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De Ponthaud C, Voron T, Paye F. Laparoscopic floppy Nissen fundoplication with valve calibration: a safe and efficient procedure. Surg Today 2024:10.1007/s00595-024-02817-x. [PMID: 38589734 DOI: 10.1007/s00595-024-02817-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/14/2024] [Indexed: 04/10/2024]
Abstract
PURPOSES A floppy Nissen fundoplication with valve calibration (FNF-VC) performed by laparotomy has been described, to reduce postoperative dysphagia and gas bloating after 360°-fundoplication. As laparoscopy is the gold standard for fundoplication, this study reports the first results of a modified FNF-VC adapted for laparoscopy (LFNF). METHODS Seventy-two consecutive patients, who underwent LFNF for refractory GERD between 2012 and 2021, were included. Postoperative outcomes and quality of life (QoL) by GERSS, GERD-HRQL, and GIQLI scores before and after surgery were assessed. RESULTS The main symptoms were pyrosis (81%), regurgitation (39%), Ear-Nose-Throat symptoms (22%), and thoracic pain (24%). Hiatal hernia was present in 85% (n = 61) of the patients. There was no postoperative mortality, and the severe postoperative morbidity rate (Dindo-Clavien ≥ III) was 6%. After a median follow-up of 3.6 years, only 8% of patients were still taking proton-pump inhibitors. Long-term residual dysphagia was noted in 15% of the patients, but none required reoperation or interventional endoscopic procedures. QoL improved, with a significant reduction in GERSS and GERD-HRQL scores and a postoperative GIQLI of 101.75 (75-117.5). CONCLUSION This series reports the safety and efficacy of an FNF-VC adapted for laparoscopy to treat GERD with a limited rate of residual dysphagia.
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Affiliation(s)
- Charles De Ponthaud
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France
- Sorbonne University, Paris, France
| | - Thibault Voron
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France
- Sorbonne University, Paris, France
| | - François Paye
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Hôpital Saint Antoine, Assistance Publique Hôpitaux de Paris, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France.
- Sorbonne University, Paris, France.
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2
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Mohr C, Ciomperlik H, Dhanani N, Olavarria OA, Hannon C, Hope W, Roth S, Liang MK, Holihan JL. Review of SAGES GERD guidelines and recommendations. Surg Endosc 2022; 36:9345-9354. [PMID: 35414134 DOI: 10.1007/s00464-022-09209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed evidence-based guidelines for the management of patients with gastroesophageal reflux disease (GERD). The aim of this study is to evaluate guidelines lacking agreement among experts (grades B-D) or lacking support from randomized controlled trials (levels II-III). METHODS Six guidelines were chosen for evaluation. A retrospective review of a multicenter database of patients undergoing fundoplication surgery for treatment of GERD between 2015 and 2020 was performed. Patients that underwent a concurrent gastrectomy or were diagnosed with pre-operative achalasia were excluded. Demographics, pre-operative, intra-operative, and post-operative variables were collected. Post-operative outcomes were evaluated based on selected SAGES guidelines. Outcomes were assessed using multivariable regression or stratified analysis for each guideline. RESULTS A total of 444 patients from four institutions underwent surgery for the management of GERD with a median (interquartile range) follow-up of 16 (13) months. Guidelines supported by our data were (1) robotic repair has similar short-term outcomes to laparoscopic repair, (2) outcomes in older patients are similar to outcomes of younger patients undergoing antireflux surgery, and (3) following laparoscopic antireflux surgery, dysphagia has been reported to significantly improve from pre-operative values. Guidelines that were not supported were (1) mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation, (2) a bougie has been found to be effective, and (3) the long-term effectiveness of fundoplication in obese individuals (BMI > 30) has been questioned due to higher failure rates. CONCLUSION Many SAGES GERD guidelines not receiving Grade A or Level I recommendation are supported by large, multicenter database findings. However, further studies at low risk for bias are needed to further refine these guidelines.
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Affiliation(s)
- Cassandra Mohr
- Department of Surgery, McGovern Medical School, Houston, TX, USA.
- Department of Surgery, Lyndon B. Johnson Hospital, 5656 Kelley St, Houston, TX, 77026, USA.
| | | | - Naila Dhanani
- Department of Surgery, McGovern Medical School, Houston, TX, USA
| | | | - Craig Hannon
- Department of Surgery, McGovern Medical School, Houston, TX, USA
| | - William Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Scott Roth
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Mike K Liang
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, TX, USA
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School, Houston, TX, USA
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3
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Greenberg JA, Stefanova DI, Reyes FV, Edelmuth RCL, Harik L, Thiesmeyer JW, Egan CE, Palacardo F, Liu M, Christos P, Schnoll-Sussman FH, Katz PO, Finnerty BM, Fahey TJ, Zarnegar R. Evaluation of post-operative dysphagia following anti-reflux surgery. Surg Endosc 2022; 36:5456-5466. [PMID: 34981222 DOI: 10.1007/s00464-021-08888-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/16/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anti-reflux surgery (ARS) has known long-term complications, including dysphagia, bloat, and flatulence, among others. The factors affecting the development of post-operative dysphagia are poorly understood. We investigated the correlation of intra-operative esophagogastric junction (EGJ) characteristics and procedure type with post-operative dysphagia following ARS. METHODS Robotic ARS was performed on 197 consecutive patients with pathologic reflux utilizing EndoFLIP™ technology. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and high-pressure zone (HPZ) length were collected. Dysphagia was assessed pre-operatively and at 3 months post-operatively. RESULTS The median pre-operative DI for all procedures was 2.6 (IQR 1.6-4.5) mm2/mmHg. There was no difference in post-operative DI between procedures [Hill: 0.9 (IQR 0.7-1.1) mm2/mmHg, Nissen: 1.0 (IQR 0.7-1.4) mm2/mmHg, Toupet: 1.2 (IQR 0.8-1.5) mm2/mmHg, Linx: 1.0 (IQR 0.7-1.2) mm2/mmHg, p = 0.24], whereas post-operative HPZ length differed by augmentation type [Hill: 3 (IQR 2.8-3) cm, Nissen: 3.5 (IQR 3-3.5) cm, Toupet: 3 (IQR 2.5-3.5) cm, Linx: 2.5 (IQR 2.5-3) cm, p = 0.032]. Eighty-nine patients (45.2%) had pre-operative dysphagia. Thirty-two patients (27.6%) reported any dysphagia at their 3-month post-operative visit and 12 (10.3%) developed new or worsening post-operative dysphagia [Hill: 2/18 (11.1%), Nissen: 2/35 (5.7%), Toupet: 4/54 (7.4%), Linx: 4/9 (44.4%), p = 0.006]. The median pre-operative and post-operative DI of patients who developed new or worsening dysphagia was 2.0 (IQR 0.9-3.8) mm2/mmHg and 1.2 (IQR 1.0-1.8) mm2/mmHg, respectively, and that of those who did not was 2.5 (IQR 1.6-4.0) mm2/mmHg and 1.0 (IQR 0.7-1.4) mm2/mmHg (p = 0.21 and 0.16, respectively). CONCLUSIONS Post-operative DI was similar between procedures, and there was no correlation with new or worsening post-operative dysphagia. Linx placement was associated with higher rates of new or worsening post-operative dysphagia despite a shorter post-procedure HPZ length and similar post-operative DI when compared to other methods of LES augmentation.
