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.     

Five-year results of laparoscopic Toupet fundoplication as the primary surgical repair in GERD patients: Is it durable?

Introduction Most surgeons operate on gastroesophageal reflux disease (GERD) patients using the concept of “tailored approach,” which depends on esophageal motility. We have abandoned this concept and performed laparoscopic Toupet fundoplication in all patients suffering from GERD, independent of their esophageal motility. Methods In a prospective trial we have assessed and evaluated our 5-year results of the first 100 consecutive patients treated with laparoscopic Toupet fundoplication. All patients were evaluated preoperatively by endoscopy and 24-h pH manometry. The patients were followed up clinically 1, 2, 6, 12 and 60 months postoperatively. The course of clinical DeMeester score, appearance and treatment of wrap-related side-effects as well as long-term outcome and patient satisfaction were evaluated. Results The 5-year follow-up rate was 87%. Laparoscopic Toupet fundoplication achieved a 5-year healing rate of GERD in 85%. Of all operated patients, 3.5% had to be reinstalled on a regular PPI treatment because of postoperative GERD reappearance. The median clinical DeMeester score decreased from 4.27 ± 1.5 points preoperatively to 0.47 ± 0.9 points 5 years postoperatively (p < 0.0005). Because of persistent postoperative dysphagia, 5% of the patients required endoscopic dilatation therapy. Persistent postoperative gas-bloat syndrome occurred in 1.1%. Wrap dislocation was identified in 3.4% of patients. Reoperation rate was 5%. Total morbidity rate was 19.5% and operative related mortality rate was 0%. Overall, 96.6% of patients were pleased with their outcome at late follow-up, and 95.4% of patients stated they would consider undergoing laparoscopic fundoplication again if necessary. Conclusion Our long-term results showing a low recurrence and morbidity rate of laparoscopic Toupet fundoplication encourage us to continue to perform this procedure as the primary surgical repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet fundoplication has proven to be a safe and successful therapeutic option in GERD patients.     

Does major depression in patients with gastroesophageal reflux disease affect the outcome of laparoscopic antireflux surgery?

Background: It is known that psychological factors can affect end points of surgical treatment. The current study aimed to evaluate the outcome of laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who experience concomitant major depression in comparison with GERD patients who have no known comorbidity. Methods: Among a sample of more than 550 patients who underwent LARS, a group of 38 GERD patients with concomitant major depression (MD) were included in this study. The patients included 24 women and 14 men, with a mean age of 51 years. A group of 38 control patients (non-MD) matched in terms of age, gender, and esophageal manometry findings was selected from the database for comparison of surgical outcomes between patients with GERD accompanied by concomitant major depression and GERD patients with no known comorbidity. In each group, 23 patients received a Toupet fundoplication and 15 patients underwent a "floppy" Nissen fundoplication. The following factors were evaluated before surgery, 3 months afterward, and 1 year after LARS: symptoms (heartburn, regurgitation, chest pain, bloating, and dysphagia), quality of life (Gastrointestinal Quality of Life Index [GIQLI]), lower esophageal sphincter pressure (LESP), and 24-h pH monitoring (DeMeester score). Results: Before and after surgery, there were no significant differences between the two groups in terms of LESP and DeMeester score. Preoperative GIQLI showed significant differences (p < 0.05) between the two groups (MD group, 71.8 ± 8.6 vs non-MD group, 91.1 ± 9.8), and significant differences (p < 0.01–0.001) between the mean data and that for healthy individuals (122.6 ± 8.5). The GIQLI scores had improved significantly at 3 months and at 1 year after surgery (p < 0.05–0.001) in all the patients (1 year postoperatively: MD group, 99.3 ± 8.6 vs non-MD group, 121.9 ± 9.7). Before surgery, when symptoms were compared between the two groups, significant differences (p < 0.001) were found in the percentage of chest pain (81.6% vs 37.4%) and bloating (92.2% vs 37.4%), showing that these symptoms were more predominant and graded as much more severe among patients with MD. In both groups, all the symptoms but dysphagia showed a significant improvement in severity (p < 0.05–0.0001). A comparison of both groups postoperatively showed that significant differences were still present in chest pain (44.7% vs 2.6%), bloating (68.4% vs 18.4), and dysphagia (50.1% vs 2.6%). A significant difference (p < 0.001) was observed only in patients with major depression and depending on the kind of wrap procedure (Nissen vs Toupet), showing that dysphagia (78.9% vs 21.1%) and chest pain (82.4% vs 17.6%) were much more predominant in patients who underwent "floppy" Nissen fundoplication. Conclusions: Even if they are good surgical candidates from a physiologic point of view, GERD patients with concomitant major depression should be selected carefully. In these patients, LARS can normalize physiologic data, but some patients have demonstrated less symptomatic relief, suffered from postoperative dysphagia, and showed less quality-of-life improvement. Eventually, laparoscopic Toupet fundoplication used with these patients could result in a better subjective outcome.     

