Laparoscopic anterior 90 degree fundoplication for reflux or large hiatus hernia

Anterior 90 degree partial fundoplication has been proposed as technique to minimize the risk of side-effects following surgery for gastro-oesophageal reflux. We have applied this approach for the treatment of gastro-oesophageal reflux and/or large hiatus hernias. Previous studies have shown that this type of procedure can achieve good control of reflux, with fewer side-effects. However, only short-term follow up has been reported. In this study, we determined later clinical outcomes in patients who have undergone this procedure. All patients who underwent a laparoscopic anterior 90 degree partial fundoplication surgery were identified from a database, which collected prospective clinical data. Patients completed a standardized questionnaire 3 months after surgery and then yearly to assess clinical symptoms of reflux and postoperative side-effects. Between February 1999 and January 2006, 246 patients underwent surgery--74 in conjunction with repair of a large hiatus hernia and 172 for reflux. Three patients underwent further surgery within 2 days of the original procedure (one for repair of a perforated oesophagus) and four underwent later surgical revision (reflux 3, dysphagia 1). Clinical follow-up data were available for 98% at 3-84 months (median 36). Most patients had effective relief of reflux symptoms at up to 3 years follow up. Dysphagia scores improved following surgery. The magnitude of this improvement was greater in patients with large hiatus hernias. More than 80% of the patients were able to belch normally at all time points after surgery and most were highly satisfied with the overall outcome. Satisfaction scores were higher following repair of a large hiatus hernia. The clinical results of laparoscopic anterior 90 degree fundoplication for either reflux or as part of repair of a large hiatus hernia are encouraging, although longer-term follow up is required to confirm durability of reflux control.     

Laparoscopic Nissen fundoplication: five-year results and beyond

HYPOTHESIS: Laparoscopic Nissen fundoplication provides long-term relief of symptoms of gastroesophageal reflux disease. DESIGN: Prospectively evaluated case series. SETTING: University teaching hospital. PATIENTS: From September 1991 to December 1999, we performed more than 900 laparoscopic antireflux procedures. The outcome for patients who underwent surgery between September 1991 and June 1994 (178 cases) was determined. This included all patients having laparoscopic Nissen fundoplication, from the first procedure onward. INTERVENTIONS: Long-term follow-up for 5 or more years after laparoscopic Nissen fundoplication was obtained by an independent investigator who interviewed patients using a structured questionnaire. MAIN OUTCOME MEASURES: Prospective evaluation of clinical symptoms using a structured questionnaire. RESULTS: Outcome data covering a period of 5 or more years after surgery was available for 176 patients (99%), with 2 patients lost to follow-up. Nine patients died (8 of unrelated causes) at some stage following surgery, and the outcome was difficult to determine in 1 patient with cerebral palsy. Hence, questionnaire data were available for 166 patients at a median follow-up of 6 years (range, 5-8 years). Three patients (1.7%) underwent revision surgery for recurrent reflux; 87% of the 176 patients remained free of significant reflux. Reoperation was required for dysphagia in 7 patients (3.9%), 2 for a tight wrap and 5 for a tight diaphragmatic hiatus. In addition, reoperation was necessary for a paraesophageal hiatus hernia in 13 patients (7.3%). Of the reoperations, 56% were performed within 12 months of the original procedure, and 22% during the second year of follow-up. Further surgery was uncommon after 2 years. The long-term outcome was considered "good or excellent" by 90% of patients. CONCLUSIONS: The long-term outcome of laparoscopic Nissen fundoplication is similar to that following open fundoplication. Good results are obtained in most patients.     

Late laparoscopic reoperation of failed antireflux procedures

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.     

Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group

BACKGROUND: Laparoscopic fundoplication effectively controls reflux symptoms in patients with gastroesophageal reflux disease (GERD). However, symptom relapse and side effects, including dysphagia and gas bloat, may develop after surgery. The aim of the study was to assess these symptoms in patients who underwent laparoscopic fundoplication, as well as in control subjects and patients with hiatal hernia. METHODS: A standardized, validated questionnaire on reflux, dysphagia, and gas bloat was filled out by 115 patients with a follow-up of 1 to 7 years after laparoscopic fundoplication, as well as by 105 subjects with an incidentally discovered hiatal hernia and 238 control subjects. RESULTS: Patients who underwent fundoplication had better reflux scores than patients with hiatal hernia ( P = .0001) and similar scores to control subjects ( P = .11). They also had significantly more dysphagia and gas bloat than patients with hiatal hernia and controls ( P < .005 for all comparisons). Gas bloat and dysphagia were more severe in hiatal hernia patients than in controls ( P < 0.005). After fundoplication, the 25% of the patients with the shortest follow-up (1.5 +/- 0.2 years) and the 25% patients with the longest follow-up (5.8 +/- 0.6 years) had similar reflux, dysphagia, and gas bloat scores ( P = .43, .82, and .85, respectively). CONCLUSION: In patients with severe GERD, laparoscopic fundoplication decreases reflux symptoms to levels found in control subjects. These results appear to be stable over time. However, patients who underwent fundoplication experience more dysphagia and gas bloat than controls and patients with hiatal hernia-symptoms that should be seen as a side effect of the procedure and of GERD itself.     

胃食管反流病的腹腔镜外科治疗

目的:探讨腹腔镜手术治疗胃食管反流病的临床效果.方法:回顾性分析2008年1月—2011年9月对33例胃食管反流病患者行腹腔镜食管裂孔疝修补和胃底折叠术的临床资料.腹腔镜单纯胃底折叠术5例(Toupet式),腹腔镜食管裂孔疝修补加胃底折叠术25例(Nissen式3例,Toupet式22例),腹腔镜单纯食管裂孔疝修补术3例.结果:全组患者手术均获成功,手术时间90～185 min.术后平均住院6d.无中转开腹及死亡病例,无术后严重并发症.术后随访1～24个月,32例临床症状完全消失,1例明显好转.结论:对于胃食管反流性疾病,腹腔镜食管裂孔疝修补和胃底折叠术是一种微创、安全、有效的治疗方法.     

先天性食管裂孔疝的诊断及外科治疗

目的：回顾性分析1991年1月至2000年2月经手术治疗的27例先天性食管裂孔疝病例,探讨其诊断,手术适应证,手术入路选择等。方法：依据胃肠钡餐造影及术中探查明确诊断及分型,全部病儿均行食管裂孔修补术,21例附加抗反流手术,其中Nissen胃底折叠术17例,Belsey术4例。经左胸入路手术9例,右胸入路3例,经腹15例。结果：手术死亡1例,失访3例。23例随访3－84个月,平均21．3个月。1例术后3个月复发,2例经右胸入路手术者有中度胃食管反流,其余效果满意。结论：1型病儿可先试行非手术治疗,其余各型应首先考虑手术。有呕吐及胃食管反流的Ⅱ型病儿应行抗反流手术。手术入路的选择与合并症有关。     

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.     

Reoperation of esophageal achalasia]

From 1980 to 1989, 18 patients with esophageal achalasia had postoperative restricture. Inadequate myotomy was shown in 7 patients, scar constriction in 5, gastroesophageal reflux in 3, and paraesophageal hiatus hernia in 1. Seventeen patients underwent reoperation including modified myotomy (11), esophagastrotomy (4), operation for esophageal hiatus hernia (1), and cardioplasty combined with fundoplication (1). The causes of restricture, diagnostic methods, operative procedure and methods of precaution are discussed.     