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Affiliation(s)
- Jacques A Greenberg
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Dessislava I Stefanova
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Fernando Valle Reyes
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Rodrigo C L Edelmuth
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Lamia Harik
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Jessica W Thiesmeyer
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Caitlin E Egan
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Federico Palacardo
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Mengyuan Liu
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Paul Christos
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Felice H Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Philip O Katz
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA.
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Bardini R, Battaglia S, Scarpa M, Savarino E. How a modified Nissen procedure works: a mechanistic study using intraoperative esophageal high-resolution manometry. Langenbecks Arch Surg 2021; 407:123-129. [PMID: 34564758 DOI: 10.1007/s00423-021-02317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed at demonstrating how a modified Nissen procedure works by analyzing intraoperatively the variations of the low esophageal sphincter pressure values using high resolution manometry. METHODS This study included 15 patients with documented gastroesophageal reflux disease who underwent a laparoscopic modified Nissen procedure. Data regarding the changes in the pressure values were recorded at each step of the procedures using high resolution manometry and after the progressive insufflation of air in the stomach. Categorical data were compared between the preoperative and postoperative periods using Fisher's test, and continuous data were compared using Mann-Whitney U non-parametric test. Preoperative versus postoperative variations in continuous data were assessed using Wilcoxon's non-parametric test for paired data. RESULTS Intraoperative manometric data showed a rise of basal LES pressure until the creation of the wrap. An evident increase of pressure values was recorded after gastric air insufflation, as consequence of the increase of intragastric pressure. No intraoperative and postoperative complications were observed. All patients experienced a significant reduction in terms of intensity and frequency of gastroesophageal reflux symptoms and no patients complained of dysphagia. CONCLUSIONS Intraoperative high resolution manometry was feasible in all patients and demonstrated that the modified Nissen procedure works by increasing the LES pressure in response to gastric distension, without impeding the progression of the bolus into the stomach.
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Affiliation(s)
- Romeo Bardini
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy. .,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy. .,Department of Surgery, Oncology and Gastroenterology - DiSCOG, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy.
| | - Silvia Battaglia
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Marco Scarpa
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Edoardo Savarino
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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5
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Nikolic M, Matic A, Kristo I, Paireder M, Asari R, Osmokrovic B, Semmler G, Schoppmann SF. Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up. Surg Endosc 2021; 36:3019-3027. [PMID: 34159461 PMCID: PMC9001554 DOI: 10.1007/s00464-021-08598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 06/06/2021] [Indexed: 01/19/2023]
Abstract
Background Various technical modifications of Nissen fundoplication (NF) that aim to improve patients’ outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF. Methods 283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed. Results Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively. Conclusion Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF.
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Affiliation(s)
- Milena Nikolic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Aleksa Matic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Matthias Paireder
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Reza Asari
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bogdan Osmokrovic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Semmler
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sebastian F Schoppmann
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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6
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Mandovra P, Kalikar V, Patankar R. Quantitative assessment of crural closure for laparoscopic anti-reflux surgeries: A novel technique to reduce post-operative dysphagia. J Minim Access Surg 2021; 17:458-461. [PMID: 32964875 PMCID: PMC8486049 DOI: 10.4103/jmas.jmas_85_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Long-term dysphagia is a known complication of laparoscopic anti-reflux surgery (LARS). Of the several factors, inadequate hiatal closure is one of the major reasons for its occurrence. The aim of this study is to develop a technique for the quantitative assessment of crural closure during LARS to reduce dysphagia. Materials and Methods: It is an analysis of prospectively collected data of 109 patients who underwent LARS at a tertiary healthcare centre in India. To identify the adequacy of hiatal closure intraoperatively, a 7 French Fogarty catheter was used, and its balloon was inflated with 1 cc air at the repaired hiatus. This inflated balloon in the repaired hiatus following cruroplasty gives an accurate quantitative assessment of the adequate closure and adequate space for food bolus to pass without causing mechanical obstruction after hiatus repair. Pre- and post-operative 12 months’ DeMeester scores and lower oesophageal sphincter (LES) pressures were calculated. Results: The patients had a significant reduction in DeMeester scores postoperatively from a mean of 68.5–12.3 (P < 0.0001). None of the patients had long-term dysphagia or the need for long-term proton-pump inhibitors. The mean LES pressures on post-operative manometry showed increase to 15.1 mmHg from a mean of 6.4 mmHg, which was statistically significant (P = 0.0001). None of the patients had a recurrence of hiatus hernia. Conclusion: Quantitative assessment of adequacy for crural closure during LARS using a 7 French Fogarty catheter balloon is a novel technique which may decrease the incidence of post-operative dysphagia or intrathoracic wrap migration or recurrence of hiatus hernia.
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7
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Peela T, Banerjee JK, Ghosh SR, Kulkarni SV, Mujeeb VR, Saranga Bharathi R. Laparoscopic Nissen’s Fundoplication for Gastro-oesophageal Reflux Disease: Audit of Experience and Short-Term Outcome from a Low Volume Centre. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02245-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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8
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Renzi A, Di Sarno G, d'Aniello F, Brillantino A, Minieri G, Coretti G, Barbato D, Barone G. Complete Fundus Mobilization Reduces Dysphagia After Nissen Procedure. Surg Innov 2020; 28:272-283. [PMID: 33236675 DOI: 10.1177/1553350620971174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Anti-reflux surgery is an effective treatment for gastroesophageal reflux disease (GERD). Nevertheless, surgery is still indicated with great caution in relation to the risk of complications, and in particular to postoperative dysphagia (PD). Objective. To compare the clinical outcomes, with particular focus on the incidence and severity of PD, of laparoscopic Nissen-Rossetti fundoplication (NRF) and floppy Nissen fundoplication (FNF) with complete fundus mobilization, in the surgical treatment of GERD. Methods. Ninety patients with GERD were enrolled. Forty-four patients (21[47.7%] men, 23[52.2%] women; mean age 42.4 ± 14.3 years) underwent NRF (Group A), and 46 patients (23[50%] men, 23[50%] women; mean age 43.3 ± 15.4 years) received laparoscopic FNF with complete fundus mobilization (Group B). Clinical assessment was performed using a structured questionnaire and SF-36 quality of life (QoL) score. PD was assessed using a validated classification, and an overall outcome was also determined by asking the patient to score it. Results. At 24-month follow-up, 38 (88.3%) patients in Group A vs 39 (86.6%) in Group B reported to be completely satisfied with reflux relief and free of protonic pump inhibitors (PPIs), while 3 (6.9%) in Group A vs 2(4.4%) in Group B reported occasional PPI intake and 2(4.6%) in Group A vs 4(8.8%) in Group B needed regular PPI use. Persistent PD was observed in 8(18.6%) patients in Group A and in 2(4.4%) in Group B (P = .03). No significant differences were found in the QoL score and in the overall outcome perceived by the patients. Conclusion. FNF, with complete fundus mobilization, appears to be associated with a lower rate of postoperative persistent dysphagia.
