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.     

Assessment of Quality of Life after Laparoscopic Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease

Background In this study two different quality of life items are compared, and correlation of patient satisfaction with preoperative and postoperative symptoms after laparoscopic Nissen fundoplication (LNF) for chronic gastroesophageal reflux disease is evaluated. Materials and Methods Between December 2002 and December 2004, 60 patients with a diagnosis of chronic gastroesophageal reflux disease scheduled for laparoscopic Nissen fundoplication were recruited prospectively and volunteered to participate in this study. Patients underwent endoscopy, and their disease-specific symptoms were scored on a scale. Quality of life was measured preoperatively and in the first and sixth postoperative months with two questionnaires: Short Form-36 (SF 36) (preoperatively) and the Gastroesophageal Reflux Disease—Health-Related Quality of Life (GERD-HRQL) (postoperatively). Results In more than 90% of the patients, typical symptoms (regurgitation and pyrozis) were controlled postoperatively (p < 0.001). In the first postoperative month, however, dysphagia (early dysphagia) was seen in 46 (76%) patients, whereas in the sixth postoperative month (late dysphagia) its incidence decreased to only 2 (3.3%) patients. Similarly, in the first postoperative month 42 (70%) patients had gas bloating, but the incidence of this symptom decreased to 26 (43.3%) patients by the sixth month (p = 0.01). The quality-of-life measurements obtained from both SF 36 and GERD-HRQL showed that quality of life of the patients improved significantly in the related domain of each item after surgery (p < 0.001). Conclusions Laparoscopic Nissen fundoplication is an effective operation that controls the typical symptoms and improves the quality of life of patients, but new-onset symptoms affect postoperative well-being. For closer evaluation of the benefits of the operation, we need new questionnaires that comprehensively evaluate the symptom spectrum of GERD both preoperatively and postoperatively.     

Reoperative fundoplications are effective treatment for dysphagia and recurrent gastroesophageal reflux

With wide application of antireflux surgery, reoperations for failed fundoplications are increasingly seen. This study was undertaken to document outcomes after reoperative fundoplications. Sixty-four patients, 26 men and 38 women, of average age 55 years+/-15.6 (SD), underwent reoperative antireflux surgery between 1992 and 2003. Fundoplication prior to reoperation had been undertaken via celiotomy in 27 and laparoscopically in 37. Both before and after reoperative antireflux surgery, patients scored their reflux and dysphagia on a Likert Scale (0 = none, 10 = continuous). Reoperation was undertaken because of dysphagia in 16 per cent, recurrent reflux in 52 per cent (median DeMeester Score 52), or both in 27 per cent. Failure leading to reoperation was due to hiatal failure in 28 per cent, wrap failure in 19 per cent, both in 33 per cent, and slipped Nissen fundoplication in 20 per cent. Laparoscopic reoperations were completed in 49 of 54 patients (91%); 15 had reoperations undertaken via celiotomy. Eighty-eight per cent of reoperations were Nissen fundoplications. With reoperation, Dysphagia Scores improved from 9.5+/-0.7 to 2.6+/-2.8, and Reflux Scores improved from 9.1+/-1.4 to 1.8+/-2.7. Seventy-nine per cent of patients with reflux prior to reoperation, 100 per cent with dysphagia, and 74 per cent with both noted excellent or good outcomes after reoperation. We conclude that failure after fundoplication occurs. Reoperations reduce the severity of dysphagia and reflux, thus salvaging excellent and good outcomes in most. Laparoscopic reoperations are generally possible. Reoperative fundoplications are effective treatment for dysphagia and recurrent gastroesophageal reflux, and their application is encouraged.     

