Nissen vs toupet laparoscopic fundoplication

BACKGROUND: Nissen fundoplication (360 degrees ) is the standard operation for the surgical management of gastroesophageal reflux disease (GERD). To avoid postoperative dysphagia, it has been proposed that antireflux surgery be tailored according to the degree of preexisting esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and the Toupet procedure (270 degrees ) has been recommended for these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques in terms of reflux control and complication rate (dysphagia). Our objective was to determine the impact of preoperative esophageal motility on the clinical and objective outcome, following Toupet vs Nissen fundoplication and to evaluate the success rate of these procedures. METHODS: From May 1999 until May 2000, 200 patients with GERD were included in a prospective randomized study. After preoperative examinations (clinical interview, endoscopy, 24-h pH study and esophageal manometry), 100 patients underwent either a laparoscopic Nissen (50 with and 50 without motility disorders), or a Toupet procedure (50 with and 50 without motility disorders). Postoperative follow-up after 4 months included clinical interview, endoscopy, 24-h pH study and esophageal manometry. RESULTS: Interviews showed that 88% (Nissen) and 90% (Toupet) of the patients, respectively, were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication than after a Toupet (30 vs 11, p <0.001) and did not correlate with preoperative motility. In terms of reflux control, the Toupet proved to be as effective as the Nissen procedure. CONCLUSION: Tailoring antireflux surgery to esophageal motility is not indicated, since motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation because it has a lower rate of dysphagia and is as effective as the Nissen fundoplication in controlling reflux.     

Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility

Objective To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication and to evaluate the success rate of these procedures. Summary background data Nissen fundoplication (360°) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been recommended to use the Toupet procedure (270°) in these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia). Methods 200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview, endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry. Results After two years 85% (Nissen) and 85% (Toupet) of patients were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication compared to Toupet (19 vs. 8, p < 0.05) and did not correlate with preoperative motility. Concerning reflux control the Toupet proved to be as good as the Nissen procedure. Conclusion Tailoring antireflux surgery according to the esophageal motility is not indicated, as motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation as it has a lower rate of dysphagia and is as good as the Nissen fundoplication in controlling reflux.     

Laparoscopic toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs. 44%;P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results teria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after, surgery. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Heartburn is more likely to recur after Toupet fundoplication than Nissen fundoplication

Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.     

Tailored Antireflux Surgery for Gastroesophageal Reflux Disease: Effectiveness and Risk of Postoperative Dysphagia

p < 0.05). There was a significant reduction of dysphagia following the Toupet fundoplication. Both procedures increased the resting pressure of the lower esophageal sphincter (LES) significantly, which was more pronounced following the Nissen fundoplication. Relaxation of the LES was significantly better following the Toupet than after the Nissen fundoplication. There was significant improvement of esophageal peristalsis following the Toupet fundoplication. Tailored antireflux surgery is an effective strategy for treatment of GERD. The incidence of postoperative dysphagia is low owing to improvement of impaired esophageal peristalsis following the Toupet fundoplication. It may be due to the fact that the Toupet fundoplication causes less esophageal outflow resistance than the Nissen fundoplication.     

Dysphagia after laparoscopic antireflux surgery. The impact of operative technique.

BACKGROUND. Concerns about laparoscopic antireflux surgery include the frequent appearance of troublesome postoperative dysphagia. This study reviews the frequency of early (less than 6 weeks) and persistent (greater than 6 weeks) solid food dysphagia in patients undergoing Toupet, Rosetti-Nissen, or Nissen fundoplications. METHODS. One hundred eighty-four consecutive patients with normal esophageal peristalsis undergoing laparoscopic antireflux surgery were prospectively studied. Before operation, all patients had endoscopy, 24-hour pH study, and an esophageal motility study. The choice of operation was dependent on anatomy and surgeon preference. Before discharge, all patients were given instructions on a soft diet. Postoperative symptoms were scored by the patients as absent, mild, moderate, or severe 4 weeks and 12 weeks after operation. The option of esophageal dilation was offered to patients with moderate to severe persistent solid food dysphagia. RESULTS. New onset moderate to severe dysphagia to solid foods was present in 30 (54%), 8 (17%), and 13 (16%) patients undergoing Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively, in the first month after operation (p < 0.001). Moderate to severe dysphagia persisted at 3 months in six (11%), one (2%), and two (2%) patients undergoing laparoscopic Rosetti-Hell, Nissen, and Toupet fundoplications, respectively (p < 0.05). Esophageal dilatation was performed in five (4%), zero, and one (1%) patients undergoing laparoscopic Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively (p < 0.05). There was no additional morbidity related to division of short gastric vessels in patients undergoing Nissen fundoplication. CONCLUSIONS. Laparoscopic Rosetti-Nissen fundoplication is associated with a higher rate of early and persistent postoperative dysphagia than either laparoscopic Nissen fundoplication or Toupet fundoplication. Consideration of complete fundus mobilization should be a part of all laparoscopic antireflux procedures.     