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Affiliation(s)
- Adolfo Renzi
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | | | | | | | - Gianluca Minieri
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Guido Coretti
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Domenico Barbato
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Gianni Barone
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
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9
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Nikolic M, Schwameis K, Kristo I, Paireder M, Matic A, Semmler G, Semmler L, Schoppmann SF. Ineffective Esophageal Motility in Patients with GERD is no Contraindication for Nissen Fundoplication. World J Surg 2020; 44:186-193. [PMID: 31605176 DOI: 10.1007/s00268-019-05229-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with preoperative ineffective esophageal motility (IEM) are thought to be at increased risk for postoperative dysphagia leading to the recommendations for tailoring or avoiding anti-reflux surgery in these patients. The aim of this study was to evaluate if IEM has an influence on postoperative outcome after laparoscopic Nissen fundoplication (LNF). METHODS Seventy-two consecutive patients with IEM underwent LNF and were case-matched with 72 patients without IEM based on sex, age, BMI, HH size, total pH percentage time, total number of reflux episodes and the presence of BE. Standardized interview assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake, GERD-health-related-quality-of-life (GERD-HRQL), alimentary satisfaction and patients' overall satisfaction was evaluated. RESULTS Although a higher rate of preoperative dysphagia was observed in patients with IEM (29% IEM vs. 11% no IEM, p = 0.007), there was no significant difference in rates of dysphagia postoperatively (2 IEM vs. 1 no IEM, p = 0.559). Furthermore, no distinction was found in the postoperative outcome regarding symptom relief, quality of life, gas bloating syndrome, ability to belch and/or vomit or revision surgery between the two groups. CONCLUSION Although preoperative IEM has an influence on GERD presentation, it has no effect on postoperative outcome after LNF. IEM should not be a cause for avoiding LNF, as is has been shown as the most effective and safe anti-reflux treatment.
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Affiliation(s)
- Milena Nikolic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Katrin Schwameis
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Matthias Paireder
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Aleksa Matic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Semmler
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Lorenz Semmler
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sebastian F Schoppmann
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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10
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Su B, Wong HJ, Attaar M, Kuchta K, Linn JG, Haggerty SP, Denham W, Ujiki MB. Comparing short-term patient outcomes after fundoplication performed over a traditional bougie versus a functional lumen imaging probe. Surgery 2020; 169:533-538. [PMID: 32919782 DOI: 10.1016/j.surg.2020.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/30/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The functional lumen imaging probe is a balloon-based catheter that can be used as a bougie during fundoplication. Our goal was to compare the short-term, quality-of-life outcomes and esophageal-injury rate after fundoplication over a functional lumen imaging probe compared to a traditional bougie. METHODS This is a retrospective review of a quality database at a single center. Three-week and 6-month Reflux Symptom Index, Gastroesophageal Reflux Disease-health Related Quality of Life, and dysphagia scores were compared. The need for endoscopy and dilation between the groups was also compared. RESULTS Between 2008 and 2020, 423 fundoplications were performed over a bougie and 62 over the functional lumen imaging probe. Six months after surgery, the functional lumen imaging probe group reported significantly worse dysphagia scores (1.5 ± 1.0 vs 1.1 ± 0.3, P = .007), but rates of endoscopy (4.8% vs 5.0%, P = .966) and dilation (4.8% vs 3.8%, P = .723) were similar. There were no differences between Reflux Symptom Index and Gastroesophageal Reflux Disease-health Related Quality of Life scores. The rate of bougie-related injuries was 2.1% vs 0% for the functional lumen imaging probe group. CONCLUSION Patients undergoing fundoplication over the functional lumen imaging probe had comparable short-term outcomes compared with those over a traditional bougie. The rate of esophageal injury while using the functional lumen imaging probe is lower than a bougie and may be preferable for fundoplication creation.
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Affiliation(s)
- Bailey Su
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Department of Surgery, University of Chicago, IL.
| | - Harry J Wong
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Department of Surgery, University of Chicago, IL
| | - Mikhail Attaar
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Department of Surgery, University of Chicago, IL
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
| | - John G Linn
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
| | | | - Woody Denham
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
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11
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Sanchez-Casalongue ME, Farrell TM. Laparoscopic Posterior Partial Fundoplication for Gastroesophageal Reflux Disease. J Laparoendosc Adv Surg Tech A 2020; 30:642-648. [PMID: 32384246 DOI: 10.1089/lap.2020.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common condition that greatly impacts quality of life. Management options include medical and surgical therapies. Nonoperative management typically relies on longitudinal use of acid-suppressive medications such as proton pump inhibitors, which is associated with a significant financial burden and an increasing number of recognized side effects. The surgical management of GERD is focused on correction of the lower esophageal sphincter dysfunction by means of a fundoplication, thus limiting acid and nonacid gastroesophageal reflux. Multiple techniques have been described, including use of complete (360°) fundoplication or partial fundoplication in either an anterior (180°) or posterior (220-270°) position. Recent studies have shown that the total and the partial fundoplications are similarly effective in controlling GERD. A partial fundoplication may also be advantageous when treating patients with GERD and poor esophageal motility. This article focuses on the posterior partial (modified Toupet) fundoplication, with attention to the key elements of the preoperative workup, appropriate patient selection, and important technical steps that are associated with the best outcomes.
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Affiliation(s)
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina, USA
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12
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Sanberg Ljungdalh J, Rubin KH, Durup J, Houlind KC. Long-term patient satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort: study protocol for a retrospective cohort study with development of a novel scoring system for patient selection. BMJ Open 2020; 10:e034257. [PMID: 32184312 PMCID: PMC7076240 DOI: 10.1136/bmjopen-2019-034257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Laparoscopic anti-reflux surgery is standard of care in surgical treatment of gastro-oesophageal reflux disease and is not without risks of adverse effects, including disruption of the fundoplication and postfundoplication dysphagia, in some cases leading to reoperation. Non-surgical factors such as pre-existing anxiety or depression influence postoperative satisfaction and symptom relief. Previous studies have focused on a short-term follow-up or only certain aspects of disease, such as reoperation or postoperative quality of life. The aim of this study is to evaluate long-term patient-satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort using a comprehensive multimodal follow-up, and to develop a clinically applicable scoring system usable in selecting patients for anti-reflux surgery. METHODS AND ANALYSIS The study is a retrospective cohort study utilising data from patient records and follow-up with patient-reported quality of life as well as registry-based data. The study population consists of all adult patients having undergone laparoscopic anti-reflux surgery at The Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital Denmark in an 11-year period. From electronic records; patient characteristics, preoperative endoscopic findings, reflux disease characteristics and details on type of surgery, will be identified. Disease-specific quality of life and dysphagia will be collected from a patient-reported follow-up. From Danish national registries, data on comorbidity, reoperative surgery, use of pharmacological anti-reflux treatment, mortality and socioeconomic factors will be included. Primary outcome of this study is treatment success at follow-up. ETHICS AND DISSEMINATION Study approval has been obtained from The Danish Patient Safety Agency, The Danish Health Data Authority and Statistics Denmark, complying to Danish and EU legislation. Inclusion in the study will require informed consent from participating subjects. The results of the study will be published in peer-reviewed medical journals regardless of whether these are positive, negative or inconclusive. TRIAL REGISTRATION NUMBER Clinicaltrials.gov (NCT03959020).
