Laparoscopic heller myotomy and anterior fundoplication for achalasia results in a high degree of patient satisfaction

HYPOTHESIS: Laparoscopic Heller myotomy with anterior fundoplication will alleviate the symptoms of achalasia and result in excellent patient satisfaction. DESIGN: Retrospective study of consecutive patients who underwent laparoscopic Heller myotomy with anterior fundoplication for achalasia between October 1995 and July 1999. A telephone survey assessed symptoms and satisfaction. Patients were asked to quantitate their symptoms on a scale of 0 to 3 (0 = none; 1, mild; 2, moderate; and 3, severe). SETTING: University referral center. PATIENTS: Twenty-four patients who underwent laparoscopic Heller myotomy with anterior fundoplication for achalasia. MAIN OUTCOME MEASURES: Postoperative symptoms and satisfaction. RESULTS: Twenty-one patients (88%) were successfully contacted. Mean follow-up was 16.5 months. The laparoscopic approach was successful in all but 3(88%). The mean dysphagia score was 2.81 preoperatively and 0.81 postoperatively (P<.000). The mean chest pain score was 1. 57 preoperatively and 0.86 postoperatively (P<.015). The mean supine regurgitation score was 2.10 preoperatively and 0.57 postoperatively (P<.000). The mean upright regurgitation score was 1.57 preoperatively and 0.52 postoperatively (P<.000). The mean heartburn score was 1.57 preoperatively and 0.57 postoperatively (P<.000). Postoperatively, 18 (86%) of 21 patients could swallow bread without difficulty and 17 (89%) of 19 patients could eat meat without difficulty (2 were excluded as they were vegetarians). Twenty (95%) of 21 patients reported improvement after the operation. CONCLUSIONS: Laparoscopic Heller myotomy with anterior fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. This procedure results in excellent overall patient satisfaction.     

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.     

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.     

Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery

BACKGROUND: One of the most frequent complications after laparoscopic antireflux surgery is estimated to be the intrathoracic herniation of the wrap into the chest. Therefore, in up to 5% of patients, revisional surgery is necessary. HYPOTHESIS: Patients who undergo laparoscopic refundoplication for postoperative intrathoracic wrap herniation using a circular polypropylene mesh for hiatal closure have a good to excellent functional outcome, during a complete follow-up of 1 year. DESIGN: Prospective nonrandomized trial of a consecutive sample. SETTING: University-affiliated community hospital. PATIENTS: Twenty-four patients undergoing laparoscopic refundoplication for persistent or recurrent symptoms of gastroesophageal reflux disease as a result of postoperative intrathoracic wrap migration. INTERVENTION: All patients underwent laparoscopic refundoplication with a circular polypropylene mesh for hiatal closure. MAIN OUTCOME MEASURES: Recurrences, complications, postoperative lower esophageal sphincter pressure, DeMeester score, esophagogastroduodenoscopy results, and barium swallow results. RESULTS: All refundoplications were completed laparoscopically. There were no intraoperative complications. Twenty-one patients underwent laparoscopic Nissen fundoplication; in 3 patients, a laparoscopic Toupet fundoplication was performed. Previous antireflux procedures included an open Nissen fundoplication (n = 5), a laparoscopic Nissen fundoplication (n = 15), and a laparoscopic Toupet fundoplication (n = 4). Postoperatively, one patient had severe dysphagia and had to undergo pneumatic dilatation once. During a follow-up of 1 year after surgery, no patient developed a recurrent hiatal hernia, with or without intrathoracic wrap herniation. The mean lower esophageal sphincter pressure increased significantly (P<.01) at 3 months (12.2 mm Hg) and 1 year (11.9 mm Hg) after refundoplication. The mean DeMeester score decreased significantly (P<.01) from 50.5 points preoperatively to 16.0 points at 3 months and 14.7 points at 1 year after refundoplication. CONCLUSION: Laparoscopic refundoplication with prosthetic hiatal closure is a safe and effective procedure for preventing recurrent intrathoracic wrap herniation, with good to excellent functional outcome for a complete follow-up of 1 year.     

