surgery when compared to preoperative values. Twelve patients (3%) have experienced recurrence of reflux symptoms, 8 presenting in the first 6 months and 4 by the second year after surgery, but only 1 has required repeat surgery. The incidence of clinical dysphagia was found to be 1.3% of the patient group. CONCLUSIONS: LNF remains an effective antireflux procedure at 2 years. Most recurrences occur early, and there is no significant deterioration in the high-pressure zone at the LES, the percentage reflux in 24 hours, or symptom control between 6 months and 2 years after surgery, suggesting that the long-term results should be satisfactory.     

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.