Long-term outcome is worse after laparoscopic than after conventional Nissen fundoplication

Objective. No long-term studies of laparoscopic and open fundoplication were available in 1994. The aim of this study was to compare reflux control and side effects after laparoscopic and open fundoplication. Material and methods. Adult patients with uncomplicated gastro-oesophageal reflux disease were included in this prospective randomized clinical trial between laparoscopic and open 360° fundoplication. Patients with uncomplicated gastro-oesophageal reflux disease were included with the exception of those with weak peristalsis or suspected short oesophagus. Two senior surgeons, well trained in laparoscopic antireflux surgery, performed the 45 laparoscopic operations. Forty-eight patients underwent open surgery performed or supervised by two other senior surgeons, also well trained in gastro-oesophageal surgery. One of the latter recruited all the patients. Manometry and 24-h oesophageal pH monitoring were performed before operation and 6 months postoperatively. Manometry also included a short-term reflux test, an acid clearing test and an acid perfusion test. Symptom evaluation was performed before surgery, 6 moths after and at long-term follow-up (33–79 months postoperatively) by the same surgeon. Long-term follow-up also included endoscopy. Results. Six months after laparoscopy 4 patients had disabling dysphagia. None of the patient had disabling dysphagia after laparotomy. Four patients had mild heartburn 6 months after laparoscopy and 2 patients after laparotomy. Between 6 months’ follow-up and long-term follow-up, 6 patients were reoperated on in the laparoscopy group and 2 patients in the laparotomy group. Three patients operated on with laparotomy had died of intercurrent diseases. After laparoscopy, at long-term follow-up, 62% of patients (28/45) were satisfied compared with 91% (41/45) after laparotomy. The difference was significant (p<0.01). Conclusions. Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. At long-term follow-up significantly more patients were satisfied after laparotomy than after laparoscopy.     

Dysphagia after laparoscopic Nissen fundoplication

OBJECTIVE: To investigate the frequency and severity of dysphagia during the first 8 weeks after laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. So far, there have been no studies reporting data on day-to-day occurrence of dysphagia after laparoscopic fundoplication in a consecutive series of patients. This may explain why the frequency of dysphagia varies greatly in the literature (4-100%). MATERIAL AND METHODS: Forty consecutive patients, undergoing elective laparoscopic Nissen fundoplication, completed a standard dysphagia registration diary each day during the first 8 weeks after surgery. Patients who preoperatively had suffered from dysphagia were excluded. Thus, none of the patients had dysphagia in the 2-month period before surgery. Ten patients undergoing elective cholecystectomy served as controls. Data were quantified, and a score value of 4 or more was considered bothersome. RESULTS: Thirty-seven patients (93%) experienced some degree of dysphagia during the observation period. Sixteen patients (44%) had at least one day with annoying dysphagia. The dysphagia started 1-2 days after surgery, was most prominent during the first few weeks, and subsided in nearly all cases after 5-6 weeks. Two patients with persistent dysphagia were treated once with balloon dilatation. None of the patients in the control group had dysphagia. CONCLUSIONS: Nearly all patients experience some degree of dysphagia after laparoscopic Nissen fundoplication, and in nearly half of the patients it is considered annoying. However, even severe dysphagia usually disappears within 5-6 weeks. These results suggest a conservative attitude for the first 1-2 months after surgery. The data may also serve as a background for preoperative information to the patients.     