Laparoscopic Nissen fundoplication after failed endoscopic gastroplication

Endoscopic techniques to treat gastroesophageal reflux have been developed and approved by the U.S. Food and Drug Administration. One of these techniques is endoscopic gastroplication with the Bard Endocinch device. Although the technique is initially effective, long-term symptom control has not yet been proved. No reports have documented the feasibility of laparoscopic fundoplication after failed endoscopic gastroplication. We report our experience. Ten patients who underwent endoscopic gastroplication subsequently had recurrent symptoms and were referred for laparoscopic antireflux surgery. Eight had typical symptoms of gastroesophageal reflux disease (GERD), whereas two had atypical symptoms. All patients had documented pathologic reflux by 24-hour pH monitoring. Preoperatively, all patients completed the GERD health-related quality of life (HRQL) symptom severity questionnaire. Nine of the 10 operations were completed laparoscopically. The one conversion was carried out because of excessive fat in the hiatal region. No patients had scarring of the esophagus or hiatal region. All patients with typical symptoms improved (decrease in total GERD-HRQL median score from 27 to 4), whereas none of the patients with atypical symptoms did. Six patients had persistent dysphagia for longer than 1 month; two required esophageal dilation. Laparoscopic Nissen fundoplication is feasible after failed endoscopic gastroplication. Symptomatic improvement is similar to that with the de novo operation. However, in some patients, dysphagia may persist longer.     

Clinical outcome at ten years after laparoscopic fundoplication: Nissen versus Toupet

Laparoscopic surgery has become the elective approach for the surgical treatment of gastroesophageal reflux disease in the last decade. Outcome data beyond 10 years are available for open fundoplication, with good-to-excellent results, but few studies report long-term follow-up after laparoscopic fundoplication. We performed a retrospective study of all the patients that underwent laparoscopic Nissen and Toupet fundoplications as antireflux surgery between 1995 and 1998 in our institution. To evaluate the long-term results, a face-to-face interview was performed in 2009. One hundred and six patients were included in the study. Surgical techniques performed were Nissen fundoplication (NF) in 56 patients and Toupet (TF) in 50. Complication rate was 4 per cent in both groups (nonsignificant [NS]). Two patients (4%) of NF required reoperation because of dysphagia. After 10 years, 10 per cent of the patients remain symptomatic in both groups. Fifteen per cent of NF take daily inhibitors of the proton pump versus 14 per cent of TF (NS). Twenty per cent of NF refer dysphagia, all of them without evidence of stenosis at endoscopy or contrasted studies. The satisfaction rate of the patients was 96 per cent in NF and 98 per cent in TF. Laparoscopic Toupet fundoplication seems to be as safe and long-term effective as Nissen, but with a lower incidence of postoperative dysphagia. In our experience Toupet fundoplication should be the elective approach for the surgical treatment of gastroesophageal reflux disease.     

Laparoscopic Nissen fundoplication offers high patient satisfaction with relief of extraesophageal symptoms of gastroesophageal reflux disease

Nissen fundoplication is applied for patients with gastroesophageal reflux disease (GERD), usually because of symptoms of esophageal injury. When presenting symptoms are extraesophageal, there is less enthusiasm for operative control of reflux because of concerns of etiology and efficacy. This study was undertaken to evaluate the efficacy of laparoscopic Nissen fundoplication in palliating extraesophageal symptoms of GERD. Patients were asked to score their symptoms before and after laparoscopic Nissen fundoplication on a Likert scale (0 = never/none to 5 = always/every time I eat). A total of 322 patients with extraesophageal symptoms (asthma, cough, gas/bloat, chest pain, and odynophagia) of 4 to 5 were identified and analyzed. After fundoplication, all extraesophageal symptom scores improved (P < 0.0001 for all, Wilcoxon matched-pairs test). Likewise, postoperative symptoms were noted to be greatly improved or resolved in 67 per cent to 82 per cent of patients for each symptom. Furthermore, after fundoplication, patients were less likely to modify their dietary (82% vs 49%) or sleeping habits (70% vs 28%) to avoid initiating/ exacerbating symptoms. Although extraesophageal symptoms are conventionally thought to be inadequately palliated by surgery, this study documents excellent relief of extraesophageal symptoms after laparoscopic Nissen fundoplication, denotes high patient satisfaction, and encourages application of laparoscopic Nissen fundoplication.     