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Affiliation(s)
- Jonas Sanberg Ljungdalh
- Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Katrine Hass Rubin
- OPEN - Open Patient Data Explorative Network, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Jesper Durup
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Kim Christian Houlind
- Department of Regional Health Research, University of Southern Denmark, Odense, Syddanmark, Denmark
- Department of Vascular Surgery, Kolding Hospital, a part of Lillebaelt Hospital, Kolding, Denmark
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13
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Håkanson BS, Lundell L, Bylund A, Thorell A. Comparison of Laparoscopic 270° Posterior Partial Fundoplication vs Total Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Randomized Clinical Trial. JAMA Surg 2020; 154:479-486. [PMID: 30840057 DOI: 10.1001/jamasurg.2019.0047] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance Restoration of the esophagogastric junction competence is critical for effective long-term treatment of gastroesophageal reflux disease. Surgical repair results in such restoration, but mechanical adverse effects seem unavoidable. Minimizing these adverse effects without jeopardizing reflux control is warranted. Objective To determine whether partial fundoplication (PF) or total fundoplication (TF) is superior in laparoscopic antireflux surgery. Design, Setting, and Participants In this double-blind, randomized clinical trial of 1171 patients scheduled for laparoscopic antireflux surgery at a single university-affiliated center between November 19, 2001, and January 24, 2006, 456 patients were randomized and followed up for 5 years. Data were collected from November 2001 to April 2012, and data were analyzed from April 2012 to September 2018. Interventions A 270° posterior PF or a 360° Nissen TF. Main Outcomes and Measures Esophageal acid exposure at 3 years after surgery. Result Of the 456 randomized patients, 268 (58.8%) were male, and the mean (SD) age was 49.0 (11.7) years. A total of 229 patients were randomized to PF, and 227 patients were randomized to TF. At 3 years postoperatively, the median (interquartile range) esophageal acid exposure was reduced from 14.6% (9.8-21.9) to 1.8% (0.7-4.4) after PF and from 16.0% (10.4-22.7) to 2.5% (0.8-6.8) after TF (P = .31). Likewise, reflux symptoms were equally and effectively controlled. Early postoperative dysphagia (6 weeks) was common in both groups but then decreased toward normality. A small but statistically significant difference in favor of PF was noted in the mean (SD) scoring of dysphagia for liquids at 6 weeks (PF, 1.6 [0.9]; TF, 1.9 [1.3]; P = .01) and for solid food at 12 months (PF, 1.3 [1.0]; TF, 1.9 [1.4]; P < .001) and 24 months (PF, 1.3 [0.9]; TF, 1.7 [1.2]; P = .001). Quality of life was reduced before surgery but increased to normal values after surgery and remained so over 5-year follow-up, with no difference between the groups. Conclusions and Relevance The results from this randomized clinical trial suggest that although PF and TF could be recommended for treatment of gastroesophageal reflux disease, PF might be superior by inducing less dysphagia. Trial Registration ClinicalTrials.gov identifier: NCT03659487.
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Affiliation(s)
- Bengt S Håkanson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Lars Lundell
- Department of Clinical Sciences, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Ami Bylund
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
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14
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Higgins RM, Gould JC. The Pros and Cons of Partial Versus Total Fundoplication for Gastroesophageal Reflux Disease. J Laparoendosc Adv Surg Tech A 2020; 30:117-120. [DOI: 10.1089/lap.2019.0297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Rana M. Higgins
- Division of General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jon C. Gould
- Division of General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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15
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Bramhall SR, Mourad MM. Wrap choice during fundoplication. World J Gastroenterol 2019; 25:6876-6879. [PMID: 31908391 PMCID: PMC6938727 DOI: 10.3748/wjg.v25.i48.6876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/03/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Gastro-oesphageal reflux disease is an increasing health burden. The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication. The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications. These complications include “gas bloat” and dysphagia and can occur relatively frequently. Various modifications have been described to the original operation and some of these have been described. In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use. This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique. The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms. The advantages and disadvantages of an anterior wrap are discussed. The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.
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Affiliation(s)
- Simon R Bramhall
- Department of Surgery, The County Hospital, Hereford HR1 2ER, United Kingdom
| | - Moustafa M Mourad
- Department of Surgery, Worcester Royal Infirmary, Worcester WR5 1DD, United Kingdom
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16
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Su B, Novak S, Callahan ZM, Kuchta K, Carbray J, Ujiki MB. Using impedance planimetry (EndoFLIP™) in the operating room to assess gastroesophageal junction distensibility and predict patient outcomes following fundoplication. Surg Endosc 2019; 34:1761-1768. [DOI: 10.1007/s00464-019-06925-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/12/2019] [Indexed: 01/20/2023]
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17
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Patti MG. Similar Effectiveness of Total and 270° Posterior Fundoplication for the Treatment of Gastroesophageal Reflux Disease. JAMA Surg 2019; 154:486. [PMID: 30840051 DOI: 10.1001/jamasurg.2019.0064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Marco G Patti
- Department of Medicine and Surgery, University of North Carolina, Chapel Hill
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18
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Preoperative High-Resolution Manometry Criteria are Associated with Dysphagia After Nissen Fundoplication. World J Surg 2018; 43:1062-1067. [PMID: 30523393 DOI: 10.1007/s00268-018-4870-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Dysphagia after Nissen fundoplication is challenging for patients. High-resolution manometry (HRM) has rarely been studied preoperatively to determine whether manometry values correlated with postoperative dysphagia after fundoplication. We aim to determine whether HRM criteria could predict dysphagia after Nissen fundoplication. METHODS A retrospective review of single-institution laparoscopic Nissen fundoplications (LNF) from 2013 to 2015 was completed. Dysphagia was graded using a standard scale. Four groups were: those with new postoperative dysphagia (ND), never had dysphagia (NV), continued dysphagia (CD), and resolved dysphagia (RD). Manometry criteria included distal contractile integral (DCI), contraction front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP), percent peristalsis (PP), and distal esophageal contraction amplitude (DECA). Statistical bootstrapping was used to power sample sizes for ANOVA analysis. RESULTS Ninety-four patients were included in the original cohort. Statistical bootstrapping sample size was 2992 patients. Among patients who did not have dysphagia prior to LNF, no HRM metric was associated with developing new dysphagia. Among those with dysphagia prior to LNF, a higher DCI, CFV, DL, PP, and DECA were associated with resolution of dysphagia. The RD group was 2.77 times more likely to have a DCI ≥ 1000 mmHg-s-cm compared with the CD group. CONCLUSIONS HRM criteria could not predict the development of postoperative dysphagia. However, in those with preoperative dysphagia and strong manometry criteria, dysphagia is more likely to resolve after Nissen fundoplication. Meanwhile, in those with preoperative dysphagia and weak manometry, dysphagia may persist and these patients may be better served with a partial fundoplication.