Laparoscopic versus open Nissen fundoplication in infants after neonatal laparotomy.

BACKGROUND: Nissen fundoplication is an effective treatment of gastroesophageal reflux in infants. Laparoscopic procedures after previous laparotomy are technically more challenging. The role of laparoscopic Nissen fundoplication after neonatal laparotomy for diseases unrelated to reflux is poorly described. METHODS: This was a retrospective review of open vs laparoscopic Nissen fundoplication in infants after neonatal laparotomy. Of 32 infants who underwent neonatal laparotomy, 26 required a surgical antireflux operation within the first year of life. Twelve infants underwent laparoscopic Nissen fundoplication versus 14 infants who underwent open Nissen fundoplication. Parameters like age, weight, operative time, number of previous operations, length of stay following fundoplication, time to feedings, and complications were compared between the 2 groups. RESULTS: No statistically significant differences existed between most of the parameters compared following laparoscopic vs open Nissen fundoplication. No conversions to open procedures were necessary in infants undergoing laparoscopic fundoplication, and these infants resumed enteral feeds earlier than those who underwent the open procedure. CONCLUSION: Laparoscopic compared with open Nissen fundoplication performed in infants after a neonatal laparotomy were comparable procedures across most data points studied. However, a laparoscopic fundoplication did allow for earlier return to enteral feeds compared with the open approach. Laparoscopic Nissen fundoplication is technically feasible, safe, and effective in the treatment of gastroesophageal reflux in infants with a previous neonatal laparotomy.     

Surgical management of gastroesophageal reflux and outcome after laryngectomy in patients using tracheoesophageal speech

BACKGROUND: Gastroesophageal reflux disease (GERD) is common in patients with head and neck carcinoma. The impact of laparoscopic fundoplication on laryngectomy patients with tracheoesophageal prostheses for voice restoration is unknown. METHODS: Nine laryngectomy patients who use tracheoesophageal speech underwent laparoscopic fundoplication for documented reflux. Preoperative and postoperative symptoms were recorded. Quality of speech was documented before and after fundoplication. RESULTS: Although 88% of patients had resolution of GERD symptoms, all developed bloating and hyperflatulence. There was no difference in quality of esophageal speech after laparoscopic fundoplication. CONCLUSIONS: Fundoplication in laryngectomy patients that use tracheoesophageal speech eliminates symptoms of gastroesophageal reflux and resolves regurgitation associated prosthesis erosion. Although nearly all patients are satisfied with outcome, there is a high incidence of postfundoplication bloating and hyperflatulence that may be life limiting. Poor quality tracheoesophageal speech should not be used as an indication for antireflux surgery.     

Quality of Life Following Laparoscopic Anterior 90° Versus Nissen Fundoplication: Results from a Multicenter Randomized Trial

Background The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90° partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90° fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient’s functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90° partial fundoplication than after Nissen fundoplication. Methods Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90° partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires – the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. Results One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90° anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. Conclusions Patients undergoing laparoscopic anterior 90° partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.     

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.     

