Outcome of laparoscopic Nissen–Rossetti fundoplication in children with gastroesophageal reflux disease and supraesophageal symptoms

Background: The role of surgery is debated for children with gastroesophageal reflux disease (GERD), particularly when they show atypical symptoms. This study was designed to evaluate the safety and outcome of laparoscopic Nissen-Rossetti fundoplication performed in a selected population of children with gastroesophageal reflux and atypical supraesophageal symtpoms. Methods: This prospective study included 595 patients younger than 14 years with GERD who reported recurrent respiratory symptoms and had no benefit from standard medical treatment. Surgery was performed for 48 patients with anatomic anomalies, life-threatening events, or respiratory complications after ineffective medical treatment. The subjective and objective outcomes were evaluated. Results: No major intraoperative complications were experienced, and there was no recurrence of gastroesophageal reflux during a postoperative follow-up period of 12 months. The parents final subjective evaluation of the outcomes 12 months after surgery was positive in 44 cases and negative in 4 cases. Conclusions: Children with difficult-to-treat chronic respiratory symptoms must be evaluated for GERD, even if the need for surgery is low (8%), because complete eradication of reflux is mandatory. Radical treatment of GERD allows the pulmonologist to perform correct respiratory treatment and to prevent the development chronic and life-threatening complications.     

Histologic and clinical outcome after laparoscopic Nissen fundoplication for gastroesophageal reflux disease and Barrett’s esophagus

Background The effectiveness of laparoscopic Nissen fundoplication for the regression of Barrett’s esophagus in gastroesophageal reflux disease remains controversial. The aim of this study, therefore, was to review endoscopic findings and clinical changes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease, particularly for patients with Barrett’s esophagus. Methods From September 1995 through June 2004, 127 patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication. All the patients had clinical and endoscopic follow-up evaluation. We further analyzed the course of 37 consecutive patients with Barrett’s esophagus (29% of all laparoscopic fundoplications performed in our institution) using endoscopic surveillance with appropriate biopsies and histologic evaluation. The median follow-up period for all the patients after fundoplication was 34 months (range, 3–108 months). The median follow-up period for the patients with Barrett’s esophagus was 19 months (range, 3–76 months). Results During the 9-year period, 70 women (55 %) and 57 (45%) men were treated with laparoscopic Nissen fundoplication. The median age of these patients was 42 years (range, 7–81 years). The clinical results were considered excellent for 67 patients (53%), good for 51 patients (40%), fair for 7 patients (6%), and poor for 2 patients (1%). Endoscopic surveillance showed regression of the macroscopic columnar segment in 23 patients with Barrett’s esophagus (62%). Regression at a histopathologic level occurred for 15 patients (40%). The histopathology remained unchanged for 14 patients with Barrett’s esophagus (38%). Conclusion Laparoscopic Nissen fundoplication effectively controls intestinal metaplasia and clinical symptoms in the majority of patients with Barrett’s esophagus.     

Gastrointestinal symptoms and patient satisfaction more than 1?year after laparoscopic Nissen fundoplication

Background  

Symptoms from poorly controlled gastroesophageal reflux disease (GERD) such as heartburn and regurgitation often resolve after laparoscopic Nissen fundoplication. Unfortunately, new gastrointestinal symptoms such as bloating may occur for some patients. Accurate data regarding the gastrointestinal symptoms experienced by patients who have had a laparoscopic fundoplication may help patients to make more informed decisions about pursuing surgery for their reflux disease.     

Significance of Nissen fundoplication after endoscopic radiofrequency ablation of Barrett’s esophagus

Objective

HALO radiofrequency ablation (RFA) has been proven as safe and efficient in eradication of both non- and dysplastic Barrett’s esophagus (BE). Definitive post-RFA treatment is yet to be determined.