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19
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Rebecchi F, Allaix ME, Cinti L, Nestorović M, Morino M. Comparison of the outcome of laparoscopic procedures for GERD. Updates Surg 2018; 70:315-321. [PMID: 30027381 DOI: 10.1007/s13304-018-0572-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/08/2018] [Indexed: 12/15/2022]
Abstract
A total laparoscopic fundoplication has become the procedure of choice for the surgical treatment of gastroesophageal reflux disease in patients with normal esophageal motility, with reduced postoperative pain, faster recovery and similar long-term outcomes compared to conventional open total fundoplication. Most controversial surgical aspects are the division of the short gastric vessels and the insertion of a bougie to calibrate the wrap. The anterior 180° and the posterior partial fundoplications lead to similar control of heartburn when compared to total fundoplication with lower risk of dysphagia. However, when performed, 24-h pH monitoring shows pathologic reflux more frequently after partial than total fundoplication. Disappointing results are achieved by anterior 90° partial fundoplication. More recently, a magnetic sphincter augmentation with the LINX Reflux Management System (Torax Medical) and the lower esophageal sphincter Electrical Stimulation (EndoStim) have been developed, seeking for a durable and effective minimally invasive alternative to laparoscopic fundoplication for the treatment of reflux. Both devices seem to be promising, with very low postoperative complications and good short-term functional outcomes. Large randomized controlled trials comparing them with laparoscopic fundoplication over a long period of follow-up are needed to verify their indications and outcomes.
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Affiliation(s)
- Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Marco Ettore Allaix
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy.
| | - Lorenzo Cinti
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Milica Nestorović
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
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20
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Persistent dysphagia is a rare problem after laparoscopic Nissen fundoplication. Surg Endosc 2018; 33:1196-1205. [PMID: 30171395 PMCID: PMC6430753 DOI: 10.1007/s00464-018-6396-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 08/20/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although around 30% of patients with gastroesophageal reflux disease (GERD) are insufficiently treated with medical therapy, only 1% opt for surgical therapy. One of the reasons behind this multifactorial phenomenon is the described adverse effect of long-term dysphagia or gastric bloating syndrome after surgical treatment. Aim of this study was to evaluate the most common side effects associated with anti-reflux surgery, as well as long-term outcomes in a large cohort of highly surgically standardized patients after laparoscopic Nissen fundoplication (LNF). METHODS Out of a prospective patients' database including all patients that underwent anti-reflux surgery between 01/2003 and 01/2017 at our institution, 350 consecutive patients after highly standardized LNF were included in this study. A standardized interview was performed by one physician assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD-Health-Related-Quality-of-Life (GERD-HRQL), Alimentary Satisfaction (AS), and patients' overall satisfaction. RESULTS After a median follow-up of 4 years, persistent dysphagia (PD) after LNF was observed in 8 (2%) patients, while postoperative gas-bloat syndrome in 45 (12.7%) cases. Endoscopic dilatation was needed in 7 (2%) patients due to dysphagia, and 19 (5%) patients underwent revision surgery due to recurrence of GERD. The postoperative GERD-HRQL total score was significantly reduced (2 (IQR 0-4.3) vs. 19 (IQR 17-32); p < 0.000) and the median AS was 9/10. Heartburn relief was achieved in 83% of patients. Eighty-three percent of patients were free of PPI intake after follow-up, whereas 13% and 4% of the patients reported daily and irregular PPI use, respectively. CONCLUSION LNF is a safe and effective surgical procedure with low postoperative morbidity rates and efficient GERD-related symptom relief. PD does not represent a relevant clinical issue when LNF is performed in a surgical standardized way. These results should be the benchmark to which long-term outcomes of new surgical anti-reflux procedures are compared.
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21
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Schlottmann F, Herbella FAM, Patti MG. Laparoscopic antireflux surgery: how I do it? Updates Surg 2018; 70:349-354. [PMID: 30039280 DOI: 10.1007/s13304-018-0566-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022]
Abstract
Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the US, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) are effective in the majority of patients. However, some patients will become candidates for surgical intervention, because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI. In these patients, a properly executed laparoscopic antireflux surgery controls esophageal and extra-esophageal symptoms and avoids life-long medical therapy. Important technical elements should be taken into account during the operation to avoid troublesome side effects and obtain optimal postoperative outcomes.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, University of North Carolina at Chapel Hill, 4030 Burnett Womack Building, 101 Manning Drive, CB 7081, Chapel Hill, NC, 27599-7081, USA. .,Department of Surgery, Hospital Alemán of Buenos Aires, University of Buenos Aires, Buenos Aires, Argentina.
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of North Carolina at Chapel Hill, 4030 Burnett Womack Building, 101 Manning Drive, CB 7081, Chapel Hill, NC, 27599-7081, USA.,Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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22
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Castelijns PSS, van de Poll MCG, Smulders JF. A Modified Technique to Create a Standardized Floppy Nissen Fundoplication Without a Bougie. J Laparoendosc Adv Surg Tech A 2018; 28:853-858. [PMID: 29466120 DOI: 10.1089/lap.2017.0734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Nissen fundoplication is frequently applied in the surgical treatment of patients with gastroesophageal reflux disease (GERD). When the gastroesophageal junction remains too large or becomes too narrow, persistent GERD or dysphagia may occur. To assure a correct size of the gastroesophageal junction, the fundoplication can be created over a bougie. However, this increases the risk of esophageal perforation. Therefore, we have modified a previously described technique to create a standardized fundoplication without the use of a bougie. In this article, we describe this technique and demonstrate the initial results. MATERIALS AND METHODS We describe a technique to create a standardized Nissen fundoplication. After suture repair of the hiatal hernia, three marking sutures were placed on the gastric fundus, based on an equilateral triangle. The size of this triangle determines the final diameter of the fundoplication. With these measurements, we assure sufficient patency, minimize rotation, and create a more reproducible fundoplication that may reduce postoperative dysphagia. RESULTS We have operated 15 patients according to this technique. Mean operative time was 69.5 (SD 8.4) minutes, no complications occurred. There was no early dysphagia and the mean length of stay was 1.3 days (1-2). Quality of life after 1 year was excellent. CONCLUSIONS This modified method for standardized Nissen fundoplication is safe and might reduce postoperative dysphagia. Quality of life after 1 year is excellent. The effect on postoperative dysphagia and the reproducibility of this technique should be established in a large prospective study.
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Affiliation(s)
- Petrus S S Castelijns
- 1 Department of Surgery, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Marcel C G van de Poll
- 1 Department of Surgery, Maastricht University Medical Centre , Maastricht, The Netherlands .,2 Department of Intensive Care Medicine, Maastricht University Medical Centre , Maastricht, The Netherlands .,3 School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University , Maastricht, The Netherlands
| | - Johannes F Smulders
- 4 Department of Surgery, Catharina Hospital Eindhoven , Eindhoven, The Netherlands
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24
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Patti MG, Schlottmann F, Farrell TM. Fundoplication for Gastroesophageal Reflux Disease: Tips for Success. J Laparoendosc Adv Surg Tech A 2016; 27:1-5. [PMID: 27858520 DOI: 10.1089/lap.2016.29014.mgp] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Gastroesophageal reflux disease affects almost 20% of the population in the United States. Today, proton pump inhibitors are the most frequently prescribed drugs, with an estimated cost of 10 billion dollars per year. Although these medications control heartburn in the majority of patients, other symptoms such as regurgitation and respiratory symptoms often are not controlled, particularly in patients with large hiatal hernias. In these patients a properly performed laparoscopic fundoplication controls esophageal and extraesophageal symptoms and avoids life-long medical therapy. Key elements for the success of a fundoplication are careful patient selection, a complete preoperative evaluation, and a properly executed operation.