Laparoscopic antireflux surgery: five-year results and beyond in 1340 patients

BACKGROUND: Although the long-term results of open fundoplication for gastroesophageal reflux disease are well documented, few reports exist on the long-term results of laparoscopic fundoplication. DESIGN: Retrospective study with clinical evaluation or mailed survey for patients unable to return to the hospital center. SETTING: Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). PATIENTS: Between January 1992 and December 1998, 2684 patients with gastroesophageal reflux disease underwent laparoscopic fundoplication in 31 hospital centers. Outcome data covering a period of 5 or more years after surgery were available for 1340 patients: 711 who underwent complete fundoplication, 559 who underwent partial posterior fundoplication, and 70 who underwent partial anterior fundoplication. MAIN OUTCOME MEASURES: Evaluation of clinical and quality-of-life actions used to treat the symptoms of gastroesophageal reflux disease. RESULTS: The overall residual severe dysphagia rate was 5.1% (n = 68). A further surgical procedure was required for 59 patients (4.4%) for a total of 63 interventions. Subsequent operation was performed laparoscopically in 32 cases (50.8%). Twelve of these procedures were for the repair of a paraesophageal hiatus hernia, 11 were for dysphagia (4 because of a tight esophageal hiatus and 7 for conversion of Nissen fundoplication to a posterior partial fundoplication procedure), 31 were for recurrent reflux (wrap undone), 2 were for intestinal obstruction (adhesiolysis), 1 was for incisional hernia, 1 was for abdominal abscess (drainage), and 1 was for gastroparesis (pyloroplasty). The recurrence rate was 10.1% (n = 136), and 122 patients (9.1%) resumed taking antisecretory medication. Gas bloat syndrome was present in 101 patients (7.5%). A total of 93.1% of the patients were satisfied (Visick classification, grades 1 and 2) and 6.9% were unsatisfied, with no difference among the 3 procedures. CONCLUSION: After 5 years of experience, laparoscopic fundoplication remains an effective antireflux procedure.     

Cannula site insertion technique prevents incisional hernia in laparoscopic fundoplication

INTRODUCTION: Incisional hernia is a common surgical problem encountered after laparotomies. The so-called trocar-site or port-site hernia is a type of incisional one that occurs after laparoscopic procedures. It has an incidence range between 0.1% and 3%. OBJECTIVE: To evaluate our patients who underwent laparoscopic Nissen fundoplication for presence of trocar-site hernia. PATIENTS AND METHODS: This study included 405 patients who underwent laparoscopic Nissen fundoplication in Ankara University, Faculty of Medicine, Department of General Surgery, Turkey. The patients were evaluated by physical examination and anterior abdominal wall ultrasound (US). RESULTS: Trocar-site hernia was not detected in any of our cases either by physical examination or by US. CONCLUSIONS: Trocar-site hernia is a rare complication of laparoscopy. It occurs at the trocar insertion site with a diameter of 10 mm or more in adult patients. Trocar insertion away from the midline can decline the incidence.     

Anatomic findings and outcomes after antireflux procedures in morbidly obese patients undergoing laparoscopic conversion to Roux-en-Y gastric bypass.

BACKGROUND: To report the anatomic findings and outcomes in patients undergoing laparoscopic takedown of Nissen fundoplication with conversion to Roux-en-Y gastric bypass. METHODS: We reviewed the records of patients who underwent laparoscopic Nissen takedown with conversion to Roux-en-Y gastric bypass from January 2001 to April 2006 at the University of Minnesota Medical Center. RESULTS: Eleven patients were identified. Nine patients had gastroesophageal reflux disease preoperatively, of whom six underwent 24-hour pH monitoring. In 2 patients, the pH study findings were negative. Eight prior procedures had been performed laparoscopically. Eight patients were women. The mean age was 44 years. The average body mass index preoperatively was 44 kg/m(2) (range 35-61). The mean follow-up was 13.8 months (range 4-39). The body mass index at follow-up was 30.2 kg/m(2). The operative time was 349 minutes (range 222-624). The hospital length of stay was 3.4 days (range 2-6). No conversions to open surgery were required. No major short-term complications developed. Minor complications included wound or drain site infection in 3 patients, with abscess in 2, pressure sore of the lateral aspect of the foot in 1, pneumonia in 2, and marginal ulcer in 2 patients. No strictures were observed. One internal hernia occurred. Of the 9 patients with gastroesophageal reflux disease preoperatively, all had 100% improvement in symptoms, with complete resolution in 7 (78%). Wrap disruption was present in 5 (45%) of 11 patients. Herniation of an intact wrap had occurred in 1 patient. One patient had both herniation and wrap disruption. CONCLUSION: Laparoscopic conversion of Nissen fundoplication to Roux-en-Y gastric bypass is a feasible salvage operation for recurrent gastroesophageal reflux disease in the morbidly obese. The incidence of wrap disruption appears to be relatively high and the incidence of intact wrap herniation low in obese patients after failed Nissen fundoplication, suggesting that the mechanism of failure after primary antireflux surgery in obese patients may be different than that in normal-weight patients.     