Dysphagia after laparoscopic Nissen fundoplication

Objective. To investigate the frequency and severity of dysphagia during the first 8 weeks after laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. So far, there have been no studies reporting data on day-to-day occurrence of dysphagia after laparoscopic fundoplication in a consecutive series of patients. This may explain why the frequency of dysphagia varies greatly in the literature (4–100%). Material andmethods. Forty consecutive patients, undergoing elective laparoscopic Nissen fundoplication, completed a standard dysphagia registration diary each day during the first 8 weeks after surgery. Patients who preoperatively had suffered from dysphagia were excluded. Thus, none of the patients had dysphagia in the 2-month period before surgery. Ten patients undergoing elective cholecystectomy served as controls. Data were quantified, and a score value of 4 or more was considered bothersome. Results. Thirty-seven patients (93%) experienced some degree of dysphagia during the observation period. Sixteen patients (44%) had at least one day with annoying dysphagia. The dysphagia started 1–2 days after surgery, was most prominent during the first few weeks, and subsided in nearly all cases after 5–6 weeks. Two patients with persistent dysphagia were treated once with balloon dilatation. None of the patients in the control group had dysphagia. Conclusions. Nearly all patients experience some degree of dysphagia after laparoscopic Nissen fundoplication, and in nearly half of the patients it is considered annoying. However, even severe dysphagia usually disappears within 5–6 weeks. These results suggest a conservative attitude for the first 1–2 months after surgery. The data may also serve as a background for preoperative information to the patients.     

Fatal portal thrombosis after laparoscopic Nissen fundoplication.

Portal and mesenteric vein thrombosis is a very uncommon complication of laparoscopic surgery, especially after anti-reflux procedures. We report the case of a twenty-year-old man with a history of alcohol and cocaine consumption. A Nissen fundoplication was performed. The patient received a single 20-mg dose of enoxaparin (Clexane, Aventis Pharma, Spain) two hours before surgery for antithrombotic prophylaxis. On the seventh postoperative day the patient had a portal and mesenteric venous thrombosis, which was confirmed at laparotomy, with both extensive small-intestine necrosis and partial colon necrosis. Despite anticoagulant therapy, the patient died 24 hours later. Surgical findings were confirmed at necropsy. Portal and mesenteric venous thrombosis is an uncommon but severe and even fatal complication after laparoscopic anti-reflux surgery. When other pro-thrombotic, predisposing conditions such as laparoscopic surgery and cocaine consumption are present, the usual prophylactic doses of low molecular weight heparin might not be sufficient to protect against this life-threatening complication.     

Obesity and its effect on outcome of laparoscopic Nissen fundoplication

Obesity has long been suspected as predisposing to gastroesophageal reflux disease, and it has also been claimed that it is an important cause of poor outcome following laparoscopic anti-reflux surgery. This study was performed to determine the validity of this proposition. The outcome of 194 patients from an overall experience of 971 laparoscopic anti-reflux procedures was determined in this study. Patients were included if they had undergone a laparoscopic Nissen fundoplication, had completed a minimum 12 months follow-up using a structured questionnaire, and had data available for the calculation of their preoperative body mass index (BMI). Patients were divided into three groups based on BMI: normal weight (BMI < 25), overweight (BMI 25-29.9), and obese (BMI >30). The association between BMI and outcome data from their most recent follow-up was analyzed. There was no correlation between increasing BMI and a poorer overall outcome. There was a slight trend toward less satisfaction with the surgical outcome in patients of normal weight. Preoperative obesity is not associated with a poorer outcome following laparoscopic Nissen fundoplication.     

The economics of laparoscopic Nissen fundoplication.

BACKGROUND & AIMS: A major impetus for laparoscopic Nissen fundoplication (LNF) is its purported cost savings compared with medical therapy, but few studies have examined these economic outcomes. The aim was to analyze health care costs and use among a cohort of patients undergoing LNF and compare them with patients with medically treated gastroesophageal reflux disease (GERD). METHODS: Comparison of health care use and direct costs from the third-party payer perspective using 13 United HealthCare Plans. Sixty-one patients who underwent LNF from January 1994 to June 1998 and 178 matched controls were used for this study. Outcome variables included the cost of hospital and outpatient visits, hospitalizations, related endoscopic procedures, and pharmacy claims for proton pump inhibitors, H(2) receptor antagonists, and prokinetics. Cost of LNF or index esophagogastroduodenoscopy was not included. RESULTS: Sixty-one LNF patients and 178 controls were studied. No differences were seen for the costs of office visits and hospital admissions or the number of gastrointestinal procedures. LNF patients had significantly lower gastrointestinal medication costs. Median total health care costs were significantly lower in the LNF group but mean total costs were not different. This was attributable to $201,000 in costs for managing complications in one patient that skewed total health care cost in the LNF group. CONCLUSIONS: For the 12 months after surgery, LNF reduced costs for gastrointestinal medications but not total costs for the cohort. LNF cost is impacted greatly by the cost of associated complications. Based on these data, LNF does not appear to significantly reduce the direct cost of health care for GERD patients on a population basis.     

Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication

AIM:To evaluate the feasibility and outcomes of laparoscopic Nissen fundoplication after failed transoral incisionless fundoplication(TIF).METHODS:TIF is a new endoscopic approach for treating gastroesophageal reflux disease(GERD).In cases of TIF failure,subsequent laparoscopic fundoplication may be required.All patients from 2010 to 2013 who had persistence and objective evidence of recurrent GERD after TIF underwent laparoscopic Nissen fundoplication.Primary outcome measures included operative time,blood loss,length of hospital stay and complications encountered.RESULTS:A total of 5 patients underwent revisional laparoscopic Nissen fundoplication(LNF)or gastrojejunostomy for recurrent GERD at a median interval of 24mo(range:16-34 mo)after TIF.Patients had recurrent reflux symptoms at an average of 1 mo following TIF(range:1-9 mo).Average operative time for revisionalsurgical intervention was 127 min(range:65-240 min)and all surgeries were performed with a minimal blood loss(<50 m L).There were no cases of gastric or esophageal perforation.Three patients had additional finding of a significant hiatal hernia that was fixed simultaneously.Median length of hospitalization was 2 d(range:1-3 d).All patients had resolution of symptoms at the last follow up.CONCLUSION:LNF is a feasible and safe option in a patient who has persistent GERD after a TIF.Previous TIF did not result in additional operative morbidity.     

Outcomes after laparoscopic Nissen fundoplication are not influenced by the pattern of reflux

SUMMARY.  The purpose of this study was to compare the outcomes of patients with different types of gastroesophageal reflux disease (upright, supine, or bipositional) after laparoscopic Nissen fundoplication and determine if patients with upright reflux have worse outcomes. Two hundred and twenty-five patients with reflux confirmed by 24-h pH monitoring were divided into three groups based on the type of reflux present. Patients were questioned pre- and post-fundoplication regarding the presence and duration of symptoms (heartburn, regurgitation, dysphagia, cough and chest pain). Symptoms were scored using a 5-point scale, ranging from 0 (no symptom) to 4 (disabling symptom). Esophageal manometry and pH results were also compared. There was no statistically significant difference in lower esophageal sphincter length, pressure or function between the three groups. There was no significant difference in any of the postoperative symptom categories between the three groups. The type of reflux identified preoperatively does not have an adverse effect on postoperative outcomes after Nissen fundoplication and should not discourage physicians from offering antireflux surgery to patients with upright reflux.     

Long-term results after 'floppy' Nissen/Rossetti fundoplication for gastroesophageal reflux disease.

Eighty-two patients (median age, 51 years; range, 27-87 years) with refractory gastroesophageal reflux disease (GERD) underwent floppy Nissen/Rossetti fundoplication during the period 1980 to 1990. The median postoperative hospital stay was 5 days (3-16). Median follow-up was 72 months and included endoscopy and a clinical and a questionnaire assessment. Subjective symptoms of reflux were abolished in 98%, and 96% of the patients were satisfied with the results. Endoscopy showed healing of the esophagitis in 98%. There had been no disruption of the fundoplication. Twenty patients complained of gaseous distention and increased flatulence; only two of them had severe problems. Three patients were unable to belch. In conclusion, the floppy fundoplication has been an effective operation with no deaths, a low incidence of morbidity and adverse side effects, and without a tendency for late failure.     