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Affiliation(s)
- Marco G Patti
- Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
| | - Francisco Schlottmann
- Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
| | - Timothy M Farrell
- Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
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Hashimi S, Bremner RM. Complications Following Surgery for Gastroesophageal Reflux Disease and Achalasia. Thorac Surg Clin 2016; 25:485-98. [PMID: 26515948 DOI: 10.1016/j.thorsurg.2015.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Surgical procedures to treat reflux disease are common, but good outcomes rely on both a thorough preoperative workup and careful surgical techniques. Although complications are uncommon, surgeons should recognize these and possess the skills to overcome them in clinical practice.
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Affiliation(s)
- Samad Hashimi
- Department of Thoracic Disease and Transplantation, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Suite 500, Phoenix, AZ 85013, USA
| | - Ross M Bremner
- Department of Thoracic Disease and Transplantation, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Suite 500, Phoenix, AZ 85013, USA.
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Abstract
Dysphagia is a symptom of swallowing dysfunction that occurs between the mouth and the stomach. Although oropharyngeal dysphagia is a highly prevalent condition (occurring in up to 50% of elderly people and 50% of patients with neurological conditions) and is associated with aspiration, severe nutritional and respiratory complications and even death, most patients are not diagnosed and do not receive any treatment. By contrast, oesophageal dysphagia is less prevalent and less severe, but with better recognized symptoms caused by diseases affecting the enteric nervous system and/or oesophageal muscular layers. Recognition of the clinical relevance and complications of oesophageal and oropharyngeal dysphagia is growing among health-care professionals in many fields. In addition, the emergence of new methods to screen and assess swallow function at both the oropharynx and oesophagus, and marked advances in understanding the pathophysiology of these conditions, is paving the way for a new era of intensive research and active therapeutic strategies for affected patients. Indeed, a unified field of deglutology is developing, with new professional profiles to cover the needs of all patients with dysphagia in a nonfragmented way.
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27
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Sternbach JM, Hungness ES. Surgical intervention for esophageal dysmotility. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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28
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Robinson B, Dunst CM, Cassera MA, Reavis KM, Sharata A, Swanstrom LL. 20 years later: laparoscopic fundoplication durability. Surg Endosc 2014; 29:2520-4. [PMID: 25487547 DOI: 10.1007/s00464-014-4012-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 11/09/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic surgery for gastrointestinal reflux disease was introduced in 1991. Early safety, efficacy, and 5-10-year durability have been amply documented, but long-term patient outcomes have been criticized. This study presents 20-year outcomes after laparoscopic fundoplication (LF) in a consecutive patient cohort. METHODS Patients who underwent primary LF procedures for gastroesophageal reflux disease (GERD) were identified from a prospectively collected IRB-approved database (1991-1995). A phone symptom questionnaire was administered using a 5-point validated GERD scoring system (heartburn, regurgitation, and dysphagia). Symptomatic success was defined by a lack of surgical re-intervention and a low symptom score. RESULTS One-hundred and ninety-three patients were identified during the time period. Fifty-one patients completed the survey (100 lost to follow-up, 40 deceased, 2 declined to answer). Respondents had a median follow-up of 19.7 years. Overall, 38/51 (74.5%) of patients reported complete control of heartburn and regurgitation. Ten patients reported only occasional heartburn. Eight of fifty-one (16%) reported daily dysphagia, and 22/51 (43%) of respondents were using proton pump inhibitors at the time of telephone interview. Nine of fifty-one (18%) underwent revision of the original surgery which did not negatively impact the satisfaction rating, with 8/9 (89%) of these patients reporting the highest satisfaction rating. Overall, 46/51 (90%) were satisfied with their choice of surgery. CONCLUSION Long-term results from the early experience with LF are excellent with 94% of patients reporting only occasional or fewer reflux symptoms at 20-year follow-up. However, 18% required surgical revision surgery to maintain their results. There is a relatively high rate of daily dysphagia but 90% of patients are happy to have had LF.
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Affiliation(s)
- Ben Robinson
- Foundation for Surgical Innovation and Education, Portland, OR, USA,
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Laparoscopic surgery for gastro-esophageal acid reflux disease. Best Pract Res Clin Gastroenterol 2014; 28:97-109. [PMID: 24485258 DOI: 10.1016/j.bpg.2013.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 11/20/2013] [Indexed: 01/31/2023]
Abstract
Gastro-esophageal reflux disease is a troublesome disease for many patients, severely affecting their quality of life. Choice of treatment depends on a combination of patient characteristics and preferences, esophageal motility and damage of reflux, symptom severity and symptom correlation to acid reflux and physician preferences. Success of treatment depends on tailoring treatment modalities to the individual patient and adequate selection of treatment choice. PubMed, Embase, The Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for systematic reviews with an abstract, publication date within the last five years, in humans only, on key terms (laparosc* OR laparoscopy*) AND (fundoplication OR reflux* OR GORD OR GERD OR nissen OR toupet) NOT (achal* OR pediat*). Last search was performed on July 23nd and in total 54 articles were evaluated as relevant from this search. The laparoscopic Toupet fundoplication is the therapy of choice for normal-weight GERD patients qualifying for laparoscopic surgery. No better pharmaceutical, endoluminal or surgical alternatives are present to date. No firm conclusion can be stated on its cost-effectiveness. Results have to be awaited comparing the laparoscopic 180-degree anterior fundoplication with the Toupet fundoplication to be a possible better surgical alternative. Division of the short gastric vessels is not to be recommended, nor is the use of a bougie or a mesh in the vast majority of GERD patients undergoing surgery. The use of a robot is not recommended. Anti-reflux surgery is to be considered expert surgery, but there is no clear consensus what is to be called an 'expert surgeon'. As for setting, ambulatory settings seem promising although high-level evidence is lacking.
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Perretta S, McAnena O, Botha A, Nathanson L, Swanstrom L, Soper NJ, Inoue H, Ponsky J, Jobe B, Marescaux J, Dallemagne B. Acta from the EndoFLIP® Symposium. Surg Innov 2013; 20:545-52. [PMID: 24379172 DOI: 10.1177/1553350613513515] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Laparoscopic fundoplication (LF) is a surgical treatment for gastroesophageal reflux disease (GERD) that has been performed for more than 20 years. High-volume centers of excellence report long-term success rates greater than 90% with LF. On the other hand, general population-based outcomes are reported to be markedly worse, leading to a nihilistic perception of the procedure on the part of the medical referral population. The lack of standardization of the technique and the lack of tools to calibrate objectively the repairs are probably among the causes of variability in the outcomes and may explain the decline in the number of LF procedures in recent years. The functional lumen imaging probe (EndoFLIP(®)) device is essentially a "smart bougie" in the form of a balloon catheter that measures shape and compliance of the gastroesophageal junction (GEJ) during surgery using impedance planimetry. With approximately 3 years of international experience gained with this tool, a symposium was convened in October 2012 in Strasbourg, France, with the aim of determining if intraoperative EndoFLIP use could provide standardization of surgical treatment of GERD through the understanding of physiological changes occurring to the GEJ during fundoplication. This article provides a brief history of the EndoFLIP system and reviews data previously published on the use of EndoFLIP to characterize the GEJ in normal subjects. It then summarizes the data from the 5 high-volume international sites with expert surgeons performing LF presented in Strasbourg to objectively profile the characteristics of a normal postoperative GEJ.
