Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective?

Background: The elderly have prevalence rates and clinical features of gastroesophageal reflux disease (GERD) similar to those in younger individuals, but the role of laparoscopic antireflux surgery (LARS) in the elderly has not been clearly established. The purpose of this study was to determine if the results of LARS in the elderly are comparable with those in younger patients. Methods: All patients undergoing LARS for GERD at the Washington University Medical Center were entered prospectively into a computerized database. Between May 1992 and June 1998, 339 patients underwent LARS and were divided into two groups based on age: nonelderly (ages, 18–64 years; n= 303) and elderly (age, ≥65 years; n = 36). Data were expressed as mean ± standard deviation (SD) and statistical analysis was performed. Results: Elderly patients had a higher American Society of Anesthesiology (ASA) score (2.3 ± 1.5) and a longer hospital stay (2.1 ± 0.2 days) than the younger group (ASA, 1.9 ± 0.5; hospital stay, 1.6 ± 0.9 days; p < 0.001). Operation times averaged 154 ± 68 min in the elderly compared with 134 ± 49 min in the nonelderly (p= NS). Grade I complications occurred significantly more frequently in the elderly (13.9%) than in the nonelderly (2.6%), but the incidence of grade II complications was similar between the groups (elderly 2.8% vs nonelderly 2.7%). There were no grade III complications in either group, but there was one death in the nonelderly group. At follow-up ranging to 81 months (median, 27 months), the two groups had similar low incidences of heartburn and dysphagia. Anatomic failures of LARS developed in 19 nonelderly patients (6.2%) compared with 2 elderly patients (5.5%; p= NS). Conclusions: As shown in this study, LARS is safe and effective in elderly patients with GERD. Age older than 65 years should not be a contraindication to laparoscopic antireflux surgery in properly selected patients. Received: 3 March 1999/Accepted: 2 April 1999     

Laparoscopic antireflux surgery in the elderly

Background: Laparoscopic antireflux surgery is frequently denied to older patients with gastroesophageal reflux disease (GERD) because of a perceived higher operative complication rate, a decreased impact of the intervention on quality of life, and decreased cost effectiveness. This study compares disease severity, surgical outcomes, and impact on quality of life between elderly and young patients with GERD. Methods: Patients were selected from a prospectively maintained database of 1100 patients who underwent various laparoscopic esophageal procedures at our institution. Only patients having chronic intractable GERD and a minimum 6 months' follow-up were included in the study. Thirty elderly patients with a mean age of 71.2 years (SD ± 5.6) were compared with a group of 30 younger patients (mean age, 43.9 ± 12.8 years). Comparisons were made between subjective and objective outcomes, operative results, and health-related quality of life (HQRL) scores using SF-36 instruments. Results: The preoperative symptom assessment scores (representing frequency of symptoms on a 0-4 scale), and preoperative pH and manometry data were comparable in the two groups. Elderly patients had significantly higher ASA (American Society of Anesthesiologists) scores. Each group demonstrated a significant improvement in the postoperative symptom assessment scores and the esophageal functional studies (p<0.05). However, no significant differences were found in terms of postoperative complications, postoperative hospital stay, postoperative symptom scores, Demeester scores, or the HRQL data. Conclusion: Laparoscopic antireflux surgery in elderly patients improves acid reflux and appears to be safe and effective as measured by postoperative testing in elderly and young 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.     

Laparoscopic revision of failed antireflux operations

BACKGROUND: A small number of patients fail fundoplication and require reoperation. Laparoscopic techniques have been applied to reoperative fundoplications. We reviewed our experience with reoperative laparoscopic fundoplication. METHODS: Reoperative laparoscopic fundoplication was undertaken in 28 patients, 19 F and 9 M, of mean age 56 years +/- 12. Previous antireflux procedures included 19 open and 12 laparoscopic antireflux operations. RESULTS: Symptoms were heartburn (90%), dysphagia (35%), and atypical symptoms (30%%). The mean interval from antireflux procedure to revision was 13 months +/- 4.2. The mean DeMeester score was 78+/-32 (normal 14.7). Eighteen patients (64%) had hiatal breakdown, 17 (60%) had wrap failure, 2 (7%) had slipped Nissen, 3 (11%) had paraesophageal hernias, and 1 (3%) had an excessively tight wrap. Twenty-five revisions were completed laparoscopically, while 3 patients required conversion to the open technique. Complications occurred in 9 of 17 (53%) patients failing previous open fundoplications and in 4 of 12 patients (33%) failing previous laparoscopic fundoplications and included 15 gastrotomies and 1 esophagotomy, all repaired laparoscopically, 3 postoperative gastric leaks, and 4 pneumothoraces requiring tube thoracostomy. No deaths occurred. Median length of stay was 5 days (range 2-90 days). At a mean follow-up of 20 months +/- 17, 2 patients (7%) have failed revision of their fundoplications, with the rest of the patients being essentially asymptomatic (93%). CONCLUSIONS: The results achieved with reoperative laparoscopic fundoplication are similar to those of primary laparoscopic fundoplications. Laparoscopic reoperations, particularly of primary open fundoplication, can be technically challenging and fraught with complications.     