Early reoperation following laparoscopic antireflux surgery

PURPOSE: To assess the outcome for patients undergoing early reoperation following laparoscopic antireflux surgery. METHODS: The outcome was prospectively determined for 28 patients who underwent 30 reoperative procedures within 4 weeks of their initial laparoscopic fundoplication between 1992 and 1998. Follow-up ranged from 3 months to 4 years (median 2 years). Before mid 1994, patients were assessed and managed based on clinical findings (first 192 patients in overall series), whereas subsequently (for the most recent 530 patients) all patients underwent routine early postoperative barium swallow radiography, and laparoscopic exploration during the first postoperative week if problems were suspected. RESULTS: The reoperations were performed for acute paraoesophageal hiatus hernia (8 patients), tight oesophageal hiatus (7), postoperative haemorrhage (3), tight Nissen fundoplication (8), early recurrent reflux (1), and coeliac/superior mesenteric artery thrombosis (1). Two patients required a second operation for persistent dysphagia due to a tight hiatus. Both patients initially underwent loosening of their fundoplication. Before mid 1994, reoperations were usually undertaken by an open approach, whereas subsequently a laparoscopic approach has usually been successful. Laparoscopic reintervention was easily achieved within 7 days of the first procedure whereas subsequent surgery was more difficult and often required open surgery. The change in protocol was associated with an improvement in overall patient satisfaction and dysphagia in the latter part of this experience. CONCLUSIONS: Routine early contrast radiology following laparoscopic fundoplication and a low threshold for laparoscopic reexploration facilitates early identification of postoperative problems at a time when laparoscopic correction is easily achieved. This may result in an improved overall outcome for patients requiring early reintervention following laparoscopic antireflux surgery.     

Durability of laparoscopic repair of paraesophageal hernia.

OBJECTIVES: To define a method of primary repair that would minimize hernia recurrence and to report medium-term follow-up of patients who underwent laparoscopic repair of paraesophageal hernia to verify durability of the repair and to assess the effect of inclusion of an antireflux procedure. SUMMARY BACKGROUND DATA: Primary paraesophageal hernia repair was completed laparoscopically in 55 patients. There were five recurrences within 6 months when the sac was not excised (20%). After institution of a technique of total sac excision in 30 subsequent repairs, no early recurrences were observed. METHODS: Inclusion of an antireflux procedure, incidence of subsequent hernia recurrence, dysphagia, and gastroesophageal reflux symptoms were recorded in clinical follow-up of patients who underwent a laparoscopic procedure. RESULTS: Mean length of follow-up was 29 months. Forty-nine patients were available for follow-up, and one patient had died of lung cancer. Mean age at surgery was 68 years. The surgical morbidity rate in elderly patients was no greater than in younger patients. Eleven patients (22%) had symptoms of mild to moderate reflux, and 15 were taking acid-reduction medication for a variety of dyspeptic complaints. All but 2 of these 15 had undergone 360 degrees fundoplication at initial repair. Two patients (4%) had late recurrent hernia, each small, demonstrated by esophagram or endoscopy. CONCLUSIONS: Laparoscopic repair in the medium term appeared durable. The incidence of postsurgical reflux symptoms was unrelated to inclusion of an antireflux procedure. In the absence of motility data, partial fundoplication was preferred, although dysphagia after floppy 360 degrees wrap was rare. With the low morbidity rate of this procedure, correction of symptomatic paraesophageal hernia appears indicated in patients regardless of age.     

Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy

Symptomatic gastroesophageal reflux after Nissen fundoplication may occur if the wrap herniates into the thorax. In an attempt to prevent recurrent hiatal hernia we employed polytetrafluoroethylene (PTFE) mesh reinforcement of posterior cruroplasty during laparoscopic Nissen fundoplication and hiatal herniorrhaphy. Three patients with symptomatic gastroesophageal reflux and a large (≥8 cm) hiatal defect underwent laparoscopic posterior cruroplasty and Nissen fundoplication. The cruroplasty was reinforced with a PTFE onlay. No perioperative complications occurred, and in follow-up (≤11 months) the patients are doing well. When repairing a large defect of the esophageal hiatus during fundoplication, the surgeon may consider reinforcement of the repair with PTFE mesh. Received: 5 March 1996/Accepted: 3 June 1996     

Laparoscopic anterior 180 degrees partial fundoplication: five-year results and beyond