Early reoperation following laparoscopic antireflux surgery

PURPOSE: To assess the outcome for patients undergoing early reoperation following laparoscopic antireflux surgery. METHODS: The outcome was prospectively determined for 28 patients who underwent 30 reoperative procedures within 4 weeks of their initial laparoscopic fundoplication between 1992 and 1998. Follow-up ranged from 3 months to 4 years (median 2 years). Before mid 1994, patients were assessed and managed based on clinical findings (first 192 patients in overall series), whereas subsequently (for the most recent 530 patients) all patients underwent routine early postoperative barium swallow radiography, and laparoscopic exploration during the first postoperative week if problems were suspected. RESULTS: The reoperations were performed for acute paraoesophageal hiatus hernia (8 patients), tight oesophageal hiatus (7), postoperative haemorrhage (3), tight Nissen fundoplication (8), early recurrent reflux (1), and coeliac/superior mesenteric artery thrombosis (1). Two patients required a second operation for persistent dysphagia due to a tight hiatus. Both patients initially underwent loosening of their fundoplication. Before mid 1994, reoperations were usually undertaken by an open approach, whereas subsequently a laparoscopic approach has usually been successful. Laparoscopic reintervention was easily achieved within 7 days of the first procedure whereas subsequent surgery was more difficult and often required open surgery. The change in protocol was associated with an improvement in overall patient satisfaction and dysphagia in the latter part of this experience. CONCLUSIONS: Routine early contrast radiology following laparoscopic fundoplication and a low threshold for laparoscopic reexploration facilitates early identification of postoperative problems at a time when laparoscopic correction is easily achieved. This may result in an improved overall outcome for patients requiring early reintervention following laparoscopic antireflux surgery.     

胃食管反流病的腹腔镜外科治疗

目的:探讨腹腔镜手术治疗胃食管反流病的临床效果.方法:回顾性分析2008年1月—2011年9月对33例胃食管反流病患者行腹腔镜食管裂孔疝修补和胃底折叠术的临床资料.腹腔镜单纯胃底折叠术5例(Toupet式),腹腔镜食管裂孔疝修补加胃底折叠术25例(Nissen式3例,Toupet式22例),腹腔镜单纯食管裂孔疝修补术3例.结果:全组患者手术均获成功,手术时间90～185 min.术后平均住院6d.无中转开腹及死亡病例,无术后严重并发症.术后随访1～24个月,32例临床症状完全消失,1例明显好转.结论:对于胃食管反流性疾病,腹腔镜食管裂孔疝修补和胃底折叠术是一种微创、安全、有效的治疗方法.     

Esophagography predicts favorable outcomes after laparoscopic Nissen fundoplication for patients with esophageal dysmotility

BACKGROUND: We undertook this study to determine if clearance of a food bolus at preoperative esophagography predicts acceptable outcomes after laparoscopic Nissen fundoplication for patients with manometrically abnormal esophageal motility. STUDY DESIGN: Patients with gastroesophageal reflux disease (GERD) or symptomatic hiatal hernia with evidence of esophageal dysmotility by stationary manometry underwent videoesophagography to document the ability of their esophagus to clear food boluses of varying consistencies. Sixty-six patients were identified who had manometric dysmotility yet were able to clear a food bolus at esophagography, and subsequently underwent laparoscopic Nissen fundoplication. These patients were compared with 100 randomly selected patients with normal motility who underwent laparoscopic Nissen fundoplication. Symptom reduction and satisfaction were assessed through followup. Patients with normal motility were compared with those with manometrically moderate and severe dysmotility. RESULTS: Preoperative patient demographic data, symptoms, and symptom scores were similar among patients with normal motility and moderate or severe dysmotility. After fundoplication, symptom reduction was notable for all patients regardless of preoperative motility (p < 0.01, paired Student's t-test). There was no notable difference in postoperative symptom scores (p = NS, Kruskal-Wallis ANOVA) or in patient satisfaction (p = NS, chi-square analysis) among patients stratified by esophageal motility. CONCLUSIONS: Patients with esophageal dysmotility documented by manometry who are able to clear a food bolus at contrast esophagography, have functional results after laparoscopic Nissen fundoplication similar to patients with normal motility. Preoperative esophagography predicts successful outcomes after laparoscopic Nissen fundoplication for patients with manometric esophageal dysmotility.     