Postprandial hypoglycemia after Nissen fundoplication for reflux esophagitis

The motility of the stomach is modulated by the complex interplay of muscular, humoral, and neuronal factors. Rapid gastric emptying has been described after gastrectomy, gastrojejunostomy, vagotomy with pyloroplasty, and with active peptic ulcer disease. Rapid emptying may result in "dumping" syndrome and in postprandial hypoglycemia. We report a patient who developed postprandial hypoglycemia after a Nissen fundoplication for reflux esophagitis. This is the first report of this complication after this surgical procedure. The hypoglycemia was secondary to a combination of rapid gastric emptying, rapid absorption of glucose causing hyperglycemia, and excessive insulin secretion. This syndrome should be considered in patients who develop hypoglycemic symptoms after fundoplication. Treatment with a low carbohydrate diet and anticholinergic agents may offer symptomatic relief.     

Outcome of erosive reflux esophagitis after Nissen fundoplication

OBJECTIVE: The aim of this study was to compare the utilization of health care resources and long term outcome of erosive esophagitis in patients treated with and without open Nissen fundoplication. METHODS: A population of 35,725 patients with erosive esophagitis was extracted from the computerized database of the US Department of Veterans Affairs. Subjects were stratified by severity of disease into erosive esophagitis alone versus erosive esophagitis complicated by esophageal ulcers or peptic strictures. During a mean follow-up period of 4.2 yr (range 1-12 yr), the consumption of health care resources, except for medications, was compared between case and control subjects treated with and without fundoplication, respectively. RESULTS: Among patients with complicated erosive esophagitis, 5,064 control subjects were treated without, and 542 case subjects were treated with, fundoplication. Cases incurred less recurrence of esophageal erosions (controls: 56% vs cases: 46%), esophageal ulcers (38% vs 33%), and peptic strictures (43% vs 32%) during follow-up. Among patients with erosive esophagitis but no complications, 29,514 control subjects were treated without, and 605 case subjects were treated with, fundoplication. Cases did not experience any change in the recurrence of esophageal erosions (controls: 25% vs cases: 24%). Irrespective of treatment type, none of the case or control subjects with erosive esophagitis alone developed esophageal ulcers or peptic strictures during follow-up. Compared with controls, however, after fundoplication in erosive esophagitis alone, cases incurred more dysphagia (2.6% vs 4.6%), postsurgical syndromes (0.8% vs 1.7%), as well as more outpatient visits (34 vs 40 visits/patient) and outpatient procedures (2.7 vs 4.3 procedures/patient). CONCLUSIONS: Fundoplication improves the clinical outcome of erosive esophagitis in patients with concomitant esophageal ulcers and strictures, but not in patients without such complications. Fundoplication does not reduce the consumption of health care resources.     

Preoperative esophageal body motility does not influence the outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease.

We evaluated a policy of performing laparoscopic antireflux surgery without tailoring the procedure to the results of preoperative esophageal motility tests. A total of 117 patients (82 with normal esophageal motility; 35 with ineffective motility, IEM) underwent laparoscopic Nissen fundoplication for symptomatic gastroesophageal reflux. There were no significant differences in preoperative symptom length, dysphagia, DeMeester symptom scores, acid exposure times or lower esophageal sphincter pressures between the two groups. Both groups showed postoperative improvements in DeMeester symptom scores, dysphagia and acid exposure, with no differences between groups. At 1 year after surgery, 95% of the normal motility group and 91% of the IEM group had a good/excellent outcome from surgery. None of the IEM group required postoperative dilatation or reoperation. Patients with IEM fare equally well from laparoscopic Nissen fundoplication as those with normal esophageal motility. There is no merit in tailoring antireflux surgery to the results of preoperative motility tests.     