Laparoscopic antireflux surgery. What is real progress?

OBJECTIVE: The authors aim to substantiate, with objective arguments, potential advantages of laparoscopic versus open antireflux surgery in the light of the recent crude experience of the Louvain Medical School Hospital. METHODS: Seventy-two consecutive patients with disabling gastroesophageal reflux disease ([GERD], n = 56), symptomatic hiatal hernia without GERD (n = 5), or unsatisfactory outcome after unsuccessful antireflux procedure (n = 11) were operated on by laparotomy (n = 28), laparoscopy (n = 39), or thoracotomy (n = 5). The antireflux procedure was a subdiaphragmatic Nissen fundoplication (n = 60), an intrathoracic Nissen fundoplication (short esophagus, n = 3), a subdiaphragmatic 240 degrees fundoplication (severe motility disorders, n = 3), a Lortat-Jacob repair (hiatal hernia without GERD, n = 5), and a duodenal diversion (delayed gastric emptying, n = 1). RESULTS: Major postoperative morbidity included two pulmonary embolisms (one laparoscopy patient and one laparotomy patient), and one hemothorax (one thoracotomy patient). Mean hospital stay was 6.4 days for laparoscopy, 7.8 days for laparotomy, and 12.5 days for thoracotomy. Postoperative morphine consumption (patient-controlled analgesia) averaged 47 mg/48 hrs (laparoscopy) versus 46 mg/48 hrs (laparotomy with primary antireflux surgery) (p > 0.05). Although 93% of the laparoscopy patients returned to work within 3 weeks after surgery, 92% of the laparotomy and thoracotomy patients resumed their activity after more than 6 weeks. At follow-up, 87.5% of the patients were asymptomatic or had inconsequential symptoms, 9.8% had disabling side effects, and 2.7% had persistent or recurring esophageal symptoms. There were four parietal herniations, i.e., one incisional hernia and one recurrence of a repaired umbilical hernia in the laparotomy group, and two herniations of the wrap into the chest--probably related to a premature return to manual work--in the laparoscopy group. Three laparoscopy patients were dissatisfied with the esthetics of their scars. Lower esophageal sphincter pressure and esophageal acid exposure in the laparoscopy patients who were investigated were normal in 100% and 95%, respectively. CONCLUSIONS: Laparoscopy is a good approach for achieving successful antireflux surgery in selected cases. However, its fails to substantially reduce postoperative complication rate and discomfort, duration of the hospital stay, and the risk of esthetic sequela. Early return to work is questionable for manual workers. The subdiaphragmatic Nissen fundoplication is not an all-purpose antireflux procedure.     

Long term quality of life after laparoscopic antireflux surgery for the elderly

Background

Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.

Methods

Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

Results

Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).There were 114 (36.6%) patients who filled out the SF36 questionnaire (98 in the younger group, rate: 37.4%; 16 in the elderly group, rate: 32.6%) pre- and post-operatively. There was no significant difference between the two age groups regarding preoperative PCS ( 45.6 ± 7.8 in YG vs. 44.2 ± 8.2 in EG; P = 0.51) and MCS ( 48.1 ± 10.7 in YG vs. 46.9 ± 9.2 in EG; P = 0.67). There was no significant difference between the two age groups regarding postoperative PCS (49.8 ± 11.9 in YG and 48.2 ± 9.5 in EG ; P = 0.61 and MCS (48.4 ± 10.7 in YG vs. 50.1 ± 6.9 in EG; P = 0.54).