Five- to eight-year outcome of the first laparoscopic nissen fundoplications

The operative mortality and morbidity of laparoscopic fundoplication are lower than for the open procedure. Questions have been raised regarding its long-term durability. One hundred seventy-one patients who had undergone laparoscopic Nissen fundoplication at least 5 years previously answered a questionnaire. During this period, 291 patients underwent a laparoscopic Nissen fundoplication. Surveillance data were available for 171 patients at a mean of 6.4 years after surgery. Overall, 96.5% were satisfied and 3.5% were not satisfied with the result of the procedure. Persistent symptoms included abdominal bloating (20.5%), diarrhea (12.3%), regurgitation (6.4%), heartburn (5.8%) and chest pain (4.1%); 27.5% reported dysphagia, and 7% had required dilatation. Fourteen percent were on continuous proton pump inhibitor therapy, but 79% of these patients were treated for vague abdominal or chest symptoms unrelated to reflux, which calls into question the indications for this therapy. Ninety-three percent of all patients were satisfied with their decision to have surgery. The overall well-being score increased significantly from 2.2 ±1.6 before surgery to 8.8 ±2 (P >0.0001) at more than 5 years after surgery. Twenty-one percent had undergone additional diagnostic procedures after surgery such as endoscopy and/or barium swallow. Laparoscopic Nissen fundoplication is an excellent long-term treatment for gastroesophageal reflux disease with persistent success for more than 5 years. Some patients have continuing symptoms and remain on therapy, but more than 90% of all patients undergoing laparoscopic Nissen fundoplication remain satisfied with their decision to have surgery. These results are at least as good as those achieved with open fundoplication and prove the long-term worth of this procedure.     

Laparoscopic Nissen fundoplication: five-year results and beyond

HYPOTHESIS: Laparoscopic Nissen fundoplication provides long-term relief of symptoms of gastroesophageal reflux disease. DESIGN: Prospectively evaluated case series. SETTING: University teaching hospital. PATIENTS: From September 1991 to December 1999, we performed more than 900 laparoscopic antireflux procedures. The outcome for patients who underwent surgery between September 1991 and June 1994 (178 cases) was determined. This included all patients having laparoscopic Nissen fundoplication, from the first procedure onward. INTERVENTIONS: Long-term follow-up for 5 or more years after laparoscopic Nissen fundoplication was obtained by an independent investigator who interviewed patients using a structured questionnaire. MAIN OUTCOME MEASURES: Prospective evaluation of clinical symptoms using a structured questionnaire. RESULTS: Outcome data covering a period of 5 or more years after surgery was available for 176 patients (99%), with 2 patients lost to follow-up. Nine patients died (8 of unrelated causes) at some stage following surgery, and the outcome was difficult to determine in 1 patient with cerebral palsy. Hence, questionnaire data were available for 166 patients at a median follow-up of 6 years (range, 5-8 years). Three patients (1.7%) underwent revision surgery for recurrent reflux; 87% of the 176 patients remained free of significant reflux. Reoperation was required for dysphagia in 7 patients (3.9%), 2 for a tight wrap and 5 for a tight diaphragmatic hiatus. In addition, reoperation was necessary for a paraesophageal hiatus hernia in 13 patients (7.3%). Of the reoperations, 56% were performed within 12 months of the original procedure, and 22% during the second year of follow-up. Further surgery was uncommon after 2 years. The long-term outcome was considered "good or excellent" by 90% of patients. CONCLUSIONS: The long-term outcome of laparoscopic Nissen fundoplication is similar to that following open fundoplication. Good results are obtained in most patients.     

