Nissen fundoplication has a vagolytic effect on the lower esophageal sphincter

Background: Laparoscopic Nissen fundoplication is an increasingly utilized option for the treatment of gastroesophageal reflux disease (GERD). However, many questions remain as to the mechanism by which this operation prevents GERD in those without hiatal hernias or incompetent lower esophageal sphincters (LES). It is known that these patients experience reflux due to excess transient lower esophageal sphincter relaxations (TLESR), inappropriate and short-lived relaxation of the LES and crural diaphragm. The purpose of this study was to determine if Nissen fundoplication affects the neural pathways involved in the TLESR reflex. Methods: Five dogs were anesthetized and intubated. Both vagal nerves and the right phrenic nerve were isolated. A continuous water perfusion manometric catheter was situated at the LES. The nerves were then electrically stimulated and the resultant pressure at the LES measured at baseline, and during and after an open Nissen fundoplication. Results: The mean LES pressures before dissection, after esophago-gastric mobilization, and after fundoplication were 47 ± 13 mmHg, 21 ± 9 mmHg, and 14 ± 4 mmHg, respectively. All differences were significant. There was no change noted in LES pressure with stimulation of either or both of the phrenic nerves without concomitant vagal stimulation. Conclusion: Nissen fundoplication may prevent GERD in those without a hiatal hernia or incompetent LES by disrupting the efferent vagal fibers to the LES. Such fibers mediate TLESR which are responsible for GERD in these patients.     

Anterior partial fundoplication for gastroesophageal reflux disease

Background This study examined the effect of anterior partial fundoplication on reflux symptoms and dysphagia in gastroesophageal reflux disease.Patients and methods Perioperative results in 249 patients were evaluated retrospectively for 93 conventional and prospectively for 156 laparoscopic procedures. The patients were followed up by standardized questionnaire. Median clinical follow-up period was 9 months (range 6–44) after laparoscopic and 88 months (range 15–194) following partial open fundoplication.Results The median operating time was 58 and 115 min for laparoscopic and open partial fundoplication. Intraoperative complications were rare (1%) for both approaches. After introduction of the laparoscopic procedure the morbidity rate was reduced (mean 3.2% vs. 1.3%) at a shorter postoperative hospital stay (10 vs. 5 days). No reflux symptoms were found in 71.4% patients after conventional and in 69% after laparoscopic partial fundoplication, dysphagia did not develop in 86% and 85%, respectively, and 66% and 82% received no medications. Among the patients with reflux symptoms 6.5% and 0.9% underwent revision surgery. Satisfaction with the surgical outcome was expressed by 78% and 85% of patients, respectively.Conclusions Anterior partial fundoplication achieves effective medium- and long-term control of reflux symptoms. Technically easy to perform and associated with few complications, the procedure is superior to fundoplication with respect to the development of postoperative dysphagia and therefore represents a viable alternative to fundoplication.     

Outcome after laparoscopic fundoplication is not dependent on a structurally defective lower esophageal sphincter

With the advent of laparoscopic surgery and the recognition that gastroesophageal reflux disease often requires lifelong medication, patients with normal resting sphincter characteristics are now being considered for surgery. The outcome of these patients after fundoplication is unknown and formed the basis of this study. The study population consisted of 123 patients undergoing laparoscopic Nissen fundoplication between 1992 and 1996. All patients had increased esophageal acid exposure on 24-hour esophageal pH monitoring. Patients were divided into those with a normal (n = 36) and those with a structurally defective (n = 87) lower esophageal sphincter (LES), based on LES resting pressure (normal >6 mm Hg), overall length (normal >2 cm), and abdominal length (normal > 1 cm), and their outcomes were assessed. Each group was subsequently divided into patients presenting with a primary symptom that was "typical" (heartburn, regurgitation, or dysphagia) or "atypical" (gastric, respiratory, or chest pain) of gastroesophageal reflux, and outcome was assessed. Median duration of follow-up was 18 months after surgery. Overall, laparoscopic fundoplication was successful in relieving symptoms of gastroesophageal reflux in 90% of patients. Patients with a typical primary symptom had an excellent outcome irrespective of the resting status of the LES (95% and 97%, respectively). Atypical primary symptoms were significantly more common in patients with a normal LES (29%) than in those with a structurally defective LES (10%; P <0.05), and these symptoms were less likely (50%) to be relieved by antireflux surgery. Laparoscopic antireflux surgery is highly successful and not dependent on the status of the resting LES in patients with increased esophageal acid exposure and primary symptoms "typical" of gastroesophageal reflux. Antireflux surgery should be applied cautiously in patients with atypical primary symptoms. Presented in part at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14,1997.     