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??Laparoscopic anterior 180° partial fundoplication versus Nissen fundoplication in elderly patients with gastroesophageal reflux disease??A randomized controlled trial ZHAO Hong-zhi, QIN Ming-fang. Center of Tianjin Minimally Invasive Surgery, Nankai Hospital, Tianjin 300100, China
Corresponding author ??ZHAO Hong-zhi, E-mail??tjzhhzh@sina.com
Abstract Objective To compare two anti-reflux procedures??laparoscopic anterior 180° partial fundoplication and Nissen fundoplication??in elderly patients with gastroesophageal reflux disease (GERD). Methods From July 2008 to June 2012, 78 elderly patients with GERD were admitted in Tianjin Nankai Hospital. All the patients were allocated into two groups randomly. Thirty-nine patients were performed laparoscopic anterior 180° partial fundoplication (anterior 180° group) and the other 39 patients were performed Nissen fundoplication (Nissen group). Perioperative clinical parameters were recorded for comparing efficacy between two groups. Results Laparoscopic surgery was accomplished in all patients. The mean operation time of anterior180° group was significantly less than that of Nissen group (P<0.05). There was no significant difference of the mean duration of postoperative hospital stay between two groups (P>0.05). The symptoms in most patients were adequately relieved after operation. Endoscopy, radiology, esophageal manometry and 24-hour pH monitoring were repeated 1 month after surgery. All the results returned to normal compared with preoperative data. A total of 76 patients got follow-up. One patient was lost. One patient died of heart infarction. During follow-up period of 6-54 months (mean 28.5 months), there was no statistical significance between groups for the recurrence rate and satisfaction rate of operation. There was a lower incidence of dysphagia and epigastric bloating in the anterior 180° group. Conclusion For elderly patients with GERD??laparoscopic anterior 180°partial fundoplication has a good and durable anti-reflux effect compared with laparoscopic Nissen fundoplication. With shorter operation time and lower incidence of postoperative complications (dysphagia and epigastric bloating) compared with Nissen fundoplication, laparoscopic anterior 180°partial fundoplication can be employed as a more appropriate procedure for treatment of GERD in elderly patients.     

Laparoskopische partielle Fundoplicatio nach Toupet als generelle chirurgische Therapieform der gastrooesophagealen Refluxkrankheit 1-Jahresresultate einer auf 5 Jahre ausgelegten prospektiven Langzeitstudie

INTRODUCTION: A variety of laparoscopic antireflux operations exist for patients with gastroesophageal reflux diseases (GERD). Most surgeons operate using the concept of "tailored approach", which depends on esophageal motility. We have abandoned this concept because of the relatively high incidence of wrap-related complications in patients treated with laparoscopic Nissen fundoplication compared with patients treated with partial fundoplication. It is our policy to perform laparoscopic Toupet partial fundoplication in all patients suffering from GERD, independent of their esophageal motility. METHODS: In a prospective trial we have assessed and evaluated our 1-year results of the first 100 consecutive patients treated with Toupet partial fundoplication. All patients underwent esophagogastroscopy and 24-h pH manometry before operation. One third of patients (n = 34) underwent control manometry 8 weeks postoperatively. The patients were followed up clinically 1, 2, 6 and 12 months postoperatively. RESULTS: In this study group we achieved a healing rate in GERD of 97%. In 3% of patients GERD recurred. The median clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to 0.25 +/- 0.5 points 1 year postoperatively (P < 0.0005). The median fractional time with pH < 4 decreased from 17.8% +/- 12.5% preoperatively to 0.9% +/- 1.2% 8 weeks postoperatively (P < 0.0005). Because of persistent dysphagia 5% of our patients required postoperative dilatation therapy. The rate of reoperation and mortality was 0%. The total morbidity rate was 18%. In 50% of patients with preoperatively recorded esophageal motility disorder, an improvement of esophageal motility was found postoperatively. CONCLUSIONS: Our 1-year results encourage us to continue to perform laparoscopic Toupet partial fundoplication as the primary repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet partial fundoplication has proven to be a safe and highly successful therapeutic option in these patients.     