HYPOTHESIS: Laparoscopic anterior 180 degrees partial fundoplication provides good long-term relief for symptoms of gastroesophageal reflux disease and is associated with few adverse effects. DESIGN: Prospectively evaluated case series. SETTING: University teaching hospital. PATIENTS: The late clinical outcome was determined for all patients who had undergone a laparoscopic anterior 180 degrees partial fundoplication by us between August 1, 1993, and November 30, 1999. INTERVENTIONS: Long-term (>/=5 years') follow-up after laparoscopic anterior 180 degrees partial fundoplication was obtained using a structured questionnaire. MAIN OUTCOME MEASURES: Overall satisfaction and the symptoms of heartburn and dysphagia were assessed using analog scales, and the presence or absence of other adverse outcomes was also determined. RESULTS: One hundred seventeen procedures were performed. The outcome at 5 to 11 years' (mean, 6.4 years') follow-up was determined for 113 patients (97%). Twelve patients (11%) died of unrelated causes during follow-up, and 1 patient underwent esophagectomy. Further surgery was undertaken in 12 patients (11%): 8 for recurrent reflux, 3 for a symptomatic hiatal hernia, and 1 for dysphagia. For 100 patients with clinical outcome data at late follow-up, gastroesophageal reflux symptoms were significantly improved following surgery and were well controlled in 80 patients. The incidence and severity of dysphagia were reduced after surgery. Normal belching was preserved in 91 patients, and almost all patients were able to eat normally. The overall outcome of surgery was rated as satisfactory, with 95 patients reporting that they considered their original decision to undergo surgery correct. CONCLUSIONS: Laparoscopic anterior 180 degrees partial fundoplication is an effective procedure for the surgical treatment of gastroesophageal reflux and is associated with a high rate of patient satisfaction at late follow-up. Compared with Nissen fundoplication, however, it is likely to be associated with a higher risk of recurrent reflux, although this is balanced by a lower rate of adverse effects.     

Failed fundoplications

BACKGROUND: Five percent of patients who undergo fundoplication will require reoperation. The cause of this high failure rate and the best management for these patients remains poorly understood. The aim of this study was to identify patterns and causes of failure of primary antireflux procedures. METHODS: Retrospective review of the medical records of patients who underwent revisional antireflux surgery at 2 tertiary referral centers. RESULTS: Between 1998 and 2003, 39 patients underwent laparoscopic revisional antireflux surgery. The time between primary and revisional surgery was 5.9 +/- 0.4 years. Primary operations included 26 laparoscopic and 13 open fundoplications. All of the 39 revisional operations were attempted laparoscopically, and there was 1 open conversion. Revisional procedures included 31 Nissen and 8 partial fundoplications. The duration of surgery was 138 +/- 10 minutes. Length of hospital stay was 2.1 +/- 0.3 days. At a mean follow-up of 6 months, reflux resolved in 94% of patients. Morbidity occurred in 23% of patients. Four types of failure were identified: type 1 = herniation of the gastroesophageal junction through the hiatus with or without the wrap (n = 21); type 2 = paraesophageal hernia (n = 9); type 3 = malformation of the wrap (n = 2). Six patients had primary wrap failure, and 1 had esophageal dysmotility. CONCLUSIONS: Laparoscopic revisional antireflux surgery is effective treatment for patients with failed primary fundoplications. Successful revisional surgery depends on identification and correction of the reason for primary fundoplication failure.     