Effect of Laparoscopic Fundoplication on Hypertensive Lower Esophageal Sphincter Associated with Gastroesophageal Reflux

For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently, the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50–61). Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7–86). Average LES pressure before the operation was 50.5 mmHg (range 35.6–81.3). Six weeks after operation, all patients were symptom free. DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure (24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure may be an etiologic factor in the development of hypertensive lower esophageal sphincter.     

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。     

Gastroesophageal Reflux Disease: Diagnosis and Patient Selection

Gastroesophageal reflux disease (GERD) has a high prevalence worldwide. Recent reports have noted a high prevalence even in Asian countries. GERD significantly affects the quality of life and can present with a wide variety of symptoms. Not all reflux is acid, and non-acid reflux disease can be more difficult to diagnose and can lead to a variety of extra-esophageal symptoms. Although proton pump inhibitors (PPIs) are effective in the majority of patients, but they are not without side effects, and their effect often diminishes with time. For patients who do not desire to be on long-term PPIs or have incomplete symptom resolution with medication, various endoscopic and minimally invasive treatment modalities are now available. The etiology of GERD can be multifactorial including dysfunctional LES, presence of a hiatal hernia, and transient lower esophageal sphincter relaxations (TLESRs). We hence believe that the treatment should be individualized to the cause of the reflux. In the following review, we describe the etiology of reflux disease and attempt to lay a framework for the diagnosis and selection of patients for the various interventions available for treatment, along with their evidence base.     

Division of the hepatic branch of the anterior vagus nerve in fundoplication: effects on gallbladder function

Background

Cutting the hepatic branch of the anterior vagus nerve makes laparoscopic fundoplication technically easier; however, there is little data about the effect of cutting the nerve on gallbladder function.

Methods

One surgeon (MPä) preserved this nerve until March 2001 when he changed the technique. We investigated patients consecutively operated on before and after this date. A symptom questionnaire was returned by 59 patients, of whom 19 in both groups were successfully further investigated. The follow-up varied from 4 to 9 years postoperatively. The volume of the gallbladder was measured by ultrasonography before and after a fatty test meal. Alkaline phosphatase (ALP), alanine aminotransferase (ALAT), bilirubin, and amylase were determined from plasma.

Results

There was no difference in symptoms or use of antireflux medication between the groups. No difference was found in the levels of bilirubin, ALAT, or ALP. A mild elevation in plasma amylase was noted after nerve division (p = 0.041). The gallbladder ejection fraction did not differ between groups, but the fasting gallbladder volume was smaller when the nerve was cut (median 18.1 (range, 6–57.7) ml versus median 23.2 (range, 7.9–66.7) ml; p = 0.049). Both differences in plasma amylase and gallbladder fasting volume were clearer in male patients.

Conclusions

Cutting the hepatic branch of the anterior vagus nerve during fundoplication may reduce the size of gallbladder, but it has no effect on the ejection fraction. No clinical significance has been noted to date. Prospective trials will be necessary to confirm these findings.     