Methods

RFA was performed in 56 patients with BE, 38 with intestinal metaplasia (IM) and 18 with low-grade dysplasia (LGD), and repeated in case of residual BE. Length of the BE was classified according to C&M criteria. Follow-up included regular upper GI endoscopies with biopsies 6 months, 1 and 2 years after the complete resolution of BE. Patients were divided into two groups regarding post-RFA treatment: those maintaining proton pump inhibitors (PPI) daily and those submitted to laparoscopic Nissen fundoplication (LNF) at least 3 months after BE eradication or synchronous with RFA.

Results

There were no perforations or strictures related to RFA. Complete endoscopic resolution of BE was observed in 83.92 % patients (86.84 % IM and 77.77 % LGD), in 25 that maintained PPI and 22 in whom LNF was done. In PPI group, 2-year follow-up revealed BE recurrence in biopsy samples in 20 % of patients, while in LNF group 9.1 % of patients had recurrent IM. In overall sample of patients, no difference was noted regarding the influence of post-RFA treatment (p < 0.423). LNF proved superiority over PPI treatment in patients with long-segment BE (cutoff C > 4 cm, p < 0.021).

Conclusion

HALO RFA is a safe procedure, with high rate of success in complete eradication of BE in symptomatic GERD patients. LNF provides good protection for neosquamous epithelium and in selected group of patients could be offered as a first line of treatment after HALO RFA.

     

No relevant difference in quality of life and functional outcome at 12 months’ follow-up—a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication

Purpose  The present randomised pilot trial was designed to compare robot-assisted (RALF) and conventional laparoscopic fundoplication (CLF) focussing on post-operative quality of life (QOL) and functional outcome. Any long-lasting advantages for patients in this regard could be a justification for the use of RALF for the treatment of gastroesophageal reflux disease (GERD). Methods  Forty patients with GERD were randomised to either RALF or to CLF. During a follow-up period of 12 months, patients’ QOL and functional outcome were investigated using disease-specific questionnaires. Results  There were no significant differences in the mean QOL (1.3 versus 1.1; P = 0.374) and functional outcome (1.27 versus 1.3; P = 0.913) between both groups. Minor side effects such as bloating and persistent diarrhoea were present in four patients of each group. Conclusion  The present study did not show any benefit for RALF over CLF regarding QOL and functional outcome at 12 months’ follow-up. B. P. Müller-Stich and M. A. Reiter contributed equally to this work.     

Patterns of esophageal acid exposure after laparoscopic Heller’s myotomy and Dor’s fundoplication for esophageal achalasia

BACKGROUND: Heller's myotomy for esophageal achalasia is associated with less esophageal acid gastroesophageal reflux when combined a Dor's fundoplication. The Aim of the study was to assess the incidence of postoperative esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication (HM-DF). METHODS: Seventy six patients (37 males) with esophageal achalasia were prospectively followed-up by clinical interview and laboratory tests before and after laparoscopic HM-DF. A symptom score was used for clinical assessment. Laboratory assessment included esophageal standard manometry, esophagogram and esophageal pH 24-hour monitoring before and 1- and 5-years after surgery. RESULTS: Symptom score improved at 1-year after surgery (P < 0.001). Heartburn was only reported by 5 patients, dysphagia or/and regurgitation by 28 and substernal pain by 12. 91% of patients had satisfactory functional results. Pathological esophageal exposure to acid was seen in 21% of the cases. Pathological acid events showed the features of pseudoreflux in 66%t and those of true GER in 34%. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum (P = 0.001) and was related to the diameter of distal esophagus and symptom score (P < 0.001). There was no reduction in esophageal acid exposure after treatment with proton pump inhibitors in 16 patients. Neither the symptom score nor esophageal acid exposure at esophageal pH monitoring changed significantly at the 5-year follow-up in 35 patients. Esophageal configuration remained unchanged. CONCLUSIONS: Increased esophageal exposure to acid after laparoscopic HM-DF for esophageal achalasia i) is detected in 21% of patients, and is rather the result of food stagnation than of true GER, ii) is more commonly seen in cases with pseudodiverticulum, iii) is related to the diameter of distal esophagus, iv) does not respond to antisecretory treatment and v) does not deteriorate by time.     

