Chronic dysphagia following laparoscopic fundoplication

BACKGROUND: Many surgeons practise tailored laparoscopic antireflux surgery in an attempt to prevent postoperative dysphagia. The aim of this study was to determine the effect of 360 degrees fundoplication (Nissen) or 270 degrees fundoplication (Toupet), and the influence of abnormal oesophageal peristalsis, upon postoperative dysphagia. METHODS: This was a cohort study from three tertiary referral centres, using dysphagia before laparoscopic fundoplication and 1 year after operation as the main outcome variable. Preoperative oesophageal manometry was performed on all patients. RESULTS: Some 761 patients underwent Nissen and 85 underwent Toupet fundoplication. Only 2 per cent reported severe postoperative dysphagia. There was a significant selection bias towards the Toupet operation for patients with abnormal oesophageal motility (P < 0.001). For patients whose oesophageal manometric findings were normal there was a significant improvement in dysphagia after Nissen fundoplication (P = 0.02), and no significant change following Toupet fundoplication. There was no significant change in the rate of dysphagia following either method of fundoplication amongst other subgroups in which oesophageal manometry was stratified as non-specific motor disorder, low-amplitude peristalsis, or aperistalsis. CONCLUSION: A tailored approach to the degree of fundoplication is unnecessary as patients with dysmotility suffer no more dysphagia after full laparoscopic Nissen fundoplication than those who have a partial Toupet wrap.     

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.     

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.     

Patterns of success and failure with laparoscopic Toupet fundoplication

Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy. Received: 29 June 1998/Accepted: 2 July 1999     

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.     

Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication

It is unclear whether a partial or complete gastric fundoplication done laparoscopically will offer the best control of reflux with the fewest side effects. Prospective evaluation of laparoscopic Rosetti-Nissen (360) and Toupet (180) fundoplication was performed with assessment of clinical and manometric data. Methods: Patients with severe gastroesophageal reflux referred for surgical correction underwent preoperative motility and upper endoscopy. A Rosetti-Nissen or Toupet fundoplication was then performed laparoscopically. Short gastrics were not divided. No bougie was used in the Toupet, which was sutured intracorporeally. A 2-cm, loose, floppy wrap about a 50-Fr bougie was performed in the Nissen. Eleven patients underwent Rosetti-Nissen and 11 Toupet fundoplication. Mean ages, duration symptoms, weight, and baseline LES, were not different. Preop esophagitis grades were similar, as were Visick Scores and presence of dysphagia. Results: Visick scores at 6 months were better in the Toupet group than the Rosetti-Nissen (P=0.07). Persistent Dysphagia in four, Gas-Bloat in two, and Odynophagia in one within the Rosetti-Nissen group accounted for the difference, and were not seen in Toupets. LES pressures differed significantly pre and postop (P<0.001). The change in LES pressure was significantly different between Toupet and Rosetti-Nissen (chart). Seven patients had postop 24-h pH tests; all had no reflux. Three Rosettis have required revision to Toupet, with resolution of their symptoms. Conclusions: In patients with severe GERD, laparoscopic Toupet and Rosetti-Nissen control symptoms and esophageal pH similarly. LES pressures are higher postop in the Rosetti-Nissen. Dysphagia and gas-bloat are more prevalent in the Nissen group. Laparoscopic Toupet fundoplication may be superior to Rosetti-Nissen in reducing the frequency of side effects frequently associated with antireflux surgery, yet with equal control of reflux. {ie724-1}     

Esophageal and lower esophageal sphincter pressure profiles 6 and 24 months after laparoscopic fundoplication and their association with postoperative dysphagia

Background: It has been suggested that antireflux surgery may cause an improvement in esophageal motor function (EMF) and lead to reduced postoperative dysphagia. Methods: We evaluated the changes in dysphagia symptom scores and esophageal and lower esophageal sphincter (LES) pressures in patients before (n= 381), at 6 months (n= 260), and at 24 months (n= 97) after laparoscopic fundoplication. Results: There was a significant increase in LES basal and nadir pressure following surgery in all patients and an improvement in EMF only in patients with poor preoperative esophageal motor function. A total of 76% of the patients reported no dysphagia or an improved dysphagia score 6 and 24 months after surgery. This improvement was more marked in patients with poor EMF. An improvement in EMF did not correlate with the improvement in dysphagia score reported by other patients. Patients with increased dysphagia scores 2 years after surgery had significantly higher LES basal and nadir pressures as compared to other patients. Conclusions: Laparoscopic Nissen fundoplication is associated with an overall reduction in dysphagia scores and leads to an improvement in esophageal motor function in patients with poor preoperative esophageal motility. Tightness and inadequate relaxation of the wrap during swallowing may be a determinant of long-term dysphagia. Received: 5 May 1997/Accepted: 19 August 1997     

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.     

