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.     

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.     

Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication

Laparoscopic Nissen fundoplication has been applied with increasing frequency in the treatment of gastroesophageal reflux disease. The aim of this study was to determine the variahles that predict outcome of laparoscopic Nissen fundoplication. A multivariate analysis was performed on data from 199 consecutive patients undergoing laparoscopic Nissen fundoplication. Variables included age, sex, body mass index, primary symptoms, clinical response to acid suppression therapy, erosive esophagitis, 24-hour esophageal pH score, and the percentage of time the esophageal pH was less than 4 on 24-hour pH monitoring, lower esophageal sphincter competence, status of the esophageal body motility, hiatal hernia, carditis, intestinal metaplasia of cardiac epithelium limited to the gastroesophageal junction, and Barrett’s esophagus of any length. Clinical outcome was obtained from all patients at a median follow-up of 15 months (range 6 to 74 months) after surgery. One hundred seventy-three patients had an excellent or good outcome (87%) and 26 had a fair or poor outcome. Three factors were significantly predictive of a successful outcome: an abnormal 24-hour pH score (odds ratio = 5.4; 95% confidence interval [CI] = 1.9–15.3), a typical primary symptom (odds ratio = 5.1; 95% CI = 1.9–13.6), and a clinical response to acid suppression therapy (odds ratio = 3.3; 95% CI = 1.3 -8.7). We conclude that 24-hour pH monitoring provides the strongest outcome predictor of laparoscopic Nissen fundoplication and that outcome is based more on the correct identification of the disease than on its severity. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of Alimentary Tract, New Orleans, La., May 17–20, 1998.     

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.     

Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication

BACKGROUND: Preoperative esophageal manometry and 24-hour pH monitoring commonly are used in preoperative evaluation of patients undergoing fundoplication. Here we review our experience with the selective preoperative workup of patients undergoing fundoplication to treat gastroesophageal reflux disease. STUDY DESIGN: A series of 628 consecutive antireflux procedures was reviewed. History and physical examination, upper endoscopy, and upper gastrointestinal videofluoroscopy were obtained preoperatively on all patients; the first 30 patients also underwent esophageal manometry and pH monitoring (routine evaluation group). Thereafter, pH monitoring only was performed for atypical reflux symptoms, and manometry only was performed for a history of dysphagia, odynophagia, or for abnormal motility on videofluoroscopy (selective evaluation group). All patients underwent a laparoscopic floppy Nissen fundoplication, and then endoscopy and fluoroscopy at 3 months and 12 months postoperatively. RESULTS: Eighty-five of the patients in the selective evaluation group (14%) required manometry, and 88 (15%) underwent pH monitoring. Eighteen of the 115 patients who underwent manometry (16%) had evidence of dysmotility. None of these 18 patients had increased dysphagia postoperatively; 8 of 18 reported improvement with swallowing. Five patients in the selective group (0.8%) had persistent postoperative dysphagia caused by technical error (four patients) or with no identifiable cause (one patient). The estimated charge or collection reduction with use of the selective evaluation was 1,253,100 US dollars or 395,000 US dollars, respectively. CONCLUSIONS: Selective use of manometry and pH monitoring was cost effective and safe in this series. Although esophageal manometry and 24-hour pH monitoring might be necessary with abnormal findings on videofluoroscopy or atypical symptoms, in our experience, their routine use is not essential in preoperative evaluation of patients undergoing fundoplication for gastroesophageal reflux disease.     

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

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

Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication

Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001.     

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication

HYPOTHESIS: Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind, randomized controlled trial. SETTING: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. PARTICIPANTS: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study. INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. RESULTS: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. CONCLUSIONS: At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.     