Conclusions

In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

     

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.     

Learning curve and his consequences in laparoscopic antireflux surgery

The laparoscopic fundoplication became the gold standard of the laparoscopic antireflux surgery (LARS). Our aim is to indicate the evolution of the learning curve as well as its consequences on the patient's outcome. We studied the gastro-esophageal reflux (GER) cases treated laparoscopically in Col?ea University Hospital throughout 6 years. We gathered a group of 40 patients with an average age of 54, 57 years and a sex ratio F:M = 1.67. The patients had either a simple GER disease, small and medium hiatal hernias (21 cases) or giant hiatal hernias (GHH--19 cases). Two equal groups resulted: group 1 consisted of the first 20 patients operated from 1999 to 2002, group 2 consisted of the rest of the patients. Operating time, hospital time, complication rate and postoperatory endoscopy were compared. The average of the operating time was calculated. For giant hiatal hernias, a separate average was also taken into account. The total operating time for GER, small and medium hiatal hernias was 115 min in group 1 and 80 min in group 2 meanwhile for GHH it was 143 min vs. 130 min. The average operatory time was 129 min vs. 105 min. All these differences were statistically significant but there were no differences concerning complication rate and post-operatory endoscopy. Although the learning of the laparoscopic fundoplication requires practice, the learning curve does not have influence on the patients' outcome.     

Long-Term Results (6–10 Years) of Laparoscopic Fundoplication

Most papers report excellent results of laparoscopic fundoplication but with relatively short follow-up. Only few studies have a follow-up longer than 5 years. We prospectively collected data of 399 consecutive patients with gastroesophageal reflux disease (GERD) or large paraesophageal/mixed hiatal hernia who underwent laparoscopic fundoplication between January 1992 and June 2005. Preoperative workup included symptoms questionnaire, videoesophagogram, upper endoscopy, manometry, and pH-metry. Postoperative clinical/functional studies were performed at 1, 6, 12 months, and thereafter every other year. Patients were divided into four groups: GERD with nonerosive esophagitis, erosive esophagitis, Barrett’s esophagus, and large paraesophageal/mixed hiatal hernia. Surgical failures were considered as follows: (1) recurrence of GERD symptoms or abnormal 24-h pH monitoring; (2) recurrence of endoscopic esophagitis; (3) recurrence of hiatal hernia/slipped fundoplication on endoscopy/barium swallow; (4) postoperative onset of dysphagia; (5) postoperative onset of gas bloating. One hundred and forty-five patients (87 M:58 F) were operated between January 1992 and June 1999: 80 nonerosive esophagitis, 29 erosive esophagitis, 17 Barrett’s esophagus, and 19 large paraesophageal/mixed hiatal hernias. At a median follow-up of 97 months, the success rate was 74% for surgery only and 86% for primary surgery and ‘complementary’ treatments (21 patients: 13 redo surgery and eight endoscopic dilations). Dysphagia and recurrence of reflux were the most frequent causes of failure for nonerosive esophagitis patients; recurrence of hernia was prevalent among patients with large paraesophageal/mixed hiatal hernia. Gas bloating (causing failure) was reported by nonerosive esophagitis patients only. At last follow-up, 115 patients were off ‘proton-pump inhibitors’; 30 were still on medications (eight for causes unrelated to GERD). Conclusion confirms that laparoscopic fundoplication provides effective, long-term treatment of gastroesophageal reflux disease. Hernia recurrence and dysphagia are its weak points.     

腹腔镜Nissen胃底折叠术治疗老年重度胃食管反流病的长期疗效观察

目的通过对老年重度胃食管反流病(gasroesophageal reflux disease,GERD)患者行腹腔镜Nissen胃底折叠术(laparoscopic Nissen fundoplication,LNF)的长期随访结果和对照组对比分析,评价该方法远期的安全性和有效性。 方法回顾分析自2005年1月至2011年1月因重度GERD行LNF治疗的老年患者21例,与同期对照组44例对比,分析两组患者的远期治疗效果。 结果两组患者均成功行LNF治疗,术后早期症状均获得缓解,手术时间和术后短期并发症两组比较无明显差异,术后胃镜见食管炎症状均较术前有所好转。术后平均随访7.4年,两组复发率比较无统计学差异,老年组远期吞咽困难发生率高于对照组。 结论LNF治疗老年重度GERD安全、有效,但远期吞咽困难发生率较高于对照组。     