The lower esophageal sphincter strength in patients with gastroesophageal reflux before and after laparoscopic Nissen fundoplication

Lower esophageal sphincter pressure (LESP) and sphincter strength (LESS) were measured before and after short and floppy laparoscopic Nissen fundoplication (LNF) in 38 patients with severe gastro-esophageal reflux disease (GERD). These patients were compared with a control group of 23 healthy volunteers. GERD was assessed by stationary manometry, 24-h pH recordings and endoscopy. LESS was verified by motorized pull-back of an air-filled balloon catheter from the stomach into the esophagus. The catheter assembly was well tolerated by all study participants. LESP increased significantly after operation from 8 mmHg to 14 mmHg (75% of normal values; P < 0.0001), but compared to the control group, LESP (22 mmHg) decreased significantly (P < 0.002). In the control group and in patients with GERD, LESP and LESS showed excellent correlation (r = 0.97, r = 0.94, respectively). After LNF, LESS increased significantly from 0.6 to 1.6 N (P < 0.0001), about 166%. We conclude that the measurement of LESS is able to explain the discrepancy between satisfactory NF operation and the distinct increase of postoperative LESP. The evaluation of LESS is a helpful tool in assessing functional understanding of laparoscopic Nissen fundoplication with a short and floppy wrap.     

Motor and sensory function of the proximal stomach in reflux disease and after laparoscopic Nissen fundoplication

OBJECTIVE: After Nissen fundoplication, dyspeptic symptoms such as fullness and early satiety develop in >30% of patients. These symptoms may result from alterations in proximal gastric motor and sensory function. METHODS: We have evaluated proximal gastric motor and sensory function using an electronic barostat in 12 patients after successful laparoscopic Nissen fundoplications (median follow-up; 12 months). Twelve age- and gender-matched patients with severe gastroesophageal reflux disease (GERD) and 12 healthy volunteers served as controls. Studies were performed in the fasting state and after meal ingestion. Gastric emptying tests were performed in all patients. Vagus nerve integrity was measured by the response of pancreatic polypeptide (PP) to insulin hypoglycemia. RESULTS: Minimal distending pressure and proximal gastric compliance were not significantly different between post-Nissen patients, GERD patients, and healthy controls. Postprandial relaxation of the stomach, however, was significantly (p < 0.05) reduced post-Nissen (267 +/- 34 ml), compared with controls (400 +/- 30 ml) and GERD (448 +/- 30 ml). Postprandial relaxation was significantly (p < 0.01) prolonged in GERD patients. Postprandial relaxation of the stomach correlated with gastric emptying of solids (r = 0.62; p = 0.01). Gastric emptying of solids became significantly (p < 0.05) faster after fundoplication. Postprandial fullness was significantly (p < 0.05) increased in the operated patients. CONCLUSIONS: Post-Nissen patients have a significantly reduced postprandial gastric relaxation and significantly accelerated gastric emptying, which may explain postoperative dyspeptic symptoms. The abnormalities result from fundoplication and not from vagus nerve injury or reflux per se, because in reflux patients gastric relaxation and gastric emptying are prolonged.     

Motion--Laparoscopic Nissen fundoplication is more cost effective than oral PPI administration: arguments for the motion.

Gastroesophageal reflux disease is a mechanical disorder of the foregut. While medications can only provide symptom relief, surgery can correct the pathophysiological abnormality of the lower esophageal sphincter. The costs of medical and surgical therapy are much greater than the costs of medication or hospitalization alone. In the case of medical therapy, one must consider the costs of serial monitoring and of failed treatment. The effectiveness of treatment also depends on patient-related factors, including weight, socioeconomic factors, smoking, alcohol use, dietary habits and the use of nonsteroidal anti-inflammatory drugs. Surgical results depend on the experience and skill of the surgeon, as well as the attributes of the institution in which the procedure is undertaken. Therefore, studies that come from specialized centres may not be applicable to the community. Data from the author's facility indicate that laparoscopic Nissen fundoplication is the most cost effective option when it is undertaken by experienced surgeons on otherwise healthy patients who have documented gastroesophageal reflux disease.