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.     

腹腔镜高选择性迷走神经切断术联合Nissen胃底折叠术:效果如何?——腹腔镜Nissen迷走神经切断术治疗胃食管返流

背景：Nissen胃底折叠术（Nissen fundoplication，NF）已不是治疗胃食管返流性疾病（gastroesophageal reflux disease，GERD）的唯一、有效的方法。对于能降低胃酸的手术方式来讲，如高选择性迷走神经切断术（highly selective vagotomy，HSV），也不仅仅是一种辅助治疗方法。对高选择性迷走神经切断术联合Nissen胃底折叠术（Nissen fundoplication with highly selective vagotomy，NFHSV）治疗GERD的作用目前尚无完整的评价。方法：2003年6月～2005年6月8例女性病人接受NFHSV，8例均有6个月GERD病史，经药物治疗症状无缓解，有餐前痛、消化性溃疡或严重的胃炎。平均随访时间12个月，术前、术后进行烧心严重程度评分测定（heart burn severity score，HSS）。结果：平均手术时间110min，无手术并发症。1例术后须用质子泵抑制剂，术后经戒烟5个月后停药。8例术后症状和烧心严重程度评分测定有明显改善。结论：NFHSV是有效的联合手术方式，尚需要进一步的研究证实这一联合术式的完全有效性和安全性。     

An inexpensive ex-vivo porcine laparoscopic Nissen fundoplication training model.

BACKGROUND: We recently implemented the use of an ex-vivo porcine model to teach residents the fundamentals of performing a laparoscopic Nissen fundoplication. METHODS: Residents were trained using intact porcine esophagus, stomach, and spleen placed in a standard video-trainer. They were later asked to complete a survey containing a course evaluation. RESULTS: Sixteen residents (R1-R4) completed the survey. They agreed that (1) the exercise was a valuable use of their limited time, (2) repeating the exercise will be of additional benefit, (3) it will improve their ability to perform or assist in an actual case in the OR, and (4) the surgical principles learned using the model will transfer to other laparoscopic cases. Significant subjective improvements were reported in resident comfort level in assisting in or performing a laparoscopic Nissen fundoplication. CONCLUSIONS: The use of an inexpensive ex-vivo porcine training model increases resident comfort level in performing a Nissen fundoplication in the operating room.     

The Durability of Laparoscopic Nissen Fundoplication: 11-Year Outcomes

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure since its introduction in 1991. There are few studies with greater than 5-year outcomes. Herein we report a series of 312 consecutive patients who underwent primary LNF before 1996. Follow-up of more than 6 years was available in 166 patients, and the mean follow-up was 11 years (median 11.1 years, range 6.1–13.3 years). Prospective data collection included preoperative and current symptom scores (scale 0 = none to 3 = severe), as well as the level of patient satisfaction and use of antireflux medications. Total symptom score for each patient was summed from seven symptoms for a maximum value of 21. Heartburn and regurgitation were the most improved symptoms; however, all symptoms were significantly improved (P < 0.01). The total symptom score at follow-up was 2.6 down from 7.5 at baseline, with a mean difference of −4.9 (range −12 to 3). The percentage of patients stating they would have the procedure again was 93.3%, and 70% were off daily antireflux medications. Outcomes at a mean of 11 years after LNF are excellent, and the majority of patients had their symptoms resolved or significantly improved and are satisfied with their results. Presented at the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 22, 2006, Los Angeles, CA     

Heller''s esophagomyotomy with or without a 360° floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study