Fundoplication improves disordered esophageal motility

Patients with gastroesophageal reflux disease (GERD) and disordered esophageal motility are at risk for postoperative dysphagia, and are often treated with partial (270-degree) fundoplication as a strategy to minimize postoperative swallowing difficulties. Complete (360-degree) fundoplication, however, may provide more effective and durable reflux protection over time. Recently we reported that postfundoplication dysphagia is uncommon, regardless of preoperative manometric status and type of fundoplication. To determine whether esophageal function improves after fundoplication, we measured postoperative motility in patients in whom disordered esophageal motility had been documented before fundoplication. Forty-eight of 262 patients who underwent laparoscopic fundoplication between 1995 and 2000 satisfied preoperative manometric criteria for disordered esophageal motility (distal esophageal peristaltic amplitude ≤30 mm Hg and/or peristaltic frequency ≤80%). Of these, 19 had preoperative manometric assessment at our facility and consented to repeat study. Fifteen (79%) of these patients had a complete fun-doplication and four (21%) had a partial fundoplication. Each patient underwent repeat four-channel esophageal manometry 29.5 ± 18.4 months (mean ± SD) after fundoplication. Distal esophageal peristaltic amplitude and peristaltic frequency were compared to preoperative data by paired t test. After fun-doplication, mean peristaltic amplitude in the distal esophagus increased by 47% (56.8 ± 30.9 mm Hg to 83.5 ± 36.5 mm Hg; P < 0.001) and peristaltic frequency improved by 33% (66.4 ± 28.7% to 87.6 ± 16.3%; P< 0.01). Normal esophageal motor function was present in 14 patients (74%) after fundoplication, whereas in five patients the esophageal motor function remained abnormal (2 improved, 1 worsened, and 2 remained unchanged). Three patients with preoperative peristaltic frequencies of 0%, 10%, and 20% improved to 84%, 88%, and 50%, respectively, after fundoplication. In most GERD patients with esophageal dysmotility, fundoplication improves the amplitude and frequency of esophageal peristalsis, suggesting refluxate has an etiologic role in motor dysfunction. These data, along with prior data showing that postoperative dysphagia is not common, imply that surgeons should apply complete fun-doplication liberally in patients with disordered preoperative esophageal motility. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Does laparoscopic Nissen fundoplication lead to chronic gastrointestinal dysfunction?

Background Laparoscopic Nissen fundoplication (LNF) efficiently controls the symptoms of gastroesophageal reflux disease (GERD); however, other nonspecific gastrointestinal (GI) symptoms have been reported following LNF. The aim of this study was to evaluate the long-term effects of LNF on nonspecific GI complaints. Methods The basis for this study is the prospective follow-up of 515 patients (mean age 46 ± 13 years) who underwent a LNF between 1992 and 1998. A questionnaire was designed to evaluate GERD symptoms (i.e., heartburn, epigastric pain, regurgitation, dysphagia, and fullness, score 0–60) and nonspecific GI symptoms (i.e., vomiting, diarrhea, constipation, and lack of appetite, score 0–48). Patients were assessed before surgery, at 6 months, 2 years, and 5 years after surgery. Results Laparoscopic Nissen fundoplication was associated with a significant decrease in both GERD and nonspecific GI symptoms score at 6 months and up to 5 years, in the whole group (p < 0.001). 360 patients (69.7%) had preoperative nonspecific GI symptoms and experienced a significant reduction in these symptoms following the surgery and lasting up to 5 years. The other 155 patients (30.3%) had no preoperative GI symptoms (GI symptoms score of 0). In this group, there was a small but statistically significant increase in GI symptoms score (p < 0.001). It was, however, clinically significant (defined as a score >12) in only 9.9% of the patients. Conclusions Laparoscopic Nissen fundoplication provides an efficient treatment of GERD up to 5 years, and in a majority of patients, it is not associated with any significant increase in nonspecific GI complaints. New nonspecific bowel symptoms can develop after LNF in some patients but are unlikely to be clinically significant. Presented to the Society of American Gastrointestinal Endoscopic Surgeons, Hollywood, Florida, April 2005     

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.     