磁力环治疗胃食管反流性疾病的实验研究

目的胃食管反流性疾病(GERD)是指胃内容物反流入食管,磁括约肌增强器能够增加食管下括约肌(LES)张力达到抗反流的效果,该研究应用宁波胜杰康生物科技有限公司生产的磁括约肌增强器,验证该手术的安全性和有效性。 方法12例实验动物(猪)通过开腹或腹腔镜的方式放置磁力环于LES处,观察饲养1、3、6个月后实验动物的饮食行为、体重和手术前后LES压力的变化;通过钡剂造影观察进食通畅度、磁力环的扩张、闭合情况。解剖实验动物后,观察植入器械是否出现移位和腐蚀,是否有食管梗阻,以及是否出现植入区域食管组织炎症、糜烂和缺血坏死等。 结果实验动物均能正常进食,3例偶有呕吐,3例进食较快有呕吐,三组实验动物体重均增加;吞钡显示钡剂通过顺畅,无明显近端食管扩张等阻碍吞咽的相关影像表现。LES测压提示术后压力较术前明显增加;大体标本显示磁力环固定于食管下段外膜附近,贴近肌层,形成纤维组织囊;10例标本磁珠附近组织镜下未见炎症细胞浸润,2例标本见少量—中等量中性粒细胞及少量淋巴细胞浸润。 结论磁力环装置可通过开腹或腔镜方便植入,研究表明该装置以及安装技术安全、可靠,可转化到GERD患者中。     

达芬奇机器人辅助与腹腔镜Nissen胃底折叠术治疗成人胃食管反流病的Meta分析

目的系统评价达芬奇机器人辅助Nissen胃底折叠术(robot-assisted Nissen fundoplication,RAF)与传统腹腔镜Nissen胃底折叠术(conventional laparoscopic Nissen fundoplication, CLF)比较治疗成人胃食管反流病(gastroesophageal reflux disease, GERD)的有效性和安全性。 方法计算机系统检索Pubmed、EMbase、Cochrane Library、Web of science、CNKI、WanFang Data和CBM数据库,同时追溯相关文献的参考文献,查找RAF与CLF比较治疗成人GERD的随机对照研究和队列研究,检索时间均限定为从建库至2018年6月30日。由2位研究员独立筛选文献、提取资料并进行纳入研究的质量评价,采用Stata/SE 12进行Meta分析,通过I²统计量反映纳入研究的异质性。 结果共纳入11篇文献,累计683例患者,其中RAF组267例、CLF组416例。Meta分析结果表明,与CLF组相比,RAF组手术时间更长(WMD＝28.83, 95%CI：12.89～44.76, P<0.05)、费用较高(P<0.05);两组围手术期并发症发生率、术中中转率、术后气胸发生率、术后吞咽困难发生率、再手术率、住院时间比较,差异无统计学意义(P>0.05)。 结论研究结果表明,RAF在治疗成人GERD中有着良好的安全性和有效性。然而,鉴于RAF更长的手术时间和更高的手术费用,使其在临床上应用受到限制。     

New alternatives in the management of gastroesophageal reflux disease

BACKGROUND: To date the mainstay of surgical treatment for gastroesophageal reflux disease (GERD) has been achieved with either open or laparoscopic fundoplication. Several new treatment modalities are attempting to augment the gastroesophageal (GE) junction function by various endoscopic means. METHODS: The Medline database from 1980 to 2002 was searched for studies on endoscopic techniques for antireflux procedures. Product investigators were contacted for data presented in abstract form only. RESULTS: Recent improvements in equipment and technique with excellent long-term follow-up have made laparoscopic Nissen fundoplication the gold standard in antireflux surgery. New techniques include using radiofrequency energy, injection of silicon type polymer and using endoluminal sutures to narrow the gastroesophageal junction. Early results have encouraging aspects, but should be evaluated thoroughly and with caution before widespread use. CONCLUSIONS: Endoscopic treatment of gastroesophageal reflux has future promise. However, more experience and perhaps further improvement in techniques and technology must occur before wide application can be encouraged.     