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Affiliation(s)
- Silvana Perretta
- 1IRCAD, Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
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Bülbüller N, Oner OZ. Esophageal Calibration with Soft Orogasrtric Tube During Laparoscopic Nissen Fundoplication may Reduce Postoperative Transient Dysphagia. Indian J Surg 2013; 77:759-63. [PMID: 27011452 DOI: 10.1007/s12262-013-0995-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 10/13/2013] [Indexed: 11/25/2022] Open
Abstract
Gastroesophageal reflux is the most common benign disorder of the esophagus and laparoscopic Nissen fundoplication has become the standard surgical treatment for its treatment. In our area, where the use of bougie calibration is debatable, postoperative dysphagia is encountered often after this surgery although it is usually not permanent. The aim of this study was to investigate the effect of using a soft silicone tube 39 F in diameter for esophageal calibration during laparoscopic Nissen fundoplication on the incidence of postoperative dysphagia. We divided cases scheduled to undergo laparoscopic Nissen fundoplication between January 2009 and November 2010 into two groups, each consisting 25 patients. Esophageal calibration with a 39 F silicone orogastric tube was used for the first group while there was no operative calibration in the second group. The surgical duration was recorded; the presence and severity of the postoperative dysphagia was calculated by using a dysphagia severity scoring system during the 1-year postoperative follow-up. The dysphagia severity scores were significantly lower in group 1 than group 2 on the postoperative second day and at the end of the first week and first month. We did not find a significant difference at the end of the 6-month and first year. There was also no significant difference regarding surgery duration. The use of a soft orogastric tube 39 F in diameter for esophagus calibration during laparoscopic Nissen fundoplication has significantly decreased the incidence of postoperative transient dysphagia without affecting the duration of surgery. Although dysphagia gradually resolves in the majority of patients, a safe and easy calibration method for its prevention is worth developing, and we believe that the use of our method in larger series could be beneficial.
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Affiliation(s)
- Nurullah Bülbüller
- Department of General Surgery, Antalya Training and Research Hospital, Antalya, Turkey ; Genel Cerrahi Klinigi, Antalya Egitim ve Arastirma Hastanesi, Varlık Mahallesi Kazım Karabekir Caddesi, 07100 Antalya, Turkey
| | - Osman Zekai Oner
- Department of General Surgery, Antalya Training and Research Hospital, Antalya, Turkey
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Allaix ME, Herbella FA, Patti MG. Laparoscopic total fundoplication for gastroesophageal reflux disease. How I do it. J Gastrointest Surg 2013; 17:822-8. [PMID: 23129120 DOI: 10.1007/s11605-012-2068-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/15/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD). DISCUSSION Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis. CONCLUSION This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, Room G-207, Chicago, IL 60637, USA
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Hirota M, Nakajima K, Souma Y, Mikata S, Iwase K, Demura K, Takahashi T, Yamasaki M, Miyata H, Kurokawa Y, Takiguchi S, Mori M, Doki Y. Assistive esophagoscopy during laparoscopic surgery for intra-thoracic stomach. Esophagus 2013. [DOI: 10.1007/s10388-013-0367-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
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Witteman BPL, Kessing BF, Snijders G, Koek GH, Conchillo JM, Bouvy ND. Revisional laparoscopic antireflux surgery after unsuccessful endoscopic fundoplication. Surg Endosc 2013; 27:2231-6. [PMID: 23292557 DOI: 10.1007/s00464-012-2685-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 10/25/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transoral incisionless fundoplication (TIF), a novel endoscopic procedure for treating gastroesophageal reflux disease (GERD), currently is under evaluation. In case of treatment failure, subsequent revisional laparoscopic antireflux surgery (rLARS) may be required. This study aimed to evaluate the feasibility, safety, and outcomes of revisional antireflux surgery after previous endoscopic fundoplication. METHODS Chronic GERD patients who underwent rLARS after a previous TIF procedure were included in the study. Pre- and postoperative assessment included GERD-related quality-of-life scores, proton pump inhibitor (PPI) usage, 24-h pH-metry, upper gastrointestinal endoscopy, and registration of adverse events. RESULTS Revisional laparoscopic Nissen fundoplication was feasible for all 15 patients included in the study without conversions to open surgery. Acid exposure of the distal esophagus improved significantly after rLARS, and esophagitis, PPI usage, and hiatal hernia decreased. Quality of life did not improve significantly after rLARS, and 33 % of the patients experienced dysphagia. CONCLUSION Revisional laparoscopic Nissen fundoplication was feasible and safe after unsuccessful endoscopic fundoplication, resulting in objective reflux control at the cost of a relatively high rate of dysphagia.
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Affiliation(s)
- Bart P L Witteman
- Department of General Surgery, Maastricht University Medical Center, P. Debyelaan 25, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
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Dysphagia postfundoplication: more commonly hiatal outflow resistance than poor esophageal body motility. Surgery 2012; 152:584-92; discussion 592-4. [PMID: 22939748 DOI: 10.1016/j.surg.2012.07.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 07/10/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND Historically, risk assessment for postfundoplication dysphagia has been focused on esophageal body motility, which has proven to be an unreliable prediction tool. Our aim was to determine factors responsible for persistent postoperative dysphagia. METHODS Fourteen postfundoplication patients with primary dysphagia were selected for focused study. Twenty-five asymptomatic post-Nissen patients and 17 unoperated subjects served as controls. Pre- and postoperative clinical and high-resolution manometry parameters were compared. RESULTS Thirteen of the 14 symptomatic patients (92.9%) had normal postoperative esophageal body function, determined manometrically. In contrast, 13 of 14 (92.9%) had evidence of esophageal outflow obstruction, 9 of 14 (64.3%) manometrically, and 4 of 14 (28.6%) on endoscopy/esophagram. Median gastroesophageal junction integrated relaxation pressure was significantly greater (16.2 mm Hg) in symptomatic than in asymptomatic post-Nissen patients (11.1 mm Hg, P = .05) or unoperated subjects (10.6 mm Hg, P = .02). Sixty-four percent (9/14) of symptomatic patients had an increased mean relaxation pressure. Dysphagia was present in 9 of 14 (64.3%) preoperatively, and elevated postoperative relaxation pressure was independently associated with dysphagia. CONCLUSION These data suggest that postoperative alterations in hiatal functional anatomy are the primary factors responsible for post-Nissen dysphagia. Impaired relaxation of the neo-high pressure zone, recognizable as an abnormal relaxation pressure, best discriminates patients with dysphagia from those without symptoms postfundoplication.