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。     

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.     

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.     

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.     

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 Toupet versus Nissen fundoplication for the treatment of gastroesophageal reflux disease

The Nissen fundoplication is the most popular laparoscopic operation performed for the surgical treatment of gastroesophageal reflux disease (GERD). However, for patients in whom esophageal peristalsis is documented to be weak preoperatively, use of a partial wrap, or Toupet procedure, has often been used as an alternative to lessen the potential for postoperative dysphagia. Recent reports have criticized the Toupet procedure as having a higher long-term failure rate than the Nissen approach, especially for patients with severe forms of GERD. We reviewed our experience performing laparoscopic antireflux surgery over a 7-year period and compared the results of patients undergoing laparoscopic Nissen versus Toupet procedures. All procedures were performed at our institution by a single surgeon. Data recorded included preoperative demographic data, preoperative disease parameters, perioperative data, postoperative course, and symptom scores. Follow-up was based on a combination of medical records and phone interviews. There were 142 patients with complete records allowing review for this study. Of these, 118 underwent 122 Nissen fundoplications and 26 underwent 27 Toupet fundoplications. Selection of the procedure was based on preoperative manometric studies. There were seven reoperations. Seven of the patients (28%) who underwent Toupet procedures had severe GERD, a percentage comparable to the Nissen group (31.6%). Preoperative parameters were comparable for both groups, although the Toupet patients had lower average preoperative LES pressures (9.79 mmHg) than did the Nissen patients (16.1 mmHg, P < 0.05). The operative duration, operative blood loss, morbidity, length of hospitalization, need for reoperation, and efficacy in terms of relieving symptoms (average follow-up = 27.5 months) were comparable for both groups. Based on this experience, the Toupet procedure seems safe and effective in treating the symptoms of GERD, including patients with severe forms of the disease. We recommend its selective use in patients with preoperative esophageal hypomotility who are undergoing laparoscopic antireflux surgery.     

Laparoscopic vs open approach for Nissen fundoplication

Background: Several studies, most of them nonrandomized, have shown similar functional results for both laparoscopic and open Nissen fundoplication, the operation of choice for the treatment of gastroesophageal reflux disease (GERD). Methods: A total of 106 patients with documented GERD were randomized to receive either a laparoscopic or an open Nissen fundoplication. Preoperative and postoperative investigations included clinical assessment, esophagogram, upper gastrointestinal endoscopy, esophageal manometry, and 24-h ambulatory pHmetry. Results: Both approaches were successful in controlling reflux. There was an overall improvement in esophageal peristalsis and an increase in lower esophageal sphincter (LES) pressure in both groups. Open Nissen fundoplication was associated with a significantly increased rate of wound (p <0.001) and respiratory (p <0.05) complications. Hospitalization was also longer after the open technique (p <0.001). At 3-month follow-up, although the rate of postoperative dysphagia was similar for the two approaches, the open approach was associated with a significantly higher incidence of postprandial epigastric fullness (p <0.05) and bloating syndrome (p <0.01). Conclusions: The open and laparoscopic approaches for the Nissen fundoplication are equally effective in controlling GERD. The open approach is associated with a significantly higher rate of wound and respiratory complications and, at early stages, an increased rate of postprandial epigastric fullness and abdominal bloating. The dysphagia rate is similar with both methods.     

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.     