The place of Belsey Mark IV fundoplication in the era of laparoscopic surgery.

OBJECTIVES: Laparoscopic fundoplication to correct or avoid gastroesophageal reflux decreased Belsey Mark IV fundoplication (BMIV) dramatically worldwide. The purpose of this paper was to determine the role of BMIV and its current indications. METHODS: We reviewed all patients who underwent fundoplication between April 1997 and December 2001. All patients underwent a complete work-up included barium meal, endoscopy, 24-h pH-metry and manometry preoperatively. RESULTS: Sixty-two consecutive fundoplications were performed. There were 23 males and 39 females. Forty-six patients were treated by laparoscopic approach (37 patients with total and nine patients with partial fundoplication). BMIV was preferred in 16 patients with the following indications: reoperations for failed oesophageal surgery (5), hiatal hernia fixed in the chest (4), epiphrenic oesophageal diverticula (3), diffuse oesophageal spam (2), hiatal hernia associated with bullous emphysema (1), leiomyoma of the oesophago-gastric junction (1). Excellent to good results were reported in 14 patients and poor in two. Follow-up was completed in all patients. CONCLUSIONS: BMIV remains a valid fundoplication although the current indications are now limited. The technique is to be considered an additional, but necessary, weapon for thoracic surgeons with interest in oesophageal disease.     

Laparoscopic conversion from Nissen to partial fundoplication for refractory dysphagia

Laparoscopic Nissen fundoplication is effective for treating gastroesophageal reflux and is usually well tolerated. Some patients, however, experience postoperative dysphagia refractory to conservative measures. We report our experience and operative technique for laparoscopic conversion of previous laparoscopic Nissen fundoplication to partial fundoplication to relieve dysphagia. We retrospectively reviewed the medical records of 6 patients with refractory dysphagia after laparoscopic Nissen fundoplication who underwent laparoscopic conversion to partial fundoplication using a laparoscopic linear stapler. There were no perioperative deaths and no fundoplication-related complications. In short-term follow-up, all patients reported improvement of dysphagia symptoms.     

Minimally invasive surgical techniques in reoperative surgery for gastroesophageal reflux disease in infants and children

Fundoplication is commonly performed in children suffering from complications of gastroesophageal reflux disease (GERD). Recently laparoscopic fundoplication has become a standard of care for GERD in children. Published reports show that 2.3 to 14 per cent of children require reoperation after failed fundoplication. The purpose of this study is to show the feasibility of minimally invasive surgical (MIS) techniques to treat children after failed fundoplication. A retrospective chart review was performed for all patients who underwent laparoscopic redo fundoplication at Children's Healthcare of Atlanta at Egleston from July 1998 to July 2000. The patients' records were reviewed for age, diagnosis, type and time of initial operation, type and time of redo operation, operative time for redo operation, and complications. Seventeen children (age 3 months to 18 years) had operations for failed fundoplication attempted using MIS techniques. Six of these children were referred after their initial operation performed elsewhere. Nine (53%) were neurologically impaired. Ten (59%) have respiratory complications of GERD. The initial procedures were as follows: One open Nissen fundoplication, two open Thal fundoplications, 13 laparoscopic Nissen fundoplications, and one laparoscopic Toupet fundoplication. The reoperative procedures performed were revision of fundoplication and hiatal hernia repair (13) or hiatal hernia repair only (four). Two patients had concurrent gastric emptying procedures. One procedure was converted to open for technical reasons. One patient developed a pelvic abscess secondary to leakage around the gastrostomy tube. One child had erosion into the esophagus of a Dacron patch that was used to close a large hiatal defect. Thirteen patients began feeding by the first postoperative day. We conclude that MIS techniques can be applied to reoperative surgery for the treatment of GERD with an acceptable complication rate in this difficult group of patients. Reoperative patients appear to have the same benefits from MIS as patients undergoing their initial procedure.     

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.