Laparoscopic antireflux surgery for the elderly: A surgical and quality-of-life study

Purpose Laparoscopic antireflux surgery (LARS) has long been introduced as an alternative method for the treatment of gastroesophageal reflux disease (GERD) in young adults. However, the safety of this procedure and the associated improvement in the quality of life for the elderly are rarely discussed. This study compared the results between young and elderly patients who underwent laparoscopic fundoplication for the treatment of GERD. Methods From January 1999 to January 2006, there were 231 adult patients who underwent LARS for GERD at a single institute. Among all patients, 33 patients were older than 70 years old (14.3%, 73.0 ± 1.9, range 70–76), 198 patients were younger than 70 years old (85.7%, 46.6 ± 11.5, range 20–69). The clinical characteristics, operation time, postoperative hospital stay, surgical complications, and quality of life were retrospectively analyzed. Results The mean operation time had no significant difference between the younger group and the elderly group. The mean postoperative hospital stay in the elderly group was slightly longer than the younger group (4.1 ± 2.5 days vs 3.4 ± 1.3 days, P = 0.19). There were no mortalities and no major complications found in each group. No patients required conversion to an open procedure. Four patients had minor complications (three in the elderly group, rate: 9.0%; one in the younger group, rate: 0.5%, P < 0.05). There were two patients in the nonelderly group who had recurrence. A comparison of the preoperative and postoperative Gastro-Intestinal Quality of Life Index (GIQLI) scores showed significant improvements (99.3 ± 19.2 points, and 110.2 ± 20.6 points, respectively, P < 0.05) with no significant difference between the two groups. Conclusion Laparoscopic antireflux surgery thus appears to provide an equivalent degree of safety and symptomatic relief for elderly patients with GERD as that observed in young patients.     

Laparoscopic management of giant paraesophageal herniation

BACKGROUND: Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of "giant" paraesophageal hernias (gPH). METHODS: Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to "pexy" the stomach within the abdomen and to control postoperative reflux. RESULTS: Mean operative time was 202+/-81 minutes. Conversion to "open" repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients. CONCLUSIONS: Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to "open" surgical approaches. Control of the herniation and the patient's symptoms are equivalent and hospitalization and return to full activity are shorter.     

Effectiveness of laparoscopic fundoplication for gastro-oesophageal reflux

BACKGROUND: Gastro-oesophageal reflux (GERD) is a common condition. Many patients respond to conservative therapy. Severe symptomatic cases and those who fail medical treatment are referred to surgery. The long-term results of open fundoplication surgery have been good with a more than 90% response after 10 years of follow-up. The introduction of laparoscopic fundoplication achieved the same results with shorter hospital stay, a better cosmetic result and less cost to the health care providers. PATIENTS AND METHODS: 74 patients who failed medical treatment for GERD were treated by laparoscopic fundoplication. The Toupet procedure was performed in 66 of these patients, the others patients had a Nissen-type fundoplication. The patients were followed up for a mean period (+/- SD) of 14.8 +/- 8.8 months (range 3-33 months). RESULTS: Most of the patients were males (n = 65). The mean age (+/- SD) of all the patients was 36.1 +/- 9.5 years (range 17-60 years). The majority (93.8%) reported disappearance of symptoms and are not using any antireflux medications. Five patients (6.7%) are considered failures of the procedures. Of these, three patients developed recurrence of reflux symptoms during the follow-up period. The other two patients developed complications, i.e. gas bloat, persistent vomiting and dysphagia which warranted taking down the wraps laparoscopically. Two patients developed a small incisional hernia at the site of the 10 mm port. The mean of hospital stay (+/- SD) was 3.1 +/- 1.3 days (range 1-7 days). CONCLUSION: Laparoscopic fundoplication is safe and effectively relieves reflux symptoms in patients who fail medical treatment.     

Results after laparoscopic fundoplication: does age matter?

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward popu lation of older patients. One hundred eight patients more than 70 years of age (range, 70-90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18-59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores (P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved (P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores (P < 0.01) and lower reflux scores (P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.     

