Outcome after laparoscopic fundoplication is not dependent on a structurally defective lower esophageal sphincter |
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Authors: | Manfred P Ritter MD Jeffrey H Peters MD Tom R DeMeester MD Peter F Crookes MD Rodney J Mason MD Lydia Green Lemeneh Tefera Cedric G Bremner MD |
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Institution: | (1) Department of Surgery, University of Southern California School of Medicine, 1510 San Pablo St., Ste. 514, 90033-4612 Los Angeles, CA |
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Abstract: | With the advent of laparoscopic surgery and the recognition that gastroesophageal reflux disease often requires lifelong medication,
patients with normal resting sphincter characteristics are now being considered for surgery. The outcome of these patients
after fundoplication is unknown and formed the basis of this study. The study population consisted of 123 patients undergoing
laparoscopic Nissen fundoplication between 1992 and 1996. All patients had increased esophageal acid exposure on 24-hour esophageal
pH monitoring. Patients were divided into those with a normal (n = 36) and those with a structurally defective (n = 87) lower
esophageal sphincter (LES), based on LES resting pressure (normal >6 mm Hg), overall length (normal >2 cm), and abdominal
length (normal > 1 cm), and their outcomes were assessed. Each group was subsequently divided into patients presenting with
a primary symptom that was "typical" (heartburn, regurgitation, or dysphagia) or "atypical" (gastric, respiratory, or chest
pain) of gastroesophageal reflux, and outcome was assessed. Median duration of follow-up was 18 months after surgery. Overall,
laparoscopic fundoplication was successful in relieving symptoms of gastroesophageal reflux in 90% of patients. Patients with
a typical primary symptom had an excellent outcome irrespective of the resting status of the LES (95% and 97%, respectively).
Atypical primary symptoms were significantly more common in patients with a normal LES (29%) than in those with a structurally
defective LES (10%; P <0.05), and these symptoms were less likely (50%) to be relieved by antireflux surgery. Laparoscopic
antireflux surgery is highly successful and not dependent on the status of the resting LES in patients with increased esophageal
acid exposure and primary symptoms "typical" of gastroesophageal reflux. Antireflux surgery should be applied cautiously in
patients with atypical primary symptoms.
Presented in part at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C.,
May 11–14,1997. |
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Keywords: | Gastroesophageal reflux lower esophageal sphincter laparoscopy Nissen fundoplication outcome |
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