Immediate postoperative complications after a laparoscopic partial posterior fundoplication. Early laparoscopic reoperation

AIM OF THE STUDY: The immediate postoperative course of laparoscopic partial posterior fundoplication can be complicated by severe dysphagia or paraesophageal hernia. The aim of this study was to describe the technical causes of these complications. PATIENTS AND METHOD: Four patients, operated for gastroesophageal reflux disease by laparoscopic partial posterior fundoplication, developed severe dysphagia (n = 2) or paraesophageal hernia (n = 2) during the immediate postoperative period. A barium swallow examination visualized the complication in both cases of dysphagia and in 1 case of paraesophageal hernia. The correct diagnosis was established by CT scan in the other case of paraesophageal hernia. Reoperations were performed by laparoscopy, 3 days (n = 2) or 6 days (n = 2) postoperatively. RESULTS: Dysphagia was due to compression of the esophagus against the hiatus by the fundoplication. A new and looser fundoplication was easily performed. Dysphagia was no longer present postoperatively. The two patients were symptom-free after 6 and 12 months of follow-up, respectively. In the cases of paraesophageal hernia, the bottoms of the crura were torn. In the patient reoperated 3 days postoperatively, the procedure was easily performed, the postoperative course was uneventful and the patient was symptom-free after a follow-up of 20 months. In the patient reoperated 6 days postoperatively, the upper part of the stomach had moved into the left pleural cavity, the procedure was difficult due to inflammation and thickening of the gastric wall, and the postoperative course was uneventful, but reflux recurred 18 months later. CONCLUSION: When severe dysphagia or paraesophageal hernia occurs during the immediate postoperative course of laparoscopic partial posterior fundoplication, reoperation, possibly by laparoscopy, identifies and cures the technical defects. Based on our experience, we suggest that surgical cure of paraesophageal hernia is easier when performed during the immediate postoperative period.     

儿童腹腔镜下胃底折叠术10年小结

目的探讨腹腔镜下不同胃底折叠术治疗儿童胃食管反流性疾病的疗效。方法回顾性分析2000年10月～2011年2月10年中2个儿童医疗中心收治儿童胃食管反流性疾病81例(上海儿童医学中心30例,新华医院51例)临床资料,包括食管裂孔疝76例,单纯严重胃食管反流5例。男49例,女32例。年龄25天～11岁。2例有食管裂孔疝修补手术史。采用5个5 mm trocar分别经脐和两上腹、两侧中腹部进腹,保留脾胃韧带完成食管裂孔疝修补和胃底折叠术。结果79例镜下完成手术(包括Nissen-Rossetti术37例,Thal术42例),2例中转开放手术。出院前均行食管钡餐(GI)复查,37例Nissen-Rossetti术后9例轻～中度食管下端狭窄,1～2次扩张后缓解症状;42例Thal术后7例存在轻度反流。术后69例获随访,时间2个月～7年,平均26个月。2例食管裂孔疝术后1个月复发,再次镜下手术,1例证实膈肌脚尼龙缝合线松脱,1例裂孔关闭不够,仍有一较小旁疝形成,均再次镜下修补,术后恢复好;1例术后出现发作性腹痛伴呕吐;1例智力发育障碍者术后吞咽功能退化,顽固性拒食,长期鼻胃管喂养;2例胃食管轻～中度反流伴有胃动力差。其余63例术后生长发育好,术前临床症状消失。结论①腹腔镜下胃底折叠术治疗各种原因导致的儿童胃食管反流是一种安全有效的手术途径。②对于食管裂孔疝,选择镜下Thal术可有效减少术后食管狭窄的发生。③对于严重胃食管反流,选择Nissen-Rossetti术,术后抗反流效果更确切,与传统的Nissen术相比,保留胃短血管的Nissen-Rossetti术操作更简便。     

360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease

Background: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However, a relatively high incidence (7–11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication has recently been reported. Methods: Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic 360° fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months. Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform an effective tension-free closure of the hiatus. A polypropylene mesh (3 × 4 cm) was placed on the hiatus behind the esophagus and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses). Results: Between August 1995 and February 1998, the technique, complete with 360° fundoplication, was used for 67 patients with GERD. At mean follow-up of 22.5 months (range, 1–30), there was no evidence of postoperative paraesophageal hernia or complications related to the use of the mesh. Conclusions: This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed. Received: 9 July 1998/Accepted: 19 April 1999     

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.     