Magnetic Augmentation of the Lower Esophageal Sphincter: Results of a Feasibility Clinical Trial

Background  The high prevalence of gastroesophageal reflux disease continues to encourage the development of treatment modalities to fill the gap between acid-suppression therapy and the laparoscopic Nissen fundoplication. The Magnetic Sphincter Augmentation device has been designed to augment the lower esophageal sphincter barrier using magnetic force. A multi-center feasibility trial was done to evaluate safety and efficacy. Methods  Patients with typical heartburn (at least partially responding to proton-pump inhibitors), abnormal esophageal acid exposure, and normal esophageal peristalsis were enrolled. Patients with hiatal hernia >3 cm were excluded from the study. The device was implanted laparoscopically around the distal esophagus. Results  Over a 1-year period, 38 out of 41 enrolled patients underwent this procedure in 3 hospitals. No operative complications were recorded. A free diet was allowed since post-operative day one, and 97% of patients were discharged within 48 h. The mean follow-up was 209 days (range 12–434 days). The GERD-HRQL score decreased from 26.0 to 1.0 (p < 0.005). At 3 months post-operatively, 89% of patients were off anti-reflux medications, and 79% of patients had a normal 24-h pH test. All patients preserved the ability to belch. Mild dysphagia occurred in 45% of patients. No migrations or erosions of the device occurred. Conclusions  Laparoscopic implant of the MSA device is safe and well tolerated. It requires minimal surgical dissection and a short learning curve compared to the conventional Nissen fundoplication. Presented at 49th Annual Meeting of the Society for Surgery of the Alimentary tract, San Diego, California, USA, May 20, 2008     

Psychiatric disorders affect outcomes of antireflux operations for gastroesophageal reflux disease

apd: 20 October 2000     

Effect of Laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms

Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11 %). These 39 patients had been symptomatic for an average of 134 months. They were all taking H-blocking agents (21 %) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisonc (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antircflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%. Presented at the Fortieth Annual Meeting ot The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS)

Background: Because it has been suggested that obesity adversely affects the outcome of LARS, it is unclear how surgeons should counsel obese patients referred for antireflux surgery. Methods: A prospective database of patients undergoing LARS from 1992 to 2001 was used to compare obese and nonobese patients. Patients were surveyed preoperatively and annually thereafter. Questionnaires were completed regarding global symptoms and overall satisfaction. Results: Of the 505 patients, the body mass index (BMI) was <25 (normal) in 16%, 25–29 (overweight) in 42%, and >30 (obese) in 42%. Although the operative time was longer in the obese group than in the normal weight group (137 ± 55 min vs 115 ± 42 min, p = 0.003), the time to discharge and rate of complications did not differ. At a mean follow-up of 35 ± 25 months, there were no differences in symptoms, overall improvement, or patient satisfaction. Further, the rates of anatomic failure were similar among the obese, overweight, and normal weight groups. Conclusions: Although the operative time is longer in the obese, complication and anatomic failure rates are similar to those in the nonobese at long-term follow-up. Obese patients have equivalent symptom relief and are equally satisfied postoperatively. Therefore, obesity should not be a contraindication to LARS. Presented at the annual meeting of the Association of Academic Surgeons, Boston, MA, USA, November 2002     

Laparoscopic antireflux surgery and its effect on cough in patients with gastroesophageal reflux disease

In addition to heartburn and regurgitation, cough is a frequent nonspecific complaint of patients with gastroesophageal reflux disease. The incidence of alternative etiologies for patients with chronic cough who are undergoing antireflux surgery is not known. To determine this, and the response of chronic cough to fundoplication, we performed a retrospective review of 129 patients with proven gastroesophageal reflux referred for surgical therapy. Chronic cough was present in 37 (29%) preoperatively. No differences were found in age, sex, or preoperative manometric findings between those with and without chronic cough. Patients with cough had a higher number of lower esophageal reflux events on preoperative 24-hour pH testing, and were more likely to have persistent dysphagia after surgery. Fifty-nine percent of patients with cough had an alternative etiology for cough, compared to 36% of those without cough. Of the common alternative etiologies, only a history of postnasal drip occurred more frequently in those with cough. Complete resolution of cough occurred in 24 patients (64%), with another 10 (27%) reporting significant improvement. The average cough score improved significantly regardless of which coexisting etiology the patients may have had. Additionally, heartburn and regurgitation were improved in 94% of all patients. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001 (oral presentation).     