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.     

Laparoskopische Fundoplicatio nach Nissen und Toupet bei Patienten mit gastroösophagealer Refluxkrankheit und Motilitätsstörung des distalen Ösophagus

INTRODUCTION: A Nissen fundoplication for gastrooesophageal reflux disease may more often lead to persistent dysphagia than a Toupet fundoplication. The aim of this study was to assess the results of laparoscopic Nissen versus Toupet fundoplication in patients with reflux disease and impaired distal esophageal motility. PATIENTS AND METHODS: In 15 patients a laparoscopic Nissen and in 17 a laparoscopic Toupet fundoplication was carried out. Criteria for an impaired motility of the distal esophagus were a mean amplitude of < 30 mm Hg of swallow-induced contractions, or > 33% non-propulsive or non-transmitted contraction waves. Before surgery, heartburn, dysphagia, regurgitation and other symptoms were scored and endoscopic, manometric and 24 hour pH-metric investigations performed. Patients were reinvestigated 3 to 30 (median 15) months after Nissen and 3 to 42 (median 7) months after Toupet fundoplication. RESULTS: After Nissen as well as after Toupet fundoplication heartburn was significantly less frequent, whereas dysphagia and all other symptom-scores remained unchanged. In the 26 patients reinvestigated manometrically, the resting pressure of the lower esophageal sphincter was significantly higher following both operations and the residual sphincter pressure upon swallowing higher only after Nissen fundoplication. The amplitude of swallow-induced contractions and the percentages of non-propulsive and non-transmitted contraction waves were not significantly changed after either operation. In the 23 patients restudied pH-metrically, reflux activity was significantly reduced after both Nissen and Toupet fundoplication. CONCLUSION: In patients with reflux disease and impaired distal esophageal motility, laparoscopic Nissen and Toupet fundoplication both yielded satisfactory results and neither operation led to increased dysphagia.     

Laparoscopic partial posterior (Toupet) fundoplication improves esophageal bolus propagation on scintigraphy

BACKGROUND: Impaired esophageal clearance is important in the pathogenesis of gastroesophageal reflux disease (GERD). It is unknown whether esophageal clearance improves following antireflux surgery. The aim of this study was to investigate the effect of laparoscopic Nissen fundoplication (NF), laparoscopic partial posterior (Toupet) fundoplication (PPF) or medical therapy on esophageal clearance. METHODS: This was a prospective nonrandomized crossover study. Sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying, and assessment of symptoms prior to surgery or medical therapy and 6 months after treatment. In 20 GERD patients with normal esophageal peristalsis an NF was performed, in 20 patients with impaired esophageal peristalsis a PPF was chosen, and 20 patients received proton-pump inhibitor (PPI) treatment. RESULTS: On endoscopy, esophagitis had resolved in all patients after surgery; two patients with medical therapy still had esophagitis. On manometry, a significant improvement of lower esophageal sphincter competence was seen in both surgical groups. LES relaxation was complete after PPF, but incomplete after NF. Esophageal peristalsis did not improve after medical therapy, was significantly improved after PPF, but had worsened after NF. On scintigraphic esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after PPF. A significant deterioration of esophageal emptying was observed after NF. There was a strong correlation between scintigraphic and manometric evaluation of peristalsis preoperatively (r(s) = -0.87, p < 0.05) and postoperatively (r(s) = -0.82, p < 0.05). There was no change in dysphagia after medical therapy and after NF but a significant improvement after PPF. Globus sensation was significantly improved after PPF but did not change after medical therapy or NF. Postprandial bloating and inability to belch were significantly more common after NF than after PPF. CONCLUSION: Laparoscopic partial posterior (Toupet) fundoplication can restore a preoperatively defective esophageal bolus propagation on scintigraphy with the same antireflux effect as the laparoscopic Nissen fundoplication, but with lower side-effects.     

Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication

BACKGROUND: In the operative management of gastro-oesophageal reflux, a balance must be achieved between adequate control of reflux and excessive dysphagia. The ideal technique is not known. A randomized study was performed to determine whether laparoscopic anterior fundoplication is associated with a lower incidence of postoperative dysphagia than laparoscopic Nissen fundoplication, while achieving equivalent control of reflux. METHODS: Patients presenting for laparoscopic antireflux surgery were randomized to undergo either a Nissen fundoplication (n = 53) or an anterior 180 degrees hemifundoplication (n = 54). Patients were blinded to which procedure had been performed, and follow-up was obtained by a blinded independent investigator. Standardized clinical grading systems were used to assess dysphagia, heartburn and patient satisfaction 1, 3 and 6 months after operation. Objective measurement of lower oesophageal sphincter pressure, oesophageal emptying time, distal oesophageal acid exposure and endoscopic healing of oesophagitis was also performed. RESULTS: Operating time was similar for the two procedures (58 min for the Nissen procedure versus 60 min for anterior fundoplication). Resting and residual lower oesophageal sphincter pressures were lower following anterior fundoplication (29 versus 18 mmHg, and 13 versus 6 mmHg), and oesophageal emptying times were faster (92 versus 116 s). Acid exposure times and ability to heal oesophagitis were similar. At 3 months' follow-up clinical outcomes were similar for the two procedures. At 6 months, however, patients who had undergone anterior fundoplication experienced significantly less dysphagia for solid food and were more likely to be satisfied with the clinical outcome. CONCLUSION: Laparoscopic anterior fundoplication achieved equivalent control of reflux, more physiological postoperative manometry parameters, and an improved clinical outcome at 6 months. Continued follow-up remains necessary to confirm the long-term efficacy of the partial fundoplication procedure.     

Nissen or partial posterior fundoplication: which antireflux procedure has a lower rate of side effects?

Introduction In patients with gastroesophageal reflux disease (GERD) it is still controversial as to which type of antireflux procedure—the Nissen or the partial posterior fundoplication—offers the lower rate of side effects in the long term.Patients and methods In this follow-up study the Nissen fundoplication was performed only in GERD patients with normal oesophageal peristalsis. The partial posterior fundoplication was preserved for patients with weak peristalsis. Only patients with effective postoperative control of GERD were included in the study. The study groups consisted of 77 patients who underwent the Nissen fundoplication and 132 patients who underwent partial posterior fundoplication. Clinical assessment of side effects was performed after a median of 52 months following surgery. Manometric assessment of the lower esophageal sphincter (LES) and of esophageal peristalsis was achieved 6 months after surgery.Results Side effects such as dysphagia, bloating, inability to belch and vomit, epigastric pain and early satiety were significantly more common after the Nissen fundoplication than after partial posterior fundoplication. Improvement of the antireflux barrier was equal in both groups; however, LES relaxation was incomplete following the Nissen fundoplication but normal after partial posterior fundoplication. Partial posterior fundoplication resulted in improved oesophageal peristalsis, whereas the Nissen fundoplication caused slight impairment of peristalsis.Conclusions Partial posterior fundoplication is a more physiological antireflux procedure than the Nissen fundoplication, and, therefore, this operation has now become our preferred technique for all GERD patients.     

Laparoscopic repair of gastroesophageal reflux disease

Summary This report describes our preliminary experience with two surgical laparoscopic fundoplication procedures, the Nissen technique and the Toupet operation, in which the fundal wrap is reduced from 360° to 180–200°. Fourteen patients with symptomatic gastroesophageal reflux disease who were refractory to pharmacologic and medical therapy underwent a laparoscopic Nissen fundoplication; in an additional 14 patients, we performed a laparoscopic Toupet partial fundoplication. Our laparoscopic approach to the two procedures does not differ significantly from the traditional open methods and the effectiveness of the laparoscopic fundoplication procedures appears similar to that of the same conventional techniques. Oral feedings can be resumed on the first postoperative day and patients typically are discharged on the second day after surgery. Operative time for performing the Toupet procedure averaged just approximately 1.6 h and was shorter than that for the Nissen fundoplication, due to the use of a stapler to secure the fundal wrap. Confirming earlier observations, the laparoscopic Toupet 180–200° fundoplication was associated with a lower incidence of postoperative digestive complications, such as dysphagia, than was the laparoscopic Nissen operation. The laparoscopic fundoplication approach offers the advantages of clear visualization, adequate dissection and precise repair, along with the benefits associated with endoscopic surgery: diminished postoperative pain and discomfort, reduced hospitalization, and quicker return to normal activities. Our experience indicates that the Toupet fundoplication may be preferable to the Nissen technique for many patients requiring surgical treatment of their reflux disease.     