Impact of smoking on disease phenotype and postoperative outcomes for Crohn’s disease patients undergoing surgery

Aim

Whether smoking affects disease distribution, phenotype, and perioperative outcomes for Crohn’s disease (CD) patients undergoing surgery is not well characterized. The aim of this study is to evaluate the impact of smoking on disease phenotype and postoperative outcomes for CD patients undergoing surgery

Methods

Prospectively collected data of CD patients undergoing colorectal resection were evaluated. CD patients who were current smokers (CS) were compared to nonsmokers (NS) and ex-smokers (ES) for disease phenotype, anatomic site involved, procedures performed, postoperative outcomes, and quality of life using the Cleveland Global Quality of Life instrument (CGQL).

Results

Of 691 patients with a diagnosis of CD requiring surgery 314 were classified as CS, 330 as NS, and 47 as ES. CS and ES in comparison to NS were significantly older at diagnosis of Crohn’s disease (mean, 29.3 vs. 29.2 vs. 26.3 years) (P?=?0.001) and older at the time of primary surgery (mean, 42.9 vs. 48.4 vs. 39 years) (P?=?0.001) with a greater frequency of diabetes. In all groups requiring surgery, there was a significant change in disease phenotype from the time of diagnosis to surgical intervention. The predominant phenotype at diagnosis was inflammatory which changed to stricturing and penetrating as the dominant phenotypes at time of surgery. All groups had a significant improvement in CGQL scores post-surgery with the greatest benefit observed in NS. Postoperative complications and 30-day readmission rates were similar between all groups.

Conclusions

The findings of this study show that in patients with CD, disease phenotype changes over time. This occurs independent of smoking. Smoking does not appear to predispose to complications for CD patients undergoing surgery. CS and ES have a persistently reduced quality of life in comparison to NS post-surgery.     

Esophageal adenocarcinoma after Nissen’s fundoplication for Barrett’s esophagus: report of a case

It remains unclear whether surgical treatment of gastro-esophageal reflux disease (GERD) and Barrett’s esophagus (BE) decreases the long-term risk of lower esophagus malignancy; yet, proposed reductions in Barrett’s epithelial transformation have been used as a rationale for antireflux surgery. We report the case of a 63-year-old woman with a 40-year history of GERD, whose symptoms returned after a Nissen fundoplication. A gastroscopy done 3 years later revealed BE. Despite close surveillance, adenocarcinoma of the lower esophagus was diagnosed 8 years after the original surgery. Thus far, there is insufficient evidence to convince practitioners that surgery should be the first line of treatment to prevent malignant change in BE. Further well-standardized, prospective trials are required. Our case demonstrates that antireflux surgery in a patient with GERD and BE cannot be relied upon to prevent adenocarcinoma.     

Is the use of a bougie necessary for laparoscopic Nissen fundoplication?

HYPOTHESIS: Esophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) is commonly used to prevent an excessively tight wrap. However, a bougie may cause intraoperative gastric and esophageal perforations. We hypothesized that LNF is safe and effective when performed without a bougie. DESIGN: Retrospective review of 102 consecutive patients who underwent LNF without a bougie. SETTING: Tertiary care university hospital. PATIENTS: All patients presented with symptoms of reflux disease. Mean (+/- SD) percentage of time with pH of less than 4 was 12.6% +/- 9.4%. Mean DeMeester score was 47.8. Mean (+/- SD) resting lower esophageal sphincter pressure was 15.0 +/- 9.4 mm Hg. Mean (+/- SD) distal esophageal amplitude was 69.4 +/- 39.2 mm Hg. INTERVENTION: During LNF, we obtained 2 to 3 cm of intra-abdominal esophagus, divided all short gastric vessels, reapproximated the crura, and performed a loose 360 degrees fundoplication without a bougie. MAIN OUTCOME MEASURES: Postoperative rates of dysphagia, gas bloat, and recurrent reflux. RESULTS: In the early postoperative period, 50 patients (49.0%) complained of mild, 11 (10.8%) of moderate, and 7 (6.9%) of severe dysphagia. Average (+/- SD) duration of early dysphagia was 4.6 +/- 2.1 weeks. Dysphagia resolved in 61 (89.7%) of 68 patients within 6 weeks. Late resolution of dysphagia was noted in 4 (5.8%) patients. Three patients were successfully treated with esophageal dilatations. Persistent dysphagia was found in 1 patient. Thirty patients (29.4%) had transient gas bloat. Mild persistent reflux, requiring daily medication, was noted in 5 (4.9%) patients. CONCLUSIONS: Performance of LNF without a bougie offers a safe and effective therapy for gastroesophageal reflux disease. While avoiding the potential risks for gastric and esophageal injury, it may provide low rates of long-term postoperative dysphagia and reflux recurrence.     

Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes

BACKGROUND: A small but significant percentage of patients are considered failures after laparoscopic Nissen fundoplication (LNF). We sought to identify preoperative predictors of failure in a cohort of patients who underwent LNF more than 10 years ago. METHODS: Of 312 consecutive patients undergoing primary LNF between 1992 and 1995, recent follow-up was obtained from 166 patients at a mean of 11.0 +/- 1.2 years. Eight additional patients who underwent reoperation were lost to follow-up but are included. Failure is broadly defined as any reoperation, lack of satisfaction, or any severe symptoms at follow-up. Potential predictors evaluated included sex, age, body-mass index (BMI), response to acid reducing medications (ARM), psychiatric history, typical versus atypical symptoms, manometry, esophageal pH, and others. Logistic regression was used to assess significance of predictors in univariate analysis. RESULTS: Of 174 known outcomes, 131 were classified as successful (75.3%), while 43 were failures (24.7%): 26 reoperations, 13 unsatisfied, and 13 with severe symptoms. Response and lack of response to ARM were associated with 77.1% and 56.0% success rates respectively (P = 0.035). Eighty five percent of patients with typical symptoms had a successful outcome, compared to only 41% with atypical symptoms (P < 0.001). Preoperative morbid obesity (BMI > 35 kg/m2) was associated with failure (P = 0.036), while obesity (BMI 30-34.9 kg/m2) was not. A history of psychiatric illness trended toward significance (P = 0.06). CONCLUSIONS: In a cohort with 11 years follow-up after LNF, factors predictive of a successful outcome include preoperative response to ARM, typical symptoms, and BMI < 35 kg/m2. Patients with atypical symptoms, no response to ARM, or morbid obesity should be informed of their higher risk of failure. Some patients in these groups do have successful outcomes, and further research may clarify which of these patients can benefit from LNF.     

Outcome of laparoscopic Nissen fundoplication in patients with body mass index ≥35

Background To date, few studies have examined the effect of morbid obesity on the outcome of laparoscopic antireflux surgery and results have been conflicting. The aim of this work was to study the outcome of laparoscopic Nissen fundoplication (LNF) in patients with body mass index (BMI) ≥ 35. Methods We prospectively followed 70 patients (15 men, 55 women) with a proven diagnosis of gastroesophageal reflux disease (GERD) and a mean BMI of 38.4 ± 0.5 (range, 35–51) who underwent LNF. All patients underwent 24-h pH study, esophageal manometry, upper gastrointestinal (GI) endoscopy, and GERD symptom score before and 6 months after LNF. Surgical outcomes were compared to those of 70 sequential nonobese patients (BMI < 30) who also underwent LNF. Results LNF was completed laparoscopically in 69 of 70 patients in the morbidly obese (MO) group and in all 70 patients in the normal-weight (NW) group. The mean operative time for the MO group was not significantly longer than that for the NW group (55.9 ± 2.3 min vs 50.0 ± 2.1 min), but the mean length of stay was significantly longer (3.17 ± 0.2 days vs 2.2 ± 0.1 days, p < 0.0001) in the MO group. There was one postoperative complication (a transhiatal herniation of the stomach) in the morbidly obese group. In both patient groups, LNF resulted in a significant increase in lower esophageal sphincter (LES) pressures. This was associated with a significant decrease in percent acid reflux in 24-h testing and a significant improvement in GERD symptom score in both groups, although patients in the MO group had a significantly higher mean reflux symptom score after surgery than did those in the NW group. After a mean follow-up of 41.6 ± 2.9 months, one patient in the MO group required reoperation and one proton pump inhibitor therapy (PRN PPI), as required. Conclusions Morbid obesity does not adversely affect the outcome of LNF. The conversion rate is low when performed by an experienced surgeon. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Los Angeles, CA, USA, 12–15 March 2003     