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

Background

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

Methods

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

Results

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

Conclusions

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.     

Factors predictive of dysphagia after laparoscopic Nissen fundoplication

Background: Persistent postoperative dysphagia occurs in up to 24% of patients who undergo a laparoscopic Nissen fundoplication for reflux disease [7]. We hypothesized that patient history, pH testing, and esophageal manometry could be used to preoperatively identify patients at risk for this complication. Methods: Of 156 laparoscopic Nissen fundoplications performed over a 27-month period, we identified 19 patients (12%) who suffered from postoperative dysphagia longer than 3 months. The presenting complaint of preoperative swallowing difficulty was noted as was the presence of a known esophageal stricture. Preoperative pH testing and esophageal manometry were performed for all subjects. We compared the following parameters to an age and gender-matched control group: history of esophageal stricture, presence of preoperative dysphagia, DeMeester reflux score, upper esophageal sphincter pressure and relaxation, esophageal body motility, location of respiratory inversion point, and lower esophageal sphincter length, resting pressure, and relaxation. Data were compared via t-test and Fisher's exact test. Results: Patients who presented before surgery with complaints of difficulty swallowing were more likely to suffer from postoperative dysphagia (p= 0.029). Incidence of stricture, DeMeester score, and manometric measurements did not differ between the dysphagia and control groups (p > 0.05 for all parameters). Conclusions: Although preoperative studies are not helpful in identifying patients at risk for persistent dysphagia after laparoscopic Nissen fundoplication, patients presenting with the preoperative complaint of difficulty swallowing are at increased risk for this complication. Received: 1 April 1999/Accepted: 22 July 1999     

Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis

Background: Partial fundoplication has traditionally been indicated for patients with gastroesophageal reflux disease (GERD) who have defective peristalsis (DP). Because partial fundoplication had been reported to be a less effective means of controlling acid reflux than total fundoplication, in 1997 we stopped performing partial fundoplication for patients with DP and switched to a floppy total fundoplication. This study analyzes the results of our new strategy and compares it to our former approach. Methods: We performed a partial fundoplication in 39 patients with DP (distal amplitude >40% of swallows) between 1994 and 1997 and a total fundoplication in 57 patients between 1997 and 2000. Symptoms scores derived from a standard questionnaire with a scale of 0–4 manometry, and 24-h pH monitoring were completed preoperatively in 86 patients and postoperatively in 40 patients. Results: Heartburn scores improved in both groups (preoperative, 2.8; postoperative, 0.65; p<0.05). Dysphagia was 1.1 preoperatively and 0.62 postoperatively (p=NS) in the partial fundoplication group and 1.2 preoperatively and 0.3 postoperatively (p<0.05) in the total fundoplication group. Furthermore, none of the patients in the total fundoplication group developed new dysphagia and none required dilatation. Distal esophageal acid exposure normalized in both groups after operative treatment (median DeMeester score:72.3 vs 11.3, p<0.05, For partial fundoplication; 57.1 vs 6.3, p<0.05, For total fundoplication). Distal esophageal amplitudes averaged 27.8 mmHg preoperatively and 35.6 mmHg (p = NS) in the partial fundoplication group, they averaged 28.2 mmHg preoperatively vs 49.0 mmHg postoperatively (p<0.005) in the total fundoplication group. Two patients with a previous partial fundoplication required a conversion to a total fundoplication. No postoperative dilation was required in either group. Conclusions: Our study shows that both a partial and a total fundoplication are effective in controlling the symptoms of GERD in patients with defective peristalsis. Dysphagia improves significantly after total fundoplication but not after partial fundoplication. Although both operations brought acid reflux to within normal limits, the effect was more pronounced with total fundoplication. Total, but not partial, fundoplication produced a significant increase in amplitude of esophageal peristalsis, which may explain the subjective improvement during deglution. Therefore, fundoplication should be the treatment of choice in patients with GERD and defective peristalsis.     