Influence of wrap length on the effectiveness of Nissen and Toupet fundoplication: a prospective randomized study

Background  Incontinence or hypercontinence of the fundic wrap depends primarily on the length of the valve or the type of procedure. Much less attention has been paid to the fundic wrap length. This study aimed to compare the effectiveness of two different wrap lengths among the patients undergoing partial or total fundoplication. Methods  For this study, 153 patients were randomized to either Nissen (1.5- or 3-cm wrap) or Toupet (1.5- or 3-cm wrap) laparoscopic fundoplication. The groups were compared according to intensity of dysphagia, esophageal manometry data, ambulatory 24-h pH monitoring data, postoperative esophagitis rate, and overall treatment failure rate. Results  In all the groups, the tone of the lower esophageal sphincter was significantly increased and the DeMeester score significantly decreased, reaching normal levels. At 6 months after surgery, the Toupet 1.5-cm group had significantly more cases of esophagitis than the 3-cm wrap group (24.2% vs 3.3%; p < 0.05). At 12 months after surgery, only one patient in the Nissen 3-cm group had moderate to severe dysphagia. In all cases, failures were associated with persistent erosive esophagitis. At the 12-month follow-up assessment, treatment failures were significantly more common in Toupet 1.5-cm group than in the Toupet 3-cm group (17.5% vs 2.7%; p < 0.05). However, such differences were not observed in the Nissen groups (7.8% for 1.5 cm and 15.6% for 3 cm; p > 0.05). Conclusions  Evaluation of the treatment results suggests that the wrap length is important in partial Toupet fundoplication to avoid treatment failures. The 3-cm wrap is superior to the 1.5-cm wrap in cases of partial posterior Toupet fundoplication. The influence of wrap length on treatment failure remains unconfirmed for the Nissen procedure.     

Fundoplications resist reflux independent of in vivo anatomic relationships

BACKGROUND: Antireflux operations restore lower esophageal sphincter (LES) function and hiatal anatomy; however, the relative contributions are unclear. METHODS: We measured the competency of fundoplications, exclusive of in vivo variables, in gastroesophageal explants from 8 cadavers. Using a multichannel manometer, esophageal, LES, and intragastric pressures were recorded during transpyloric distension. Data were compared at baseline, and after Nissen (360 degrees) and Toupet (270 degrees) fundoplications. RESULTS: Before fundoplication, stomachs refluxed immediately upon distension. Nissen fundoplications never refluxed before gastric rupture (46.8 +/- 15.0 mm Hg). LES pressure averaged 2.0 +/- 0.5 times intragastric pressure during distension. Toupet fundoplications refluxed at intragastric pressure <2 mm Hg, then became competent until gastric rupture (49.9 +/- 15.0 mm Hg). LES pressure averaged 2.4 +/- 1.0 times intragastric pressure during distension. CONCLUSIONS: Nissen and Toupet fundoplications increase LES pressure linearly at 2 to 2.5 times intragastric pressure, independent of in vivo variables. Toupet fundoplication lacks the competency of Nissen fundoplication at low intragastric pressures.     

Physiologic mechanism and preoperative prediction of new-onset dysphagia after laparoscopic Nissen fundoplication

The aim of this study was to determine whether preoperative physiologic factors can account for and be used to predict the development of postoperative dysphagia after laparoscopic Nissen fundoplication. One hundred sixty-three patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication with a median follow-up of 14 months (range 6 to 81 months). Preoperative dysphagia was present in 37% (60 of 163) and was relieved in all but five patients (92%). Female sex (P = 0.01) and the presence of a stricture (P = 0.02) were the only preoperative variables associated with the presence of preoperative dysphagia. Eight percent (8 of 103) of patients without preoperative dysphagia developed new-onset dysphagia, and of these 63% (5 of 8) had a normal lower esophageal sphincter (LES) (pressure >6 mm Hg; length >2 cm; abdominal length >1 cm). New-onset dysphagia was significantly more common in patients with a normal LES (22% [5 of 23] vs. 4% [3 of 80], P = 001). Patients with a normal LES had almost a sixfold increase in the risk of developing dysphagia as those with an abnormal LES (relative risk = 5.8). Only a preoperative normal LES (P = 0.02) or mean LES pressures (P = 0.04) were positively associated with the development of postoperative dysphagia. The severity of this dysphagia also showed a strong positive trend of increasing with mean preoperative LES pressures (P = 0.07). Finally, preoperative LES pressure significantly correlated with postoperative LES pressure (r = 0.48, P = 0.01) and with mean residual LES (nadir) pressure (r = 0.33, P = 0.05) offering insight into the mechanism of this dysphagia. In conclusion, preoperative LES parameters play a role in the development of dysphagia after laparoscopic Nissen fundoplication. Patients with a normal LES or high mean LES pressures are at increased risk for developing this complication and should be informed of this before laparoscopic Nissen fundoplication. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001.