Quality of life before and after laparoscopic Nissen fundoplication

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder in the Western world. The acute disease can usually be managed by medical therapy. To prevent relapse, many patients require lifelong medication. In these patients, laparoscopic antireflux surgery offers a good alternative. The aim of this study was to evaluate the postoperative results and compare pre- and postoperative quality of life after laparoscopic Nissen fundoplication. METHODS: Clinical investigations, including esophageal manometry, pH monitoring, and endoscopy, and a previously validated Quality of Life Index, were performed before and a median of 41 month after antireflux surgery in 75 patients. RESULTS: After laparoscopic Nissen fundoplication, the percentage of total time with pH <4 decreased from 10.4% to 3.2% on 24-h pH monitoring. The mean pressure of the lower esophageal sphincter improved from 8.1 to 12.3 mmHg. Esophagitis healed in 63 of 66 patients in whom it was present prior to surgery. The overall Quality of Life Index improved significantly from 86 +/- 16 to 116 +/- 16. CONCLUSION: Laparoscopic fundoplication provides effective and durable relief of reflux in patients with GERD. The Quality of Life Index showed significant improvement after surgery.     

Measuring improved quality of life after laparoscopic Nissen fundoplication

BACKGROUND: While the correction of pathologic gastroesophageal reflux by means of laparoscopic Nissen fundoplication (LNF) has been well documented, the psychological profiles of patients with this disease and the impact on their quality of life are less well understood. We obtained a baseline psychological profile and measured the impact of LNF on patients' quality of life with 2 standardized instruments: the psychological general well-being index (PGWB) and the gastrointestinal symptoms rating scale (GSRS). The study included 34 consecutive patients with typical symptoms of gastroesophageal reflux who underwent LNF in 1995 at a tertiary care university medical center. METHODS: Patients filled out PGWB and GSRS surveys preoperatively and at 2 weeks, 2 months, and 12 months postoperatively. Data were collected in a blinded fashion by a study nurse and analyzed after completion of the study. Data are expressed as mean +/- standard deviation. RESULTS: The mean preoperative PGWB score (69.6 +/- 17.3) of study patients with gastroesophageal reflux disease was lower than that expected for a healthy population. This was primarily attributable to low scores in the general health domain of the questionnaire, although LNF patients also had low scores in the vitality and positive well-being domains of the PGWB scale. LNF improved the PGWB score to a normal level (78.7 +/- 19.3) (P = .05 vs the preoperative PGWB score) at 12 months post surgery. The GSRS also showed improvement from 34.7 +/- 7.8 to 28.1 +/- 10 (P = .008). The improvement in GSRS was attributed to improvement in the heartburn (7.12 +/- 2.4 to 2.72 +/- 1.2, P < .001) and abdominal pain (6.58 +/- 2.5 to 4.92 +/- 1.6, P = .006) domains of the scale. LNF had no impact on the diarrhea, indigestion, and obstipation domains of the GSRS. CONCLUSIONS: Patients with gastroesophageal reflux disease who are candidates for LNF have low psychological and general well-being scores that are restored to normal levels by successful LNF. When compared with baseline measurements, LNF effectively relieved heartburn and did not cause significant new gastrointestinal complaints.     

Dysphagia after laparoscopic Nissen fundoplication

The aim of the study was to consider all the factors associated with the development of postoperative dysphagia which, in its transitory form, can be present in as many as 40 to 70% of cases. From 1996 to 2007, 302 Nissen fundoplications were performed at our department of surgery. We divided this series into two groups, the first consisting of 149 cases (from March 1996 to March 2004) where short gastric vessels were not dissected (nl-VGB) and the second of 153 cases (from April 2004 to December 2007) where short gastric vessels were dissected (I-VGB).The incidence of postoperative dysphagia was distinctly lower in I-VGB than in nl-VGB (4.5% vs 19.5%). One month after operation, the incidence of postoperative dysphagia in I-VGB and nl-VGB was 12% and 1,5%, respectively, while 3 months after surgery the percentages were 2% and 0.5%. Exclusion of cases performed during the learning curve period yielded similar results. At postoperative examinations we noticed a substantial reduction in gastro-oesophageal reflux disease symptoms in both groups, with no significant difference between the two. L-VGB patients appeared clearly more satisfied after operation than nl-VGB patients (97% vs 88%), even if the results were similar after 3 months. Our experience confirms the good results obtained with Nissen fundoplication with a distinct, rapid reduction in postoperative dysphagia.     