Impact of laparoscopic nissen fundoplication with prosthetic hiatal closure on esophageal body motility: Results of a prospective randomized trial

HYPOTHESIS: Prosthetic crural closure does not adversely influence esophageal body motility. In most patients, postoperative increased dysphagia resolves spontaneously during the first months after surgery. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatal closure and those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: Forty consecutive patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease. INTERVENTIONS: A 360 degrees Nissen fundoplication with simple sutured crura (n = 20; nonmesh group) vs the same procedure with posterior 1 x 3-cm polypropylene onlay mesh prosthesis (n = 20; mesh group). MAIN OUTCOME MEASURES: Recurrences; postoperative dysphagia rate; localization, length, and pressure of the lower esophageal sphincter (LES); results of 24-hour pH monitoring; esophageal body motility; peristalsis; and esophageal amplitude of contraction and interrupted waves. RESULTS: Preoperatively, both groups had pathological LES pressure and DeMeester scores. These values improved significantly (P < .01) after surgery and remained stable at 1 year after surgery. Patients in the nonmesh group had a significantly lower LES pressure 1 year after surgery compared with those in the mesh group. There were no significant differences in postoperative mean LES length (4.1 vs 3.8 cm), LES relaxation (93.4% vs 92.4%), and intra-abdominal LES length (2.1 vs 2.1 cm). Patients in the mesh group had fewer simultaneous waves and interrupted waves 1 year after surgery, but the difference between groups was not significant. There were no significant differences in interrupted waves and amplitude of contraction between groups 1 year after surgery. CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic crural closure does not impair postoperative esophageal body motility compared with laparoscopic Nissen fundoplication with simple suture hiatal closure, although it is associated with a higher rate of short-term dysphagia.     

腹腔镜下治疗食管裂孔疝55例报告

目的：探讨腹腔镜下治疗食管裂孔疝的可行性和有效性。方法2008年3月～2013年3月腹腔镜手术治疗55例食管裂孔疝,腹腔镜下完成食管裂孔疝的还纳及修补之后,进一步行胃底折叠术。结果55例均在腹腔镜下完成手术,在食管裂孔修补基础上辅以不同的胃底折叠术,其中Nissen胃底折叠术17例,Toupet 胃底折叠术19例,Dor胃底折叠术19例。3种术式的手术时间：Nissen术式（69．6±13．0）min,Toupet术式（68．0±8．2）min,Dor术式（63．8±10．1）min;3种术式的术中出血量：Nissen术式（20．0±5．8）ml,Toupet术式（20．6±9．5）ml,Dor术式（21．7±5．0）ml,无一例输血;3种术式的术后拔管时间：Nissen术式（3．1±1．1） d,Toupet术式（2．7±0．7） d,Dor术式（2．3±1．1） d;3种术式的术后住院时间：Nissen术式（9．1±4．9）d,Toupet术式（8．4±2．6）d,Dor术式（7．6±1．5）d。术后患者的临床症状均得到有效缓解,无围术期死亡,3例（5．4％）出现术后并发症,其中2例胃排空障碍,1例吞咽困难,治疗后均缓解。55例中位随访时间45个月（6～60个月）,口服钡餐造影或胃镜等检查无食管裂孔疝复发,无食管狭窄和食管憩室发生。结论腹腔镜下治疗食管裂孔疝安全有效,可根据病人的情况选择不同的胃底折叠术。     

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.     

The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture

BACKGROUND: Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS: Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS: Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.     

Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak

BACKGROUND: About a decade ago, partial (240 degrees) fundoplication became popular for treating gastroesophageal reflux disease in cases where the patient's primary esophageal peristalsis was weak. A total (360 degrees) fundoplication was reserved for patients with normal peristalsis (tailored approach). The theory was that partial fundoplication was an adequate antireflux measure, and by posing less resistance for the weak esophageal peristalsis to overcome, it would give rise to less dysphagia. Short-term results seemed to confirm these ideas. STUDY DESIGN: This study reports the longterm followup of patients in whom a tailored approach (type of wrap chosen to match esophageal peristalsis) was used, and the results of a nonselective approach, using a total fundoplication regardless of the amplitude of esophageal peristalsis. We analyzed clinical and laboratory findings in 357 patients who had an operation for gastroesophageal reflux disease between October 1992 and November 2002. Group 1 was composed of 235 patients in whom a tailored approach was used between October 1992 and December 1999 (141 patients, partial fundoplication and 94 patients, total fundoplication). Group 2 contained 122 patients in whom a nonselective approach was used (total fundoplication regardless of quality of peristalsis). RESULTS: In group 1, heartburn from reflux (ie, pH monitoring test was abnormal) recurred in 19% of patients after partial fundoplication and in 4% after total fundoplication. In group 2, heartburn recurred in 4% of patients after total fundoplication. The incidence of postoperative dysphagia was similar in the two groups. CONCLUSIONS: These data show that laparoscopic partial fundoplication was less effective than total fundoplication in curing gastroesophageal reflux disease, and compared with a partial (240 degrees) fundoplication, a total (360 degrees) fundoplication was not followed by more dysphagia, even when esophageal peristalsis was weak.     