Paradigm shift in the management of gastroesophageal reflux disease

OBJECTIVE: To compare the short-term results of the radiofrequency treatment of the gastroesophageal junction known as the Stretta procedure versus laparoscopic fundoplication (LF) in patients with gastroesophageal reflux disease (GERD). SUMMARY BACKGROUND DATA: The Stretta procedure has been shown to be safe, well tolerated, and highly effective in the treatment of GERD. METHODS: All patients presenting to Vanderbilt University Medical Center for surgical evaluation of GERD between August 2000 and March 2002 were prospectively evaluated under an IRB-approved protocol. All patients underwent esophageal motility testing and endoscopy that documented GERD preoperatively, either by a positive 24-hour pH study or biopsy-proven esophagitis. Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett's esophagus. Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett's were offered LF. All patients were studied pre- and postoperatively with validated GERD-specific quality-of-life questionnaires (QOLRAD) and short-form health surveys (SF-12). Current medication use and satisfaction with the procedure was also obtained. RESULTS: Results are reported as mean +/- SEM. Seventy-five patients (age 49 +/- 14 years, 44% male, 56% female) underwent LF and 65 patients (age 46 +/- 12 years, 42%, 58% female) underwent the Stretta procedure. Preoperative esophageal acid exposure time was higher in the LF group. Preoperative LES pressure was higher in the Stretta group. In the LF group, 41% had large hiatal hernias (>2 cm), 8 patients required Collis gastroplasty, 6 had Barrett's esophagus, and 10 had undergone previous fundoplication. At 6 months, the QOLRAD and SF-12 scores were significantly improved within both groups. There was an equal magnitude of improvement between pre- and postoperative QOLRAD and SF-12 scores between Stretta and LF patients. Fifty-eight percent of Stretta patients were off proton pump inhibitors, and an additional 31% had reduced their dose significantly; 97% of LF patients were off PPIs. Twenty-two Stretta patients returned for 24-hour pH testing at a mean of 7.2 +/- 0.5 months, and there was a significant reduction in esophageal acid exposure time. Both groups were highly satisfied with their procedure. CONCLUSIONS: The addition of a less invasive, endoscopic treatment for GERD to the surgical algorithm has allowed the authors to stratify the management of GERD patients to treatment with either Stretta or LF according to size of hiatal hernia, LES pressure, Barrett's esophagus, and significant pulmonary symptoms. Patients undergoing Stretta are highly satisfied and have improved GERD symptoms and quality of life comparable to LF. The Stretta procedure is an effective alternative to LF in well-selected patients.     

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??Laparoscopic anti-reflux surgery for gastroesophageal reflux disease with hiatal hernia??A clinical analysis of 650 patients Kelimu??Alimujiang·Maisiyiti??ZHANG Cheng??et al. Department of Hernia and Abdominal Wall Surgery & Minimally Invasive Surgery??People’s Hospital of Xinjiang Uyghur Autonomous Region??Urumqi 830001??China
Corresponding author??Kelimu??E-mail??klm6075@163.com
Abstract Objective To evaluate the efficacy and safety of laparoscopic hiatal hernioraphy plus fundoplication for gastroesophageal reflux disease (GERD). Methods The clinical data of 650 patients underwent laparoscopic hiatal hernioraphy plus fundoplication from September 2005 to August 2013 in People’s Hospital of Xinjiang Uyghur Autonomous Region were analyzed retrospectively. Results Laparoscopic hiatal herniorrhaphy plus fundoplication were successfully performed in all 650 patients without conversion. Combined operation was performed in 135 patients (20.8%). The average duration of operation was 64.3 min (45-90min) and the average amount of bleeding was 18 mL??5-50mL??. No intraoperative or postoperative blood transfusion. Liquid diet was used in 24-48 h after operation. Postoperative hospital stay was 2-8 d. All the patients were followed up for 6 months to 8 years. Postoperative dysphagia occurred in 21 patients. Recurrent hiatal hernia (gastric wrap herniated into the chest) occurred in 4 patients. Recurrence of symptoms occurred in 14 patients. Gas bloating syndrome occurred in 6 patients. Conclusion Laparoscopic hiatal hernioraphy plus fundoplication is safe and effective with less invasive??faster recovery??fewer complication, which can combine surgical treatment of other diseases and is the ideal choice for GERD with hiatal hernia.     