On-table Endoscopy Following Laparoscopic Fundoplication

Background Laparoscopic fundoplication represents the gold standard in the surgical management of gastro-esophageal reflux disease (GERD). The achievement of long-lasting symptomatic and physiological control of reflux is the goal of therapy, as well as the minimization of troubling sequelae, in particular, dysphagia. On-table endoscopy after fundoplication was introduced in this Unit as a quality initiative in an attempt to minimize dysphagia and technical errors, and the aim of this study is to report the experience to date, and compare outcomes with the previous 100 cases performed by an experienced team. Methods Eighty patients who underwent laparoscopic Rosetti-Nissen fundoplication and on-table endoscopy (group 2) were compared with 100 consecutive prior cases (group 1). Patients were prospectively evaluated and had pre- and postoperative symptom scoring and analysis of complications (all patients), and manometry and 24-h pH testing in 120 patients (60 in each group). Results Both groups were similar with respect to demographics, esophagitis, pH score, and dysmotility. No bougie was used in either group. On-table endoscopy resulted in technical modifications in 4 (5%) patients. Early grade 2 or 3 dysphagia was evident in 4 (5%) patients in group 2, compared with 15 (15%) in group 1 (p < 0.001). Late dysphagia was evident in one patient (1.5%) in group 2 compared with 7 (7%) in group 1 (p < 0.05). Dilatation was performed in four patients (5%) in group 2, compared with 11 (11%) in group 1 (p < 0.05). Conclusions These data suggest that on-table endoscopy may be a useful quality assurance adjunct in laparoscopic anti-reflux surgery, in particular, reducing the incidence of dysphagia and reinterventions.     

Short-term outcome after laparoscopic and open 360° fundoplication

Background: Despite the lack of randomized trials supporting the laparoscopic approach, laparoscopic antireflux surgery has gained widespread acceptance during the last decade. The aim of this study was to compare the short-term symptomatic and objective outcome after laparoscopic and open 360° fundoplication in a prospective randomized clinical trial. Methods: Sixty patients with GERD were randomized to undergo either laparoscopic (LF) or open 360° fundoplication (OF). Endoscopy, esophageal manometry, 24-h pH monitoring, clinical symptom evaluation, and symptom scoring according to a validated questionnaire (the Gastrointestinal Symptom Rating Scale [GSRS]) was performed preoperatively and 6 months after surgery. Results: Five patients randomized to the laparoscopic group were converted to open surgery. Esophageal acid exposure was restored to normal in all patients. Lower esophageal sphincter length and resting pressure were significantly increased after both laparoscopic and open fundoplication (p <0.001); there were no differences between the groups. No significant differences were seen in symptomatic outcome, although there was a trend toward a higher rate of mild dysphagia (p = 0.051) after laparoscopic surgery. GSRS revealed a decrease in reflux score (p <0.001) and abdominal pain score (p <0.001) postoperatively. There were no significant differences in GSRS scores between the two groups. Conclusion: Laparoscopic 360° fundoplication is as effective in treating reflux disease as open fundoplication. Six months postoperatively, no significant differences were seen in symptomatic or objective outcome. Long-term evaluation is needed.     

Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia

Background The standard Heller myotomy (SM) for achalasia extends 1 to 2 cm on to the stomach. The authors perform an extended myotomy (EM) (>3 cm) with the goal of reducing postoperative dysphagia. This study examines the long-term efficacy and durability of EM compared with SM. Methods Patients with achalasia who underwent a laparoscopic Heller myotomy were identified from a prospective database that includes symptom evaluation and results of esophageal functional studies. From September 1994 to August 1998, the authors performed SM with Dor fundoplication, and from September 1998 through 2003, they performed EM with Toupet fundoplication. In 2001, they performed a telephone survey of all available patients. This was repeated in 2005 for the EM group. The survey included scales of symptom frequency (0 [never], 1 [once per month], 2 [once per week], 3 [once per day], 4 [more than once per day]) and severity (0 [no symptoms] to 10 [symptoms equal to preoperative state]) as well as the need to undergo postoperative intervention for dysphagia. Results For this study, 52 patients underwent SM with Dor fundoplication (median follow-up period, 46 ± 24 months), and 63 patients underwent EM with Toupet fundoplication (median follow-up period, 45 ± 17 months. Postoperative dysphagia severity was significantly better in the EM group (4.8 ± 2.3 vs 3.1 ± 2.6; p < 0.005). There was no significant difference in postoperative heartburn frequency, esophageal acid exposure, or lower esophageal sphincter pressure. In the SM group, 9 patients (17%) required reintervention for dysphagia: 14 endoscopic interventions for 5 patients (10%) and reoperation for 4 patients. Three patients (5%) in the EM group required reintervention for dysphagia: one endoscopic intervention each and no reoperations (p < 0.05). A total of 30 patients in the EM group were contacted in both 2001 (median follow-up period, 19 ± 11 months) and 2005 (median follow-up period, 63 ± 10 months). There was no significant change over time in dysphagia severity (2.6 ± 1.9 vs 3.7 ± 2.0; p = 0.19). Conclusions For the treatment of achalasia, EM with Toupet fundoplication provides excellent durable dysphagia relief that is superior to SM with Dor fundoplication.     

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

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

Laparoscopic antireflux surgery

Background: Concern has been raised about operating on patients with gastroesophageal reflux disease (GERD) and normal lower esophageal sphincter (LES) pressure for the fear that a fundoplication may fail to control reflux and result in a high rate of postoperative dysphagia. We hypothesized that fundoplication is effective in patients with GERD irrespective of the preoperative LES pressure, and that in patients with normal LES pressure, a total fundoplication does not result in a high incidence of dysphagia. Methods: We studied 280 unselected patients with GERD who underwent laparoscopic fundoplication. They were divided in three groups based on the preoperative LES pressure (normal, 14–24 mmHg): group A (LES pressure, 0–6 mmHg; 61 patients; 22%); group B (LES pressure, 7–13 mmHg; 178 patients; 64%); group C (LES pressure, ?14 mmHg; 41 patients; 14%). De novo dysphagia was defined as new onset of postoperative dysphagia lasting more than 10 weeks. The average follow-up period was 17 ± 22 months. Results: There was no difference in resolution of symptoms among the three groups. Heartburn and regurgitation resolved or improved respectively in 96% of group A, 90% of group B, and 91% of group C patients. In addition, there was no difference in the incidence of de novo dysphagia, which occurred in 8% of group A, 7% of group B, and 2% of group C. Conclusions: We conclude that fundoplication controlled GERD irrespective of preoperative LES pressure, and that a normal LES pressure before surgery was not associated with a higher rate of postoperative dysphagia.     

Surgical management of hypertensive lower esophageal sphincter with dysphagia or chest pain

Hypertensive lower esophageal sphincter (LES) is an uncommon manometric abnormality found in patients with dysphagia and chest pain, and is sometimes associated with gastroesophageal reflux disease (GERD). Preventing reflux by performing a fundoplication raises concerns about inducing or increasing dysphagia. The role of myotomy in isolated hypertensive LES is also unclear. The aim of this study was to determine the outcome of surgical therapy for isolated hypertensive LES and for hypertensive LES associated with GERD. Sixteen patients (5 males and 11 females), ranging in age from 39 to 89 years, with hypertensive LES (>26 mm Hg; i.e., >95th percentile of our control population) who had surgical therapy between 1996 and 1999 were reviewed. Patients with a diagnosis of achalasia and diffuse esophageal spasm were excluded. All patients had dysphagia or chest pain. Eight of 16 patients had symptoms of GERD, four had a type III hiatal hernia, and four had isolated hypertensive LES pain. Patients with hypertensive LES and GERD or type III hiatal hernia had a Nissen fundoplication, and those with isolated hypertensive LES had a myotomy of the LES with partial fundoplication. Outcome was assessed as follows: excellent if the patient was asymptomatic; good if symptoms were present but no treatment was required; fair if symptoms were present and required treatment; and poor if symptoms were unimproved or worsened. All patients were contacted by telephone for symptom assessment at a median of 3.6 years (range 3 to 6.1 years) after surgery. Patients with hypertensive LES and GERD or type III hiatal hernia had significantly lower LES pressure than those with isolated hypertensive LES (29.9 vs. 47.4 mm Hg; P = 0.013). Dysphagia and chest pain were relieved in all patients at long-term follow up. Outcome was excellent in 10 of 16, good in 3 of 16, and fair in 3 of 16. All patients but one were satisfied with their outcome. Patients with hypertensive LES are a heterogeneous group in regard to symptoms and etiology. Treatment of patients with hypertensive LES should be individualized. A Nissen fundoplication for hypertensive LES with GERD or type III hiatal hernia relieves dysphagia and chest pain suggesting reflux as an etiology. A myotomy with partial fundoplication for isolated hypertensive LES relieves dysphagia and chest pain suggesting a primary sphincter dysfunction. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 17–22, 2003.     