抗胃食管反流外科治疗的远期疗效观察

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

Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study

BACKGROUND: Postoperative intrathoracic wrap migration is the most frequent morphological complication after laparoscopic antireflux surgery. Previous authors have studied the use of prosthetic materials for hiatal closure to prevent recurrence of hiatal hernia and/or postoperative intrathoracic wrap herniation. HYPOTHESIS: Patients with prosthetic hiatal closure have a higher rate of short-term dysphagia but a significantly lower rate of postoperative intrathoracic wrap herniation at follow-up. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatoplasty with those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: One hundred consecutive patients undergoing laparoscopic Nissen fundoplication for gastroesophageal reflux disease and hiatal hernia repair. INTERVENTION: Laparoscopic Nissen fundoplication with simple sutured crural closure (n = 50 [group 1]) vs laparoscopic Nissen fundoplication with simple sutured cruroplasty and onlay of a polypropylene mesh (n = 50 [group 2]). MAIN OUTCOME MEASURES: Recurrences; complications; results of esophageal manometry, 24-hour pH monitoring, esophagogastroduodenoscopy, and barium swallow test; and symptomatic outcome. RESULTS: Patients in both groups had similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring. At the 3-month and 1-year follow-ups, functional outcome variables (lower esophageal sphincter pressure and DeMeester score) improved significantly compared with the preoperative values. A higher postoperative dysphagia rate could be evaluated in group 2. An intrathoracic wrap migration occurred in 13 patients (26%) in group 1 vs 4 (8%) in group 2 (P<.001). CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic cruroplasty is an effective procedure to reduce the incidence of postoperative hiatal hernia recurrence and intrathoracic wrap herniation.     

Laparoscopic partial posterior fundoplication provides excellent intermediate results in GERD patients with impaired esophageal peristalsis.

BACKGROUND: Gastroesophageal reflux disease (GERD) is frequently associated with impaired esophageal peristalsis, and many authorities consider this condition not suitable for Nissen fundoplication. METHODS: To investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, 78 consecutive GERD patients with poor esophageal contractility who underwent laparoscopic partial posterior fundoplication were studied. A standardized questionnaire, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring were performed preoperatively and at a median of 31 months (range 6-57 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus, frequency of peristaltic, simultaneous, and interrupted waves, and the total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter were evaluated. RESULTS: After antireflux surgery, 76 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy. The rate of dysphagia decreased from 49% preoperatively to 10% postoperatively (P < .001). Features defining impaired esophageal body motility improved significantly after antireflux surgery. The median DeMeester score on 24-hour esophageal pH monitoring decreased from 33.3 to 1.1 (P < .001). CONCLUSIONS: Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility. Postoperative dysphagia is diminished, probably because of improved esophageal body function.     

Symptomatic and physiologic outcomes after operative treatment for extraesophageal reflux

Background: Pharyngeal pH monitoring has recently been used to identify patients with extraesophageal symptoms induced by gastroesophageal reflux. We employed this method of acid detection to evaluate patients with respiratory symptoms prior to and after laparoscopic Nissen fundoplication to further elucidate the relationship between GERD and respiratory symptoms. Methods: Twenty-one consecutive patients with extraesophageal symptoms thought to be caused by reflux underwent symptomatic and functional evaluation (esophageal manometry and 24-h pH monitoring with a pharyngeal probe) before and after laparoscopic Nissen fundoplication. Episodes of pharyngeal acid exposure were considered abnormal if the pH dropped below 4, occurred simultaneously with esophageal acidification, and occurred outside meal times. Results: All patients had gastroesophageal reflux disease (GERD) and respiratory symptoms; nine of 15 (60%) had evidence of pharyngeal reflux preoperatively. Antireflux procedures resulted in a significant decrease in pharyngeal reflux (7.9 to 1.6 episodes/24h; p <0.05) and esophageal acid exposure (7.5% to 2.1%; p <0.05). In patients with pharyngeal reflux and complete postoperative testing, three (60%) obtained improvement of respiratory symptoms and resolution of pharyngeal reflux. In two patients with recurrent respiratory symptoms after surgery, persistent pharyngeal reflux was detected. Conclusions: Operative treatment of GERD is effective in controlling extraesophageal reflux, measured subjectively and objectively. Evidence of pharyngeal reflux on pH testing helps to identify which patients with respiratory symptoms will benefit from an antireflux procedure.     

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.     