Heller's esophagomyotomy relieves dysphagia but does not restore esophageal peristalsis. The myotomy may induce reflux and the addition of a 360 degrees fundoplication may be hazardous with regard to the remaining aperistaltic esophagus. The aim of this prospectively randomized clinical trial was to compare the outcome for patients with uncomplicated achalasia who underwent an anterior Heller's esophagomyotomy (H group) with or without an additional floppy Nissen fundoplication (H + N group). Between 1984 and 1995, 20 patients were prospectively randomized to one or other of the performed operations, 10 patients per group. Esophagitis including Barrett's esophagus (n = 2) was seen under medical treatment, in 6 of 9 in the H group but none in the H + N group. No patient in the H + N group required postoperative continuous acid-reducing drugs. Twenty-four-hour esophageal pH-studies in median 3.4 years after surgery showed pathological reflux expressed as a percentage of time below pH 4 of 13.1% in the H group compared to 0.15% (P < 0.001) in H + N group. One patient with recurrent dysphagia in the H + N group later had an esophagectomy. The remaining patients reported significant improvement of dysphagia without symptoms of reflux at 8.0 years follow-up. Heller's esophagomyotomy eliminates dysphagia, but can induce advanced reflux that requires medical treatment. The addition of a 360 degrees fundoplication eliminates reflux without adding dysphagia in the majority of patients and can be recommended for most patients with uncomplicated achalasia.     

Comparison of laparoscopic Toupet and laparoscopic Nissen fundoplications in neurologically normal children

Introduction

We compared laparoscopic Toupet fundoplication (LTF) and laparoscopic Nissen fundoplication (LNF) in neurologically normal children.

Methods

Forty neurologically normal children who were followed up for more than 3 years after LTF (n = 22) or LNF (n = 18) were reviewed retrospectively. LTF and LNF were performed between 2006 and 2012.

Results

There were no significant differences in gender (LTF, 15 male and 7 female patients; LNF:, 12 male and 6 female patients), mean age at surgery (LTF vs LNF: 2.5 vs 2.3 years), mean weight at surgery (LTF vs LNF: 9.6 vs 8.9 kg), preoperative symptoms, preoperative pH monitoring (pH <4) (LTF vs LNF: 26.7% vs 21.8%), mean operative time (LTF vs LNF: 117 vs 126 min), postoperative recommencement of enteral feeding (LTF vs LNF: 3.7 vs 3.8 days), or duration of hospitalization (LTF vs LNF: 5.5 vs 6.3 days). Intraoperative complications were esophageal trauma (LTF; n = 1; 4.5%) and liver trauma (LNF; n = 1; 5.6%) (P = 0.70). Post‐LTF complications were wrap stenosis (n = 1; 4.5%), and post‐LNF complications were wrap stenosis (n = 1; 5.5%) and gastric outlet obstruction (n = 1; 5.5%) (P = 0.43); all were managed conservatively. No case required conversion to open repair. There was no recurrence after LTF, but there were three cases (16.7%) after LNF (P = 0.08). Reoperation was performed at 4, 11, and 13 months, respectively.

Conclusion

Despite LTF and LNF appearing to be equally effective, three LNF cases required reoperation.     

腹腔镜Nissen胃底折叠术治疗胃食管反流病

目的 探讨腹腔镜Nissen胃底折叠术治疗胃食管反流病的效果.方法 对近2年来收治的109例胃食管反流病实施腹腔镜Nissen胃底折叠术患者的临床资料进行回顾性分析.结果 108例成功完成手术.1例因难以控制的脾上极胃短血管出血而中转开腹.手术用时30-245(平均68.1)min,术中出血5～450(平均30.0)mL;术后住院天数2～8(平均4.2)天.术后102例获3～27个月的随访,7例失访.随访患者中99例(97.1%)反酸、烧心等消化道症状基本消失,2例(2.0%)明显缓解,1例(0.9%)无效.术后2例出现较严重的吞咽困难,1例严重上腹胀气,2例腹泻,1例出现术后食管裂孔疝.结论 腹腔镜Nissen胃底折叠术是治疗胃食管反流病的一种微创、安全、有效的治疗方法.     

The anomalous splenic vein: a case report and review of the literature

The spleen arises from a mesenchymal bulge at the 6-mm stage of development. There are a wide variety of splenic anomalies and variations that range from benign to clinically significant, and this article presents a brief review of splenic embryology and a case report of an anomalous splenic vein that precluded the formation of a Nissen fundoplication.     

Management of congenital distal esophageal stenosis with combined Collis gastroplasty-Nissen fundoplication

Surgical resection for the treatment of congenital distal esophageal stenosis due to tracheobronchial remnants is sometimes complicated by esophageal shortening and gastroesophageal reflux. We propose the combined operation of Collis gastroplasty and Nissen fundoplication to prevent these complications. It can be safely performed through an abdominal approach.