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.     

Long-term outcomes of Roux-en-Y gastric diversion after failed surgical fundoplication in a large cohort and a systematic review

BackgroundRoux-en-Y gastric diversion (RNYG) is an alternative approach for patients with persistent or recurrent gastroesophageal reflux disease (GERD) after surgical fundoplication, especially in patients with esophageal dysmotility or morbid obesity, because redo fundoplication could offer unfavorable outcomes.ObjectiveTo evaluate long-term outcomes of RNYG for failed fundoplication and its impact on esophageal function.SettingA retrospective cohort study and a systematic review.MethodsPatients who underwent RNYG after failed fundoplication between 1995 and 2019 were identified. Surgical-related complications, GERD, dysphagia, and endoscopic and esophageal manometric findings were reviewed. A literature search for relevant studies was performed from several databases from database inception to September 2019.ResultsA total of 101 patients (mean age, 52.1 yr; 86.1% female; mean body mass index, 35.8 kg/m²) were included. Overall complication rates within and more than 30 days after surgery were 36.3% and 53.5%. GERD symptoms were resolved in 70.1% after RNYG. However, 39.7% had a recurrence during a median follow-up of 56.2 months. In patients with no baseline dysphagia (n = 36), 16 (44%) developed new-onset dysphagia after surgery. In patients with severe baseline dysphagia (n = 9), 5 patients (56%) had persistent dysphagia after surgery. Seven studies involving 381 patients were included in our systematic review. High rates of GERD improvement have been reported across studies; however, long-term GERD, dysphagia, and objective outcomes were infrequently reported.ConclusionRNYG is an effective alternative surgery in a subset of patients with intractable symptoms who failed fundoplication. However, patients should be informed of the risks of postoperative GERD symptoms and dysphagia. Referral for a careful evaluation by a multidisciplinary foregut team is warranted.     

Effect of partial and total laparoscopic fundoplication on esophageal body motility

Background Abnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis. Methods The pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14). Results The LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B. Conclusions Laparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients. Presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, Texas, 27–29 April 2006     

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.     

Persistent dysphagia after laparoscopic vagotomy

BACKGROUND: Laparoscopic vagotomy represents a new and less invasive treatment for peptic ulcer disease, but the problem of postvagotomy dysphagia has not been solved. The aim of this study was to determine the etiologic factors related to long-term laparoscopic postvagotomy dysphagia. METHODS: Two female and 11 male patients with a mean age of 48.5 years who underwent laparoscopic vagotomy were investigated retrospectively. Preoperative diagnosis included duodenal ulcer resistant to medical treatment, gastric hypersecretion, gastric outlet obstruction, cholelithiasis, and gastroesophageal reflux disease (GERD). Ten patients underwent laparoscopic highly selective vagotomy, and three patients had laparoscopic truncal vagotomy with gastrojejunostomy or pyloroplasty. Nine of these patients had a Nissen fundoplication in conjunction with the vagotomy. RESULTS: The median long-term follow-up period was 47 months. Two patients complained of severe dysphagia, one of moderate dysphagia, and two of mild dysphagia. Neither type of vagotomy nor an additional fundoplication was correlated with the severity of postoperative long-term dysphagia. Severity of postoperative dysphagia was associated with severity of preoperative dysphagia (r = 0.752, p = 0.003) but not with heartburn (r = 0.358, p = 0.531) or regurgitation (r = 0.024, p = 0.938). The cause of preoperative dysphagia varied; however, all of these patients had GERD and consequent esophageal lesions. CONCLUSION: Preexisting dysphagia appears to play an integral role in persistent postoperative dysphagia. Care must be taken to construct a loose fundoplication in patients with dysphagia.