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     

Laparoscopic hiatal hernia repair in patients with poor esophageal motility or paraesophageal herniation

Laparoscopic repair for gastroesophageal reflux disease is now an accepted therapy. However, controversy exists with regard to the choice of operation between complete 360-degree Nissen fundoplication versus partial 270-degree Toupe fundoplication. In addition there is some controversy with regard to the proper choice of operation in patients with poor esophageal motility. Another class of hiatal hernia patients are those patients with paraesophageal herniation. Questions regarding the approach to these patients include whether or not to use a reflux procedure at the time of repair and the role of mesh in repair of these large hernias. This retrospective study was undertaken to compare the results of laparoscopic Nissen fundoplication and Toupe fundoplication in patients with both normal and abnormal esophageal motility. In addition the subset of patients with paraesophageal herniation was studied in an effort to ascertain the best surgical approach in these patients. In this study a retrospective analysis was performed on 188 consecutive patients during the period 1995 to 2001. All patients who presented with hiatal hernia surgical problems during this period were included. Endoscopy was performed in all patients with esophageal reflux. Manometry was performed in all patients except those presenting as emergency incarcerations. pH probe testing was performed in those patients in whom it was deemed necessary to establish the diagnosis. Upper gastrointestinal radiographs were used to define anatomy in paraesophageal hernia patients when possible. All patients with esophageal reflux were first treated with a trial of medical therapy. Patients with esophageal reflux and normal esophageal motility underwent 360-degree Nissen fundoplication. Those patients with poor esophageal motility (less than 65 mm of mercury) underwent laparoscopic 270-degree Toupe fundoplication. Patients presenting with paraesophageal herniation underwent laparoscopic repair. When possible esophageal manometry was performed on these patients preoperatively and if normal peristalsis was documented a Nissen fundoplication was performed. If poor esophageal motility was documented before surgery a Toupe fundoplication was performed. Mesh reinforcement of the diaphragmatic hiatus was used if necessary to complete a repair without tension. Patients were followed both by their primary gastroenterologist and their surgeon. Follow-up studies including endoscopy, pH probe, and upper gastrointestinal series were used as necessary in the postoperative period to document any problems as they occurred. Of the 188 patients in the study 141 patients underwent Nissen fundoplication, 21 patients underwent Nissen fundoplication and repair of paraesophageal hernia, 15 underwent Toupe fundoplication, seven underwent Toupe and paraesophageal hernia repair, and four paraesophageal hernia repair alone. One hundred eighty-three patients underwent a laparoscopic operation. Five patients of the 188 underwent an initial open operation-two of these patients because of the size of their paraesophageal hernia. Three of these patients had reoperations of remote operations done years before at other institutions. Twenty-two patients with poor esophageal motility (11.7 %) were included in the study. Fifteen patients required Toupe fundoplication whereas seven patients required Toupe fundoplication and repair of paraesophageal hernias. Mesh repair of paraesophageal hernias was accomplished in ten patients. Patients undergoing Toupe fundoplication had a 13 per cent dysphagia rate less than 4 weeks postoperatively and a 0% dysphagia rate greater than four weeks postoperatively. Patients undergoing Nissen fundoplication had a 16 per cent dysphagia rate less than 4 weeks postoperatively, 2 per cent dysphagia rate greater than 4 weeks postoperatively and no dysphagia at 6 weeks postoperatively. Recurrent symptomatic reflux occurred in 1.4 per cent of Nissen fundoplications and 6.7 per cent of Toupe fundoplications. Of Nissen and paraesophageal repairs 14.2 per cent had reflux and 14.3 per cent of Toupe and paraesophageal repairs had recurrent symptomatic reflux. Overall, complication rate was low. Use of mesh to repair large paraesophageal hernias resulted in a recurrence rate of 0 per cent. There was no instance of infection or bowel fistulization related to the use of mesh. We conclude that laparoscopic Nissen fundoplication in patients with normal esophageal motility is associated with a low rate of dysphagia and a low rate of recurrent reflux. Toupe fundoplication when used in reflux patients with poor esophageal motility is associated with a low rate of dysphagia and an acceptable rate of recurrent reflux. Laparoscop     