Prevention of gastroesophageal reflux using nissen fundoplication in the staged repair of esophageal atresia with distal tracheoesophageal fistula

To prevent the reflux of gastric contents into the bronchial tree through the tracheoesophageal fistula in patients with esophageal atresia with tracheoesophageal fistula, Nissen fundoplication was performed in the first-stage repair of staged operations. After elimination of the pulmonary complication, a correction of esophageal atresia and tracheoesophageal fistula was successfully performed through the extrapleural route at the age of 16 days. Thus, because Nissen fundoplication is simple to perform and effective in preventing gastroesophageal reflux, this procedure is considered to be useful in the staged repair of esophageal atresia with tracheoesophageal fistula.     

胃食管反流病患者伴有或不伴有食管黏膜损伤与食管上、下括约肌压力相关性研究

目的研究伴或不伴食管黏膜损伤的胃食管反流病（gastroesophageal reflux disease,GERD）患者在食管动力方面的差异。 方法回顾性分析2015年1月至2017年12月,解放军总医院就诊的有反酸、烧心、胸痛等症状的患者,24 h食管pH监测Demeester积分≥14.72分,根据内镜检查结果分为糜烂性反流病（ERD）组和非糜烂性反流病（NERD）组,比较2组患者食管动力学指标的变化。 结果NERD组与ERD组UESP平均值数值相似,差异无统计学意义（P=0.168）。其余指标UESRP平均值、LESP最小值、LESP平均值、LESRP平均值、LESRP最大值、DCI中NERD组均高于ERD组,差异均有统计学意义（P<0.001）。NERD组平均年龄明显小于ERD组,差异有统计学意义（P<0.000 1）。NERD组患者身高较ERD组偏低,体重较轻,身体质量指数（body mass index,BMI）也较小,差异有统计学意义（P<0.000 1）。 结论随着年龄的增大或BMI的增加,可能增加GERD患者食管黏膜损伤的风险。此外,糜烂性反流病患者较非糜烂性反流病的上、下食管括约肌动力障碍更严重。     

Endoscopic implantation of polymethylmethacrylate augments the gastroesophageal antireflux barrier: a short-term study in a porcine model

Background and aims  Endoscopic injection of filler agents into the esophagogastric junction has been developed to augment the antireflux barrier and decrease gastroesophageal reflux (GER). However, evidence of efficacy is lacking and serious complications have been reported in humans. The aim of this study was to assess whether endoscopic implantation of polymethylmethacrylate augments the antireflux barrier in a porcine model for GER. Methods  Large White pigs underwent esophageal manometry, gastric yield pressure (GYP), and gastric yield volume (GYV) measurements and implantation of PMMA in the distal esophagus under general anesthesia. After follow-up of 28 days, esophageal manometry and gastric yield measurements were repeated and animals sacrificed. Results  Implantation of PMMA was performed in 18 animals, and 14 animals survived 28 days. There was a significant increase in GYP (10.7 mmHg versus 8.1 mmHg; p = 0.017) and GYV (997 ml versus 393 ml; p < 0.001) after PMMA implantation, whereas resting LES pressure did not change significantly. Acute inflammatory changes and fibrous tissue deposits were found surrounding the PMMA implants during histology. One animal died after esophageal perforation and three others due to pneumonia (two) and colon perforation (one) in the postoperative period. Conclusions  Endoscopic implantation of PMMA in the distal esophagus augments the antireflux barrier 28 days after the procedure. However, esophageal perforation points to the need for technical refinements to make the procedure safer.