Giant hiatal hernias: direct hiatus closure has an acceptable recurrence rate

The purpose of this retrospective study was to analyze our results after laparoscopic repair of giant hiatal hernias with direct closure of the hiatus, since the reports document a radiological recurrence rate as high as 42%. Various studies have shown that laparoscopic hernia repair is safe and effective, and carries a lower morbidity than the open approach, but the high recurrence rates still being reported (ranging from 10 to 42%) have prompted many authors to recommend using a prosthesis. This is a report on the follow-up of 38 patients with type III and IV hiatal hernia who underwent laparoscopic repair with direct hiatal closure without the aid of meshes. From January 2000 to March 2010, 38 patients with III and IV hiatal hernia were treated at the Surgery Division of Cisanello Hospital in Pisa. Data were collected retrospectively and included demographics, preoperative symptoms, radiographic and endoscopic findings, intraoperative and postoperative complications, postoperative symptoms, barium X-ray and follow-up by medical examination and symptoms questionnaire. The sample included 12 males and 26 females, between 36 and 83 years (median age 62) with 26 type III (68.4%) and 12 type IV (31.6%) hernias. There were no conversions to laparotomy and no intraoperative or postoperative mortality. A 360° Nissen fundoplication was performed in 22 patients (57.9%) and a 270° Toupet fundoplication in 16 patients (42.1%). One patient had intraoperative complications (2.6%), and postoperative complications occurred in another three (7.9%). The follow-up was complete in all patients and ranged from 12 to 88 months (median 49 months). Barium swallow was performed in all patients and recurrence was found in five patients (13.1%); three of these patients (7.9%) were asymptomatic, while two (5.2%) were reoperated. All 38 patients' symptoms improved. Judging from our data, the recurrence rate after laparoscopic giant hiatal hernia repair with direct hiatal closure can be lowered by complying with several crucial surgical principles, e.g., complete sac excision and appropriate crural closure, adequate esophageal lengthening, and the addition of an antireflux procedure and a gastropexy. We recorded a radiological recurrence rate of 13.1% (5/38) and patient satisfaction in our series was quite high (92%). Based on these findings, the laparoscopic treatment of giant hernias with direct hiatal closure seems to be a safe and effective procedure.     

Long-term results after laparoscopic Thal procedure in children

As the laparoscopic approach to gastroesophageal reflux disease (GERD) was introduced in pediatric surgery in the last decade of the 20th century, it became apparent that this approach was beneficial. The favorable results have led to a more general acceptance and implementation of this type of surgery at the beginning of the 21st century. We give an overview of the first decade of laparoscopic antireflux procedures in children with an emphasis on the laparoscopic Thal fundoplication and its implication on morbidity and cure of GERD in the long term both for normal and mentally handicapped children. Between 1993 and 2002, 149 children with GERD underwent 157 laparoscopic antireflux procedures, of whom 48% were mentally handicapped. Follow-up ranged from 6 months to 9 years (median age 4.5 years). Nineteen children died. All but one were not related to the antireflux procedure. Immediate relief of symptoms occurred in 120 children (80.5%). In 29 children, the results were less than optimal. Eight patients underwent a laparoscopic redo procedure (5.4%). However, none of the children with a follow-up of more than 5 years show any symptoms anymore. In conclusion, the laparoscopic Thal fundoplication is a safe procedure, and results in the long term are favorable, irrespective of the nature of the cause, ie, mental retardation.     

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.     

Laparoscopic splenectomy in the elderly: a morbid procedure?

BACKGROUND: Laparoscopic splenectomy has emerged as the gold standard for elective splenectomy. Few reports have critically evaluated the results of laparoscopic splenectomy in elderly patients. METHODS: All laparoscopic splenectomies performed between August 19, 1998 and June 8, 2004 were reviewed retrospectively. RESULTS: Of 235 splenectomies, 188 were performed for patients younger than age 65 years (group 1), and 45 were performed for patients 65 years of age or older (group 2). The groups were demographically similar, except for the average age and the American Society of Anesthesiology (ASA) classification. Operative characteristics were similar, but the average length of hospital stay differed: 2.2 days for group 1 and 3.9 days for group 2 (p < 0.03). Complications occurred for 8.5% of group 1 and 17.8% of group 2, but the percentages were similar by ASA class. CONCLUSIONS: Elderly patients have a higher rate of complications after laparoscopic splenectomy. The complications are similar when matched for ASA class, but a larger percentage of elderly patients fall into higher ASA class ratings.