Gastric ulceration after Nissen fundoplication

Thirteen patients developed gastric ulcers between 6 months and 8.5 years after Nissen fundoplication. Eight patients presented with epigastric pain alone, 3 with bleeding alone and 2 with both pain and bleeding. Nine ulcers (69 per cent) were high on the lesser curve, close to the fundoplication and 7 of these patients had recurrent hernias. Anatomical distortion produced by fundoplication is probably the most important aetiological factor, though gastric distention, bile reflux gastritis and ischaemia may be contributory.     

Quality of life,surgical outcome,and patient satisfaction three years after laparoscopic Nissen fundoplication

Quality of life data and patient satisfaction are important issues in estimating the outcome of laparoscopic antireflux surgery (LARS). Long-term of quality of life assessment has not yet received wide attention. The aim of this prospective study was to evaluate surgical outcome, including quality of life and patient satisfaction, after laparoscopic "floppy" Nissen fundoplication up to 3 years after surgery. Between 1994 and 1996, a total of 150 consecutive patients with severe gastroesophageal reflux disease underwent laparoscopic "floppy" Nissen fundoplication. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). The GIQLI questionnaire was given to the patients prior to surgery, and again 3 months, 1 year, and 3 years postoperatively. In addition, 24-hour pH monitoring and esophageal manometry were performed preoperatively and at each follow-up date. Finally, surgical side-effects and patient satisfaction with the surgical outcome were evaluated 3 years after LARS. Postoperatively lower esophageal sphincter pressure improved significantly in all patients, whereas pH values showed normal data in all but 5 patients. Before surgery, all patients had a poor quality of life (GIQLI score, 90.1 ± 8.9 points). Postoperatively, GIQLI improved significantly (p <.01) and remained stable for at least 3 years, with a mean value of 123.7 ± 9.8 points. This is comparable to 122.6 ± 8.5 points of healthy individuals. Ninety-eight percent of the patients rated their satisfaction with surgical treatment as excellent or good and would undergo surgery again if necessary. Nine patients suffered from minimal surgical side-effects, but these did not significantly impair their quality of life. Laparoscopic reoperation was performed in 2 patients 3 months after initial surgery because of severe dysphagia. Both patients were free of symptoms 3 years after surgery. The efficacy and long-term outcome of treatment of gastroesophageal reflux disease with laparoscopic "floppy" Nissen fundoplication can be evaluated by objective testing, but also with subjective judgment of the patient, including quality of life assessment.     

Significant weight loss after laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication (LNF) has evolved as a gold standard in antireflux surgery. However, the association between body weight and gastroesophageal reflux disease (GERD) is still unclear, and no data are available concerning the effect of fundoplication on body weight. We present the first report elucidating the impact of LNF on body weight in GERD patients with special emphasis on patients quality of life.Methods From July 2000 to March 2003, LNF was carried out in 213 patients (85 women and 128 men) after thorough preoperative examination including clinical interview with standardized assessment of symptoms and quality of life (QoL), endosocopy, barium swallow, 24-h pH-metry, and manometry. Follow-up investigations were performed 3 and 12 months after LNF obtainable from 209 patients (98.1%) and 154 patients (72.3%), respectively.Results The mean body mass index (BMI) decreased significantly after LNF (27.6 ± 5.6 kg/m² before LNF vs 26.0 ± 3.8 kg/m² after LNF, p < 0.001). Twelve months after LNF, neither a tendency toward a renewed increase nor a further decrease in BMI was observable. The average body weight loss was 3.9 kg. BMI reduction was higher in women than in men (p < 0.002), and obese patients lost more weight than lean patients (p < 0.001). There was no association between BMI reduction and dysphagia. Plasma cholesterol and triglyceride levels did not change after LNF. The mean general score of the Gastrointestinal Quality of Life Index markedly improved (90.1 ± 21.3 before LNF vs 118.0 ± 16.2 after LNF, p < 0.01), as did the GERD-Health Related Quality of Life Index (21.9 ± 6.4 before LNF vs 3.5 ± 2.7 after LNF, p < 0.001). However, there was no association between changes in BMI and QoL.Conclusion LNF leads to significant and persistent body weight loss.     