Acid normalization and improved esophageal motility after Nissen fundoplication: equivalent outcomes in patients with normal and ineffective esophageal motility

BACKGROUND: Severe gastroesophageal reflux disease may result in acquired esophageal dysmotility. The correct surgical approach to associated gastroesophageal reflux disease and dysmotility is controversial, in particular whether the "gold-standard" total fundoplication of Nissen is appropriate compared with partial fundoplication. Our unit has performed total fundoplication for all patients, irrespective of esophageal motility, and this article describes that experience. METHODS: Ninety-eight patients undergoing antireflux surgery were divided into 2 groups. Group 1 (n=60) consisted of patients with normal esophageal motility, and group 2 (n=38) had dysmotility. All patients underwent preoperative and postoperative manometry, 24-hour pH testing, symptom scoring, and quality-of-life assessment. RESULTS: The median postoperative acid score was not significantly different between groups 1 and 2. Eighty-eight percent of patients with normal motility and 89% of patients with dysmotility had no symptoms or minor symptoms, with a significant improvement in quality of life 6 months after surgery. There was a significant increase in esophageal wave amplitude in both groups, and 20 patients (53%) in the dysmotility group reverted to normal motility after surgery. Recurrent symptoms were associated with postoperative abnormal pH profiles in 5 patients from group 1 and 3 from group 2. CONCLUSIONS: Preoperative dysmotility is not a contraindication for total fundoplication. Postoperative acid control is associated with improved esophageal clearance and symptoms.     

The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with "typical" symptoms.

OBJECTIVE: To evaluate prospectively the outcome of laparoscopic fundoplication in a large cohort of patients with typical symptoms of gastroesophageal reflux. SUMMARY BACKGROUND DATA: The development of laparoscopic fundoplication over the past several years has resulted in renewed interest in the surgical treatment of gastroesophageal reflux disease (GERD). METHODS: One hundred patients with typical symptoms of GERD were studied. The study was limited to patients with positive 24-hour pH studies and "typical" symptoms of GERD. Laparoscopic fundoplication was performed when clinical assessment suggested adequate esophageal motility and length. Outcome measures included assessment of the relief of the primary symptom responsible for surgery; the patient's and the physician's evaluation of outcome; quality of life evaluation; repeated upper endoscopy in 30 patients with presurgical esophagitis; and postsurgical physiologic studies in 28 unselected patients, consisting of 24-hour esophageal pH and lower esophageal sphincter manometry. RESULTS: Relief of the primary symptom responsible for surgery was achieved in 96% of patients at a mean follow-up of 21 months. Seventy-one patients were asymptomatic, 24 had minor gastrointestinal symptoms not requiring medical therapy, 3 had gastrointestinal symptoms requiring medical therapy, and 2 were worsened by the procedure. Eighty-three patients considered themselves cured, 11 were improved, and 1 was worse. Occasional difficulty swallowing not present before surgery occurred in 7 patients at 3 months, and decreased to 2 patients by 12 months after surgery. There were no deaths. Clinically significant complications occurred in four patients. Median hospital stay was 3 days, decreasing from 6.3 in the first 10 patients to 2.3 in the last 10 patients. Endoscopic esophagitis healed in 28 of 30 patients who had presurgical esophagitis and returned for follow-up endoscopy. Twenty-four-hour esophageal acid exposure had returned to normal in 26 of 28 patients studied after surgery. Lower esophageal sphincter pressures had also returned to normal in all patients, increasing from a median of 5.1 mmHg to 14.9 mmHg. CONCLUSIONS: Laparoscopic Nissen fundoplication provides an excellent symptomatic and physiologic outcome in patients with proven gastroesophageal reflux and "typical" symptoms. This can be achieved with a hospital stay of 48 hours and a low incidence of postsurgical complications.     

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.     

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease.