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

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

Minimally invasive surgery for gastroesophageal reflux disease

Surgical treatment of gastroesophageal reflux disease (GERD) is indicated for patients with moderate to severe signs and symptoms or a need for increasing doses of antisecretory drugs. Long segment Barrett's metaplasia is another indication, especially in young patients. Preoperative evaluation differs somewhat depending on whether the patient's symptoms are typical or atypical of GERD. Laparoscopic fundoplication is described. Follow-up of as long as 8 years indicates that more than 90% of patients are satisfied with the results, although 14% are using antisecretory drugs regularly. Recurrent symptoms or dysphagia may indicate surgical failure, and medical therapy, esophageal dilatation, or surgery may be appropriate. Laparoscopic surgery in these patients takes longer than the original procedure but has many benefits if performed by an experienced surgeon.     

Postprandial bloating after laparoscopic Nissen fundoplication.

OBJECTIVE: To evaluate the prevalence and possible contributing factors to postprandial bloating in patients having chronic gastroesophageal reflux disease (GERD) before and after laparoscopic Nissen fundoplication. DESIGN: A prospective cohort study. SETTING: A tertiary care teaching hospital. PATIENTS: Five hundred and seventy-eight patients with proven GERD. INTERVENTION: Laparoscopic Nissen fundoplication. OUTCOME MEASURES: Symptom severity scores for postprandial bloating and dysphagia, esophageal motility and 24-hour pH measurement before and at 6 months, 2 years and 5 years after laparoscopic Nissen fundoplication. RESULTS: Of the 598 patients, 436 (73%) reported some postprandial bloating before the procedure. The symptom score for bloating significantly improved after surgery (p < 0.0001). There were no significant differences in the lower esophageal sphincter basal pressures or 24-hour pH scores between those who reported improvement or worsening of their postprandial bloating. At 6 months after surgery, 54% of patients experienced postprandial bloating; of these, 49% reported improvement, 21% reported worsening and 30% reported no change in bloating symptoms compared with the preoperative state. Of the patients who reported worsening of postprandial bloating 6 months after surgery, 86 were reassessed 2 years after surgery and 71% reported improvement of this symptom over this time interval. CONCLUSIONS: Bloating is a common symptom in patients who suffer from chronic GERD. Laparoscopic Nissen fundoplication lessens the severity of this symptom in most patients. In a small subgroup of patients, antireflux surgery may exacerbate the bloating, but this improves over time.     

Ten-year follow up after laparoscopic Nissen fundoplication for gastroesophageal reflux disease