地市级医院初期开展腹腔镜下食管裂孔疝修补及胃底折叠术的经验

目的探讨地市级医院初期开展腹腔镜下食管裂孔疝修补及胃底折叠术的技术要点及临床疗效。 方法回顾分析咸阳市中心医院2016年3月至2019年3月,行腹腔镜下食管裂孔疝修补、胃底折叠术31例患者的临床资料。按胃底折叠术的术式不同,分为Dor术式组、Toupet术式组、Nissen术式组。观察并记录各术式组患者的手术时间、术中出血量、住院时间。随访3~36个月时的并发症及复发率。 结果31例均行腹腔镜下食管裂孔疝修补联合胃底折叠术。其中Dor折叠4例、Toupe折叠3例、Nissen折叠24例;各术式手术时间分别为（60±4.5）、（68±6.3）、（70±9.2）min;各术式术中出血量分别为（21±4.8）、（24±5.4）、（30±9.1）ml;术后出院时间（7±2.1）、（8±2.8）、（9±2.4）d。31例患者术后不适症状均得到缓解,4例患者术后出现吞咽困难并发症,其中1例患者因保守对症治疗效果不理想,行二次手术拆除胃底折叠后好转,其余3例患者经对症治疗后缓解。31例患者术后随访,失访患者1例,随访3~36个月,中位时间28个月。经胃镜、上消化道造影检查,未复发且无其他并发症发生。 结论腹腔镜下食管裂孔疝修补、胃底折叠术安全、有效,微创优势明显,值得临床推广。     

腹腔镜Nissen与Toupet胃底折叠术治疗胃食管反流性疾病的临床分析

目的 比较腹腔镜Nissen与Toupet胃底折叠术治疗胃食管反流性疾病（GERD）的优缺点及其适应证。方法 回顾分析2001年6月至2005年12月腹腔镜胃底折叠术后GERD的83例临床资料。其中65例行腹腔镜Nissen胃底折叠术，18例行腹腔镜Toupet胃底折叠术。结果 两组均无中转开腹及死亡病例。术后两组症状均完全消失。平均随访2．6年，Nissen组未出现症状复发，Toupet组2例病人症状复发，需服抑酸药物控制。术后4个月复查食道测压和酸反流的指标两组均在正常范围内。Nissen组食道炎症的治愈率为84．6％，Toupet组为66．7％。术后4d，Nissen组吞咽困难、腹胀的发生率明显高于Toupet组（分别为27．7％和16.7％）；术后1年，两组之间的差别明显减小（分别为1．5％和0）。结论 Toupet胃底折叠术后短期内吞咽困难的发生率明显低于Nissen胃底折叠术，但随着术后恢复时间的延长，两者间差异明显减小。对中重度GERD应首选腹腔镜Nissen胃底折叠术，对高龄，术前检查提示食管蠕动功能明显减弱的病人，可考虑行腹腔镜Toupet胃底折叠术。     

食管测压在Nissen胃底折叠术中的应用

目的通过Nissen胃底折叠术中监测食管下括约肌压力（LESP）、食管下括约肌总长度（LESL）的变化,判断胃底折叠缝合的松紧程度,改进Nissen胃底折叠术抗反流的治疗效果。方法84例经腹手术治疗滑动型食管裂孔疝患者,根据手术方式分成3组：典型Nissen手术组27例,短松式Nissen手术组39例,短松式Nissen加术中测压组（测压组）18例。对患者术前、术中及术后LESP和LESL、术后并发症、手术远期疗效等进行观察记录。结果全组无术中死亡。术后1个月内典型Nissen手术组患者吞咽困难2例,反酸1例,短松式Nissen手术组反酸2例,测压组无术后吞咽困难或反酸。72例术后随访。典型Nissen手术组中2例有明显吞咽困难,1例恶心、呕吐;短松式Nissen手术组中1例复发;测压组仅1例24hpH监测有明显酸反流,但无症状。结论经腹的典型Nissen手术、短松式Nissen手术治疗食管裂孔疝可取得较为理想的效果,但通过抗反流手术加术中测压,能够更准确判断胃底折叠缝合的松紧程度,有利于避免或减少术后并发症。