OBJECTIVE: The open Nissen fundoplication is effective therapy for gastroesophageal reflux disease. In this study, the outcomes in 198 patients treated with the laparoscopic Nissen fundoplication was evaluated for up to 32 months after surgery to ascertain whether similar positive results could be obtained. SUMMARY BACKGROUND DATA: To ensure surgical success, patients were required to have mechanically defective sphincters on manometry and increased esophageal acid exposure on 24-hour pH monitoring. The patients either had severe complications of gastroesophageal reflux disease or had failed medical therapy. These requirements have been found to be necessary to ensure a successful surgical outcome. METHODS: The disease was complicated by ulceration (46), stricture (25) and Barrett's esophagus (33). Patients underwent standard Nissen fundoplications identical in every detail to open procedures except that the procedures were carried out by the laparoscopic route. RESULTS: Perioperative complications included gastric or esophageal perforation (3), pneumothorax (2), bleeding (2), breakdown of crural repair (2) and periesophageal abscess (1). The only mortality occurred from a duodenal perforation. Six patients required conversion to the open procedure. The median hospital stay was 3 days. One hundred patients were observed for follow-up for 6 to 32 months (median 12 months), with outcomes similar to the open Nissen fundoplication. Further surgery was required for two patients who had recurrent gastroesophageal reflux and one who developed an esophageal stricture. Ninety-seven percent are satisfied with their decision to have the operation. CONCLUSIONS: The laparoscopic Nissen fundoplication can be carried out safely and effectively with similar positive results to the open procedure and with all of the advantages of the minimally invasive approach.     

Effect of laparoscopic antireflux operation on esophageal manometry, 24 hours pH-metry and quality of life in gastroesophageal reflux disease

It has been suggested that laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastroesophageal reflux disease (GERD). Twenty-six patients with chronic gastroesophageal reflux disease underwent laparoscopic floppy Nissen fundoplication. 24 hours pH-metry, manometry and Gastrointestinal Quality of Life Index (GIQLI) questionnaire were done preoperatively, six-month and one year after the operation. The six weeks control investigation was limited to 24 pH-metry and GIQLI interview. Adequate reflux control was obtained in all patients, with reduction in acid reflux variables at six weeks, six months as well as at one year after the operation. Preoperative reflux index and DeMeester score was significantly higher than those we found postoperatively at both time period. Preoperative lower esophageal sphincter tone and length was abnormal on average. Both parameters increased significantly at six-month and one year after the operation. GIQLI also showed characteristic changes. Compared to preoperative values we found significantly higher GIQLI at both six-month and one year following surgery. Laparoscopic Nissen fundoplication provides an excellent symptomatic and physiologic outcome in patients with esophageal reflux disease.     

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.     

Excellent quality of life after Nissen fundoplication depends on successful elimination of reflux symptoms and not the invasiveness of the surgical approach

BACKGROUND: Quality of life, poor in patients with reflux disease, improves significantly after an antireflux operation. The aim of this study was to determine the relative importance of the operative approach used for a fundoplication, as well as the successful elimination of reflux symptoms on long-term quality of life in patients with gastroesophageal reflux disease. METHODS: A questionnaire, including the medical outcome study short-form health survey (SF-36), was completed by 105 patients who had undergone either a laparoscopic Nissen fundoplication (n = 72) or a transthoracic Nissen fundoplication (n = 33); median follow-up was 25 and 31 months, respectively. Patients were classified as completely or incompletely relieved of reflux symptoms based on the frequency of reflux symptoms and the use of acid-suppression medication. RESULTS: Patients selected for transthoracic Nissen fundoplication had significantly worse preoperative gastroesophageal reflux disease based on the presence of a large hiatal hernia, Barrett's esophagus, or stricture. Long-term quality of life was similar for the two approaches, but was significantly decreased in patients with recurrent reflux symptoms. Compared with laparoscopic Nissen fundoplication patients, transthoracic Nissen fundoplication patients were less likely to use acid-suppression medication and tended to be more satisfied with their operation. CONCLUSIONS: Long-term quality of life was independent of the invasiveness of the procedure, but significantly dependent on successful elimination of reflux symptoms and the necessity for acid suppression medication. Patients who underwent a transthoracic Nissen fundoplication, despite having more advanced disease preoperatively, tended to have less reflux symptoms and less long-term acid-suppression medication usage after their procedure. These findings support the continued use of a transthoracic antireflux procedure in patients with advanced gastroesophageal reflux disease.