Laparoscopic Nissen fundoplication was first undertaken in the early 1990s. Appreciable numbers of patients with 10-year follow up are only now available. This study assesses long-term outcome and durability of outcome after laparoscopic Nissen fundoplication for treatment of gastro-esophageal reflux disease. Since 1991, 829 patients have undergone laparoscopic fundoplications and are prospectively followed. Two hundred thirty-nine patients, 44 per cent male, with a median age of 53 years (+/- 15 standard deviation) underwent laparoscopic Nissen fundoplications at least 10 years ago; 28 (12%) patients were "redo" fundoplications. Before and after fundoplication, among many symptoms, patients scored the frequency and severity of dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before versus after fundoplication were compared using a Wilcoxon matched-pairs test. Data are reported as median, mean +/- standard deviation, when appropriate. After fundoplication, length of stay was 2 days, 3 days +/- 4.8. Intra-operative inadvertent events were uncommon and without sequela: 1 esophagotomy, 1 gastrotomy, 3 cardiac dysrhythmias, and 3 CO2 pneumothoraces. Complications after fundoplication included: 1 postpneumonic empyema, 3 urinary retentions, 2 superficial wound infections, 1 urinary tract infection, 1 ileus, and 1 intraabdominal abscess. There were two perioperative deaths; 88 per cent of the patients are still alive. After laparoscopic Nissen fundoplication, frequency and severity scores dramatically improved for all symptoms queried (P < 0.001), especially for heartburn frequency (8, 8 +/- 3.2 versus 2, 3 +/- 2.8, P < 0.001) and severity (10, 8 +/- 2.9 versus 1, 2 +/- 2.5, P < 0.001). Eighty per cent of patients rate their symptoms as almost completely resolved or greatly improved, and 85 per cent note they would again have the laparoscopic fundoplication as a result of analysis of our initial experience, thereby promoting superior outcomes in the future. Nonetheless, follow up at 10 years and beyond of our initial experience documents that laparoscopic fundoplication durably provides high patient satisfaction resulting from long-term amelioration of the frequency and severity of symptoms of gastroesophageal reflux disease. These results promote further application of laparoscopic Nissen fundoplication.     

Upright,supine, or bipositional reflux

INTRODUCTION: This study was undertaken to determine if the body position in which gastroesophageal reflux occurs before fundoplication--i.e., pattern of reflux--affects symptoms before or after laparoscopic Nissen fundoplication. METHODS: A total of 417 patients with gastroesophageal reflux disease (GERD) underwent pH studies, and the severity of reflux in the upright and supine positions was determined. The percent time with pH less than 4 was used to assign patients to one of four groups: upright reflux (pH < 4 more than 8.3% of time in upright position, n = 80), supine reflux (pH < 4 more than 3.5% of time in supine position, n = 73), bipositional reflux (both supine and upright reflux, n = 163), or neither (n = 101). Before and after laparoscopic Nissen fundoplication, the frequency and severity of symptoms of reflux (e.g., dysphagia, regurgitation, choking, heartburn, chest pain) were scored on a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). For each patient, symptom scores before versus after fundoplication were compared using the Wilcoxon matched pairs test; comparisons of symptom scores among patients grouped by reflux patterns were made using Kruskal-Wallis test. RESULTS: Before fundoplication, the patterns of reflux did not affect the frequency or severity of reflux symptoms. After laparoscopic fundoplication, all symptoms of bipositional reflux improved, and essentially all symptoms of isolated supine or upright reflux or neither improved. CONCLUSIONS: Preoperatively, regardless of the patterns of reflux, symptoms among patients were similar. After fundoplication, symptoms of GERD improved for all patterns of reflux. Laparoscopic fundoplication imparts dramatic and broad relief of symptoms of GERD, regardless of the patterns of reflux. Application of laparoscopic Nissen fundoplication is encouraged.     

Five-year comprehensive outcomes evaluation in 181 patients after laparoscopic Nissen fundoplication

BACKGROUND: We conducted an objective followup of 181 patients after laparoscopic Nissen fundoplication during a 5-year period after surgery. STUDY DESIGN: Patients underwent 24-hour pH recording, esophageal manometry, and symptom score assessment for six gastroesophageal reflux disease symptoms preoperatively and at 6 months, 2 years, and 5 years after surgery. RESULTS: Laparoscopic fundoplication was associated with a significant (p < 0.0001) increase in lower esophageal sphincter pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours, and symptom score, 6, 24, and 60 months after surgery when compared with preoperative values. Twenty-one patients (12%) have experienced recurrence of reflux-type symptoms, but only six have required repeat surgery. Lower esophageal sphincter tone dropped between 6 months and 5 years after surgery, but was still an effective antireflux barrier. Patient satisfaction with surgery dropped over the 5-year followup but remained high, at 86%, after 5 years. CONCLUSIONS: Laparoscopic Nissen fundoplication remains an effective antireflux procedure at 5 years.     