Metaanalysis of trials comparing laparoscopic and open surgery for Crohn’s disease

Background: Several studies in the literature have suggested that laparoscopic surgery for Crohn’s disease is associated with faster postoperative recovery and a morbidity and recurrence rate similar to that for open surgery. Most of these studies have been limited by a small sample size and a short follow-up period. Methods: To clarify whether open or laparoscopic resection results in a better outcome, a metaanalysis of studies was performed comparing the two procedures for Crohn’s disease. Pooled effects were estimated using a random-effects model. Results: Laparoscopic surgery required more operative time than open surgery (26.8 min; 95% confidence interval [CI], 6.4–47.2 min), but resulted in a shorter duration of ileus and a decreased hospital stay (−2.62 days; 95% CI, −3.62 to −1.62). Laparoscopic surgery also was associated with a decreased rate for postoperative bowel obstruction and surgical recurrences. Conclusions: Laparoscopic surgery for Crohn’s disease is feasible, safe, and associated with shorter duration of ileus and a shorter hospital stay.     

Patients’ experiences of laparoscopic fundoplication in day surgery

Previous research has concentrated mainly on surgical aspects and postoperative complication rates after day surgery laparoscopic fundoplications (LF), due to gastrooesophageal reflux (GERD) and less on patients'experiences and nursing care aspects. A qualitative study was conducted aimed at investigating patients’ experiences of day surgery LF. The very first patients who had day surgery LF (n=7) were interviewed. The findings demonstrate that patients with GERD experience limitations in their daily lives and feelings of social handicap. At discharge after day surgery, amnesia was experienced and the respondents did not recall important information about the operation given by the surgeon. Experience of postoperative pain varied greatly. All respondents experienced dysphagia, vomiting, distension and bloating. The need for additional pain medication, additional follow-ups by the Advanced Medical Home Care team and extended preoperative information was expressed. However, the great majority felt that returning home on the same day as the operation was positive.     

Impact of examinees’ stereopsis and near visual acuity on laparoscopic virtual reality performance

Purpose

Laparoscopic surgery represents specific challenges, such as the reduction of a three-dimensional anatomic environment to two dimensions. The aim of this study was to investigate the impact of the loss of the third dimension on laparoscopic virtual reality (VR) performance.

Methods

We compared a group of examinees with impaired stereopsis (group 1, n = 28) to a group with accurate stereopsis (group 2, n = 29). The primary outcome was the difference between the mean total score (MTS) of all tasks taken together and the performance in task 3 (eye–hand coordination), which was a priori considered to be the most dependent on intact stereopsis.

Results

The MTS and performance in task 3 tended to be slightly, but not significantly, better in group 2 than in group 1 [MTS: ?0.12 (95 % CI ?0.32, 0.08; p = 0.234); task 3: ?0.09 (95 % CI ?0.29, 0.11; p = 0.385)]. The difference of MTS between simulated impaired stereopsis between group 2 (by attaching an eye patch on the adominant eye in the 2nd run) and the first run of group 1 was not significant (MTS: p = 0.981; task 3: p = 0.527).

Conclusion

We were unable to demonstrate an impact of impaired examinees’ stereopsis on laparoscopic VR performance. Individuals with accurate stereopsis seem to be able to compensate for the loss of the third dimension in laparoscopic VR simulations.