Laparoscopic Nissen fundoplication after failed endoscopic gastroplication

Endoscopic techniques to treat gastroesophageal reflux have been developed and approved by the U.S. Food and Drug Administration. One of these techniques is endoscopic gastroplication with the Bard Endocinch device. Although the technique is initially effective, long-term symptom control has not yet been proved. No reports have documented the feasibility of laparoscopic fundoplication after failed endoscopic gastroplication. We report our experience. Ten patients who underwent endoscopic gastroplication subsequently had recurrent symptoms and were referred for laparoscopic antireflux surgery. Eight had typical symptoms of gastroesophageal reflux disease (GERD), whereas two had atypical symptoms. All patients had documented pathologic reflux by 24-hour pH monitoring. Preoperatively, all patients completed the GERD health-related quality of life (HRQL) symptom severity questionnaire. Nine of the 10 operations were completed laparoscopically. The one conversion was carried out because of excessive fat in the hiatal region. No patients had scarring of the esophagus or hiatal region. All patients with typical symptoms improved (decrease in total GERD-HRQL median score from 27 to 4), whereas none of the patients with atypical symptoms did. Six patients had persistent dysphagia for longer than 1 month; two required esophageal dilation. Laparoscopic Nissen fundoplication is feasible after failed endoscopic gastroplication. Symptomatic improvement is similar to that with the de novo operation. However, in some patients, dysphagia may persist longer.     

Postprandial bloating after laparoscopic Nissen fundoplication.

OBJECTIVE: To evaluate the prevalence and possible contributing factors to postprandial bloating in patients having chronic gastroesophageal reflux disease (GERD) before and after laparoscopic Nissen fundoplication. DESIGN: A prospective cohort study. SETTING: A tertiary care teaching hospital. PATIENTS: Five hundred and seventy-eight patients with proven GERD. INTERVENTION: Laparoscopic Nissen fundoplication. OUTCOME MEASURES: Symptom severity scores for postprandial bloating and dysphagia, esophageal motility and 24-hour pH measurement before and at 6 months, 2 years and 5 years after laparoscopic Nissen fundoplication. RESULTS: Of the 598 patients, 436 (73%) reported some postprandial bloating before the procedure. The symptom score for bloating significantly improved after surgery (p < 0.0001). There were no significant differences in the lower esophageal sphincter basal pressures or 24-hour pH scores between those who reported improvement or worsening of their postprandial bloating. At 6 months after surgery, 54% of patients experienced postprandial bloating; of these, 49% reported improvement, 21% reported worsening and 30% reported no change in bloating symptoms compared with the preoperative state. Of the patients who reported worsening of postprandial bloating 6 months after surgery, 86 were reassessed 2 years after surgery and 71% reported improvement of this symptom over this time interval. CONCLUSIONS: Bloating is a common symptom in patients who suffer from chronic GERD. Laparoscopic Nissen fundoplication lessens the severity of this symptom in most patients. In a small subgroup of patients, antireflux surgery may exacerbate the bloating, but this improves over time.     

Recurrence after laparoscopic and open Nissen fundoplication

Background: Laparoscopic Nissen fundoplication as treatment for gastroesophageal reflux disease (GERD) in adults has a reported recurrence rate of 2–17%. We investigated the rates and mechanisms of failure after laparoscopic Nissen fundoplication in children. Methods: All patients who underwent a laparoscopic Nissen fundoplication for GERD and who subsequently required a redo Nissen were reviewed (n = 15). The control group consisted of the most recent 15 patients who developed recurrent GER after an open Nissen, fundoplication. Results: Between 1994 and 2000, laparoscopic Nissen fundoplication was performed in 179 patients. Fifteen patients (8.7%) underwent revision. The mechanisms of failure were herniation in four patients, wrap dehiscence in four, a too-short wrap in three, a loosened wrap in two, and other reasons in two. The reoperation was performed laparoscopically in five patients (33%). The failure mechanisms were different in the open patients: eight were due to slipped wraps; three to dehiscences; and two to herniations. Conclusion: The failure rate after laparoscopic Nissen is acceptably low. A redo laparoscopic Nissen can be performed safely after an initial laparoscopic approach.     

Quality of life before and after laparoscopic fundoplication

BACKGROUND: Laparoscopic fundoplication is a well-established surgical option for the treatment of gastroesophageal reflux disease. The aim of this study was to assess the surgical outcomes from the patient's point of view by using a validated quality of life instrument. METHODS: Fifty patients have been prospectively included. All patients underwent a standardized 270-degree posterior fundoplication. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36-item-questionnaire. The patients received the questionnaire before surgery, and 3 months and 1 year after surgery. RESULTS: Preoperative score was 95.6+/-21 points. The score increased significantly (P <0.0005) at 3 months (103.6+/-16) and 1 year (111.4+/-22) after surgery. This improvement concerned the four domains of the questionnaire (symptoms, social functioning, physical status, and emotions). The score in patients at 1 year remained, however, significantly lower than that in healthy persons (126+/-18). CONCLUSIONS: GIQLI is a sensitive tool to assess surgical outcomes after fundoplication. The quality of life after surgery did not reach the level of healthy population, not because of failure of surgery to treat GERD but probably because of functional dyspepsia that was present prior to surgery and did not change after 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     