Outcomes of laparoscopic Nissen fundoplication in patients with the "hypercontractile esophagus"

HYPOTHESIS: To determine if a hypercontractile esophagus, manifested by high-amplitude peristaltic contractions (HAPCs) or hypertensive lower esophageal sphincter (HLES), affects the outcome of antireflux surgery. DESIGN: Case series. Prospectively maintained database. Direct contact with patients. Mean follow-up 28.7 months. SETTING: University hospital. PATIENTS: Of 643 patients who had antireflux surgery for uncomplicated gastroesophageal reflux disease (GERD), 15 had HAPCs (> or = 150 mm Hg) and 4 HLES (> or = 45 mm Hg). INTERVENTION: Laparoscopic Nissen fundoplication in all patients. MAIN OUTCOME MEASURES: (1) Frequency of hypercontractile esophagus in patients considered for antireflux procedure. (2) Effect of fundoplication on esophageal acid exposure and symptoms. (3) Establish whether dysphagia or chest pain develop after fundoplication. RESULTS: The typical GERD symptoms of heartburn and/or regurgitation occurred in 15 (79%) and 13 (69%) of 19 patients. Dysphagia was present in 5 of 15 patients with HAPCs and in 0 of 4 with HLES; chest pain was found 5 of 15 patients with HAPCs. After fundoplication acid exposure was improved in all (92%, 16/17) but 1 and was totally normal in 10 patients (83%). Heartburn improved in 11(78%) of 14 and resolved in 8 patients (57%) of the 14. Chest pain improved in 4 (80%) of the 5 patients who had it, and developed in 3 (23%) who did not have it preoperatively. In patients with HAPCs, dysphagia improved in 4 (80%) of 5 patients with complete resolution in 3 (60%). New dysphagia developed in 2 (11%) of the 19 patients, 1 in each group. No patient with HLES developed chest pain. CONCLUSIONS: High-amplitude peristaltic contractions or HLES may be associated with GERD in a subset of patients with dysphagia or chest pain. In such patients, a Nissen fundoplication, by effectively controlling GERD, relieves these symptoms in most patients. A hypercontractile esophagus in patients with GERD should not be considered a contraindication to a total fundoplication. The surgeon and the patient should be aware of the risk of developing chest pain after the operation.     

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.     

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.     

抗胃食管反流外科治疗的远期疗效观察

目的探讨胃食管反流外科治疗的远期疗效。方法1988年11月至2004年1月手术治疗129例胃食管反流病(GERD),分别采用N issen手术(65例)、贲门斜行套叠术(39例)、Belsey4号手术(17例)、Toupet手术(3例)、Thal手术(1例)、Dor手术(4例)等6种方法治疗。116例得到随访,计算临床症状评分,并与术前比较。手术前后分别有95例及51例行食管压力测定检查,56例及35例行24 h食管pH值监测及DeM eester评分;术前常规行内镜检查,术后48例行内镜检查,对结果进行比较。结果在随访的116例患者中,临床症状评分由术前的(4.1±0.4)分降为术后的(1.1±1.0)分,较术前显著降低(t=27.21,P<0.01)。手术疗效优42例(36.2%),良60例(51.7%),可7例(6.0%),差7例(6.0%),手术远期优良率87.9%(102/116)。N issen、Belsey 4号和贲门斜行套叠术三者间疗效无差异。结论外科手术是治疗GERD的有效方法,N issen手术、贲门斜行套叠术和Belsey 4号手术疗效相近。