     

Advantages of laparoscopic resection for ileocolic Crohn’s disease

BACKGROUND: Laparoscopic colorectal procedures are considered to be technically challenging, and there is a lack of consensus regarding the magnitude of their benefits. The laparoscopic approach is generally held to be more expensive. Using a model of a single procedure performed for a single indication (ileocolic resection for Crohn's disease [CD]), we set out to demonstrate the feasibility of this procedure by determining the conversion rate, documenting the patient benefits, and performing a formal cost analysis. METHODS: Consecutive cases of laparoscopic ileocolic resection for CD were identified (LAP). Case-match methodology identified a series of open laparotomy controls (OPEN) that were matched for five potential confounding criteria: age, gender, diagnosis, type of resection, and date of operation. Pre-, intra-, and postoperative details were gathered. Medical resource utilization was tracked using a standardized database, and all costs were reported in 1999 dollars. RESULTS: The conversion rate was 5.9%. Resolution of ileus occurred more rapidly in the LAP than in the OPEN group. The time to clears in the LAP group was a median of 0 days (range, 0-4) vs 3.0 days (range, 2-8) in the OPEN group (p = 0.0001). Time to regular diet was 2.0 days (range, 1-6) in the LAP group vs 5.0 days (range, 3-12) in the OPEN group (p = 0.0001). Length of hospital stay was significantly reduced in the LAP group (4.0 days [range, 2-8], vs 7.0 days [range, 3-14], p = 0.0001). The LAP group had significantly lower direct costs ($8684 vs $11,373) and indirect costs ($1358 vs $2349) than the OPEN group (p < 0.001). This resulted in total costs of $9895 for LAP vs $13,268 for OPEN (p < 0.001). CONCLUSION: Laparoscopic ileocolic resection for CD is feasible. There are significant postoperative benefits in terms of resolution of ileus, narcotic use, and hospital stay. This approach translates into cost savings of >$3300 for laparoscopic patients.     

Impact of the patient’s body position on the intraabdominal workspace during laparoscopic surgery

Background  

The effects of the patient’s body position on the intraabdominal workspace in laparoscopic surgery were analyzed.     

Impact of diabetes mellitus and cardiometabolic syndrome on the risk of Alzheimer’s disease among postmenopausal women

BACKGROUNDIn spite of an increase in the incidence and prevalence of diabetes mellitus (DM) and Alzheimer’s disease (AD) in the aging population worldwide, limited attention has been paid to their potential association.AIMTo investigate the association of DM and cardiometabolic syndrome (CMS, a precursor to DM) with risk of incident AD among postmenopausal women.METHODSPostmenopausal women aged 50-79 (n = 63117) who participated in the U.S. Women’s Health Initiative Observational Study (WHIOS), recruited in 1993-1998, without baseline AD and followed up through March 1, 2019, were analyzed. AD was classified by participant-reported history of doctor-diagnosis of incident AD in the WHIOS. DM was defined by participant-report or treated because of diabetes or serum glucose concentrations ≥ 126 mg/dL. CMS was defined as having ≥ 3 of five CMS components: large waist circumference, high blood pressure, elevated triglycerides, elevated glucose, and low high-density lipoprotein cholesterol. The associations of DM and CMS with AD were analyzed using Cox’s proportional hazards regression analysis.RESULTSDuring a median follow-up of 20 years (range: 3.36 to 23.36 years), of 63117 participants, 8340 developed incident AD. Women with DM had significantly higher incidence of AD [8.5, 95% confidence interval (CI): 8.0-9.0 per 1000 person-years (PY)] than those without DM (7.1, 95%CI: 6.9-7.2 per 1000 PY). Multivariate Cox’s regression analysis indicated that women with DM or CMS had a significantly higher risk of AD than those without DM or CMS. The corresponding hazard ratios [HR (95%CI)] were 1.22 (1.13-1.31, P < 0.001) in subjects with DM, and 1.18 (1.09-1.27, P < 0.001) in subjects with CMS. The HRs diminished with age and became non-significant in the oldest age group.CONCLUSIONDuring a median follow-up of 20 years, DM and CMS were significantly associated with the risk of AD among postmenopausal women. More specifically, women aged 50-69 with DM or CMS vs those without these conditions had significantly higher relative risks of AD than the relative risks of AD in those aged 70-79 with DM or CMS vs those without DM or CMS.