Laparoscopic modified Thal fundoplication for gastroesophageal reflux in a patient with severe scoliosis and sliding esophageal hiatal hernia

A 14-year-old girl with severe scoliosis and sliding esophageal hiatal hernia underwent laparoscopic fundoplication for gastroesophageal reflux. Of various fundoplication procedures, anterior partial fundoplication (Thal fundoplication) was performed because it is effective, with less postoperative gas bloat syndrome. Laparoscopic fundoplication in severely scoliotic children could allow improved operative visibility and easier access to the hiatus in comparison with the open approach. In our “modified anterior partial fundoplication,” the sutures between the crura and the esophagus and the sutures on the left of esophageal wall with the fundus of the stomach could be exactly performed by laparoscopic surgical technique. The wrapping of the esophagus in fundoplication was done over the ventral 180° to 270°. Six months postoperatively, the patient did not develop gas bloat syndrome, distal esophageal obstruction from fundoplication, and delayed gastric emptying. Modified anterior partial fundoplication achieves effective control of reflux symptoms.     

Excellent quality of life after Nissen fundoplication depends on successful elimination of reflux symptoms and not the invasiveness of the surgical approach

BACKGROUND: Quality of life, poor in patients with reflux disease, improves significantly after an antireflux operation. The aim of this study was to determine the relative importance of the operative approach used for a fundoplication, as well as the successful elimination of reflux symptoms on long-term quality of life in patients with gastroesophageal reflux disease. METHODS: A questionnaire, including the medical outcome study short-form health survey (SF-36), was completed by 105 patients who had undergone either a laparoscopic Nissen fundoplication (n = 72) or a transthoracic Nissen fundoplication (n = 33); median follow-up was 25 and 31 months, respectively. Patients were classified as completely or incompletely relieved of reflux symptoms based on the frequency of reflux symptoms and the use of acid-suppression medication. RESULTS: Patients selected for transthoracic Nissen fundoplication had significantly worse preoperative gastroesophageal reflux disease based on the presence of a large hiatal hernia, Barrett's esophagus, or stricture. Long-term quality of life was similar for the two approaches, but was significantly decreased in patients with recurrent reflux symptoms. Compared with laparoscopic Nissen fundoplication patients, transthoracic Nissen fundoplication patients were less likely to use acid-suppression medication and tended to be more satisfied with their operation. CONCLUSIONS: Long-term quality of life was independent of the invasiveness of the procedure, but significantly dependent on successful elimination of reflux symptoms and the necessity for acid suppression medication. Patients who underwent a transthoracic Nissen fundoplication, despite having more advanced disease preoperatively, tended to have less reflux symptoms and less long-term acid-suppression medication usage after their procedure. These findings support the continued use of a transthoracic antireflux procedure in patients with advanced gastroesophageal reflux disease.     

Revisional surgery after failed laparoscopic anterior fundoplication.

Background: Partial fundoplication may have functional advantages over a circumferential wrap but the reconstruction is more complex. Revisional surgery for recurrent reflux may be more difficult because of the additional suturing involved in the original operation. We report experience with revisional surgery in a large cohort of patients who had undergone laparoscopic anterior fundoplication and hiatal repair. Methods: Between August 1993 and September 1999, 11 (3.5%) of 309 patients who had laparoscopic anterior fundoplication for uncomplicated gastroesophageal reflux disease required revisional surgery (1 open and 10 laparoscopic revisions). Data were retrieved from a prospective database supplemented by a postal questionnaire following the second operation. Results: The operative findings were posterior hiatal disruption (n = 9), anterior paraesophageal hernia (n = 1), and inadequate initial esophageal mobilization (n = 1). There were no conversions to open surgery in the laparoscopic group. Ten (91%) of the respondents described the outcome of their repeat procedure as either good or excellent. All patients would recommend the repeat procedure to patients with similar symptoms. Conclusions: Revisional surgery after laparoscopic anterior fundoplication can be performed safely with a good outcome. Modifications to technique both in the primary procedure and for revision may decrease the incidence of early technical failure.