Laparoscopic Nissen fundoplication

Passing the stomach behind the esophagus during laparoscopic Nissen fundoplication is a common source of frustration for the laparoscopic surgeon. It often leads to an incorrect formation of the fundoplication, resulting in a wrapping or twisting of the fundus around the distal esophagus. The correct technique should result in the distal esophagus being enveloped inside the fundus without distorting the orientation of the greater curve. We have developed an easy, precise, and reproducible technique to perform this maneuver. The steps for performance of this maneuver are described. Received: 12 March 1999/Accepted: 24 September 1999     

Gastric volvulus after laparoscopic Nissen fundoplication with gastrostomy

The authors present the case report of a 13-year-old boy in whom organoaxial gastric volvulus developed four months after a laparoscopic Nissen fundoplication and placement of gastrostomy. Intraoperative findings were significant for volvulus about an axis defined by 2 fixation points, one at the fundoplication site and the other in the area of the gastrostomy tube, positioned close to the pylorus. Of the 142 pediatric cases of gastric volvulus reported to date, only 7 describe it as a complication subsequent to gastric surgery, and just one case has been reported after laparoscopic Nissen fundoplication. This case shows that fundoplication and gastrostomy, a recommended treatment for gastric volvulus, does not always preclude its development. Increasing numbers of pediatric surgeons are performing laparoscopic Nissen fundoplication procedures. The authors advise surgeons to consider this potentially fatal complication, both intraoperatively when selecting a location for gastrostomy and postoperatively when evaluating complaints.     

Laparoscopic management of chyle leak after Nissen fundoplication

A 41-year-old man presented with chylous ascites 6 weeks after a laparoscopic Nissen fundoplication. The chyle leak was successfully treated with laparoscopic ligation of the leaking duct at the right crus. We would now recommend early consideration of this as a treatment option for this rare complication.     

Complications and reoperation after Nissen fundoplication in childhood

Over a 10 year period, 429 Nissen fundoplications were performed on children with gastroesophageal reflux. Postoperative complications occurred in 69 children (16 percent), including wrap herniation or breakdown in 29; postoperative bowel obstruction in 18; stricture in 10; intraabdominal abscess and enterocutaneous fistula in 3 patients each; and wound infection, wound dehiscence, and inadvertent splenectomy in 2 patients each. The postoperative mortality rate was 0.9 percent (4 of 429 patients) and was related to sepsis in 1 patient, a metabolic disorder in 1 patient, and underlying pulmonary disease in 2 patients. All four patients were neurologically impaired. Fundoplication successfully controlled symptoms of gastroesophageal reflux in 395 children (92 percent) over a follow-up period ranging from 6 months to 10 years. Thirty-eight patients (8.8 percent) required a second antireflux operation because of recurrent symptoms. Twenty-nine patients had severe neurologic impairment (76 percent), 5 had associated congenital malformations (13 percent), and 3 had significant pulmonary problems (8 percent). Only one child requiring reoperation was considered otherwise normal. Indications for reoperation included wrap breakdown or herniation (28 patients), stricture (6 patients), and inadequate wrap (4 patients). Twenty-four of 28 children with wrap herniation or breakdown had neurologic impairment. A second fundoplication was successful in 35 of 38 patients (92 percent). A second procedure failed in three children, who required subsequent resection and colon interposition.     

Postoperative gastrointestinal complaints after laparoscopic Nissen fundoplication.

OBJECTIVES: Approximately 80% of patients complain of various symptoms immediately after laparoscopic Nissen fundoplication. These symptoms typically are treated medically without an extensive evaluation to identify the cause. We reviewed our experience of laparoscopic Nissen fundoplication to determine the course of postoperative symptomatology in our patient population, and present a rational approach to this problem. METHODS: Over a 10-year period, 628 patients underwent primary laparoscopic Nissen fundoplication for gastroesophageal reflux disease; patients were evaluated with a standard set of questions for postoperative gastrointestinal complaints. Three- and 6-month follow-up data were compared by using the chi square test. RESULTS: One-year follow-up data were available for 615 patients (98%). All of these patients had symptoms during the first 3 postoperative months. Early satiety (88%), bloating/flatulence (64%), and dysphagia (34%) were the most common; however, 94% of patients had resolution of their symptoms by the 1-year follow-up visit, and most had resolved after 3 months. Patients with persistent reflux or dysphagia after 3 months typically had an anatomic failure of the operation. CONCLUSIONS: Most patients who have undergone laparoscopic Nissen fundoplication for gastroesophageal reflux disease will have gastrointestinal complaints during the initial 3 postoperative months. Nearly all of these patients will have resolved their symptomatology after 3 months. Those with persistent symptoms after 3 months warrant evaluation for operative failure.