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Wee JO. Redo laparoscopic repair of benign esophageal disease. J Thorac Cardiovasc Surg 2012; 144:S71-3. [PMID: 22608677 DOI: 10.1016/j.jtcvs.2012.03.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 03/22/2012] [Indexed: 01/11/2023]
Abstract
Laparoscopic fundoplication for gastroesophageal reflux disease has been associated with excellent symptom control. Compared with medical treatment, laparoscopic Nissen fundoplication has shown favorable control of typical reflux symptoms. However, in approximately 2% to 17% of patients, surgical treatment fails. The role of reoperative repair for reflux disease and the factors that contribute to it are examined.
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Affiliation(s)
- Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Ramos RF, Lustosa SAS, Almeida CAPD, Silva CPD, Matos D. Surgical treatment of gastroesophageal reflux disease: total or partial fundoplication? systematic review and meta-analysis. ARQUIVOS DE GASTROENTEROLOGIA 2012; 48:252-60. [PMID: 22147130 DOI: 10.1590/s0004-28032011000400007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 06/09/2011] [Indexed: 11/22/2022]
Abstract
CONTEXT Although the high incidence of gastroesophageal reflux disease (GERD) in the population, there is much controversy in this topic, especially in the surgical treatment. The decision to use of a total or partial fundoplication in the treatment of GERD is still a challenge to many surgeons because the few evidence found in the literature. OBJECTIVE To bring more clear evidence in the comparison between total and partial fundoplication. DATA SOURCES A systematic review of the literature and metaanalysis with randomized controlled trials accessed from MEDLINE, LILACS, Cochrane Controlled Trials Database was done. The outcomes remarked were: dysphagia, inability to belch, bloating, recurrence of acid reflux, heartburn and esophagitis. For data analysis the odds ratio was used with corresponding 95% confidence interval. Statistical heterogeneity in the results of the metaanalysis was assessed by calculating a test of heterogeneity. The software Review Manager 5 (Cochrane Collaboration) was utilized for the data gathered and the statistical analysis. Sensitive analysis was applied using only trials that included follow-up over 2 years. RESULTS Ten trials were included with 1003 patients: 502 to total fundoplication group and 501 to partial fundoplication group. The outcomes dysphagia and inability to belch had statistical significant difference (P = 0.00001) in favor of partial fundoplication. There was not statistical difference in outcomes related with treatment failure. There were no heterogeneity in the outcomes dysphagia and recurrence of the acid reflux. CONCLUSION The partial fundoplication has lower incidence of obstructive side effects.
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Affiliation(s)
- Rodrigo F Ramos
- Departamento de Cirurgia, Universidade Federal Fluminense, Niterói, RJ, Brazil.
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Jarral OA, Athanasiou T, Hanna GB, Zacharakis E. Is an intra-oesophageal bougie of use during Nissen fundoplication? Interact Cardiovasc Thorac Surg 2012; 14:828-33. [PMID: 22392936 DOI: 10.1093/icvts/ivr140] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best-evidence topic was written according to a structured protocol. The question addressed was whether the use of an intra-oesophageal bougie during Nissen fundoplication reduces post-operative dysphagia. A total of 34 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The popularity of bougie placement is likely to have been encouraged by an early study reported in this article in 1986 associating the use of a larger bougie with reduction of postoperative dysphagia. A more recent randomized study in 2000 also associated the use of bougie with significantly less long-term and severe dysphagia. Four retrospective studies showed no advantage from the use of a bougie, and the potential benefit are countered by the largest published series in the literature reporting the incidence of oesophageal perforation owing to bougie placement at 0.8%. Despite this risk, a survey of 393 German surgeons in 2005 revealed that 46% use a bougie. In summary, we conclude that there is some evidence to suggest that both the presence and size of bougie may have an impact on dysphagia. The evidence is not substantial enough to recommend change in clinical practice and its use must be weighed against the risk of oesophageal injury which patients should be consented for. These conclusions are in accordance with the 2010 Guidelines for Surgical Treatment of Gastroesophageal Reflux disease by the Society of American Gastrointestinal and Endoscopic Surgeons who give a Grade B recommendation for the placement of an oesophageal dilator. It is important that future studies are adequately powered and designed to measure longitudinal outcomes such as dysphagia severity with validated assessment tools at appropriate follow-up points. The measurement and usefulness of health-related quality of life needs to be investigated further in this patient population.
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Affiliation(s)
- Omar A Jarral
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, UK
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Rantanen T, Neuvonen P, Iivonen M, Tomminen T, Oksala N. The impact of fibrin glue in the prevention of failure after Nissen fundoplication. Scand J Surg 2011; 100:181-5. [PMID: 22108746 DOI: 10.1177/145749691110000308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Good long term result after Nissen fundoplication is achieved in most of the patients in specialized centres. Still failure occurs in some cases and reoperation after failed conservative treatment is done in 3-6% of the cases. Reoperation is more dangerous and results worse than after primary fundoplication. Therefore we wanted to analyze factors related to failure of Nissen fundoplication with special emphasis on utilization of crural closure, anchor-ing of the fundic wrap and the use of fibrin glue. MATERIAL AND METHODS Patients records of 258 patients were analyzed by an independent ob-server. Defective fundic wrap, recurrent oesophagitis and hiatal hernia were defined as failure. RESULTS Failure after Nissen fundoplication was found in 29 patients (14.9%). Crural closure (p = 0.021), anchoring of the wrap (p = 0.020) and fibrin glue (p = 0.029) decreased the incidence of failure. However, only crural closure (p = 0.010) and fibrin glue (p = 0.019) were independent factors in the prevention of failure. CONCLUSIONS Fibrin glue as a new method might be worth utilizing to further decrease the incidence of failure after Nissen fundoplication. Because our study was retrospective, prospective randomized study should be performed before universal use of fibrin glue in the prevention of failure after fundoplication.
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Affiliation(s)
- T Rantanen
- Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland Department of Surgery, Central Hospital of Seinäjoki, Seinäjoki, Finland.
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Postoperative dysphagia is not predictive of long-term failure after laparoscopic antireflux surgery. Surg Endosc 2011; 26:451-7. [PMID: 21909851 DOI: 10.1007/s00464-011-1898-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 08/06/2011] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Dysphagia is a common postoperative symptom after laparoscopic antireflux surgery, usually attributed to postoperative edema or a "too tight" fundoplication. Although it is usually self-limited, it occasionally requires endoscopic dilation and rarely revisionary surgery. It has not been previously described whether postoperative dysphagia is associated with poorer long-term reflux control after fundoplication. METHODS We hypothesized that the presence of dysphagia in the early postoperative period is associated with long-term failure of the antireflux procedure and recurrence of gastroesophageal reflux disease (GERD) symptoms. A retrospective review of a prospectively maintained database of patients undergoing antireflux surgery was performed. The study population included patients, who underwent primary laparoscopic Nissen fundoplication between the years 1991 and 2010. The presence of dysphagia on their first postoperative visit (<30 days) was used to classify them in the early-dysphagia (ED) and the no-early-dysphagia (NED) groups. The recurrence of heartburn or regurgitation, as well as the pH studies on long-term follow-up (more than 6 months) were compared between the two groups. A grading system (range 0-4) was used to measure the severity of foregut symptoms. RESULTS 1223 patients underwent primary laparoscopic Nissen fundoplications during the study period and met the inclusion criteria. Both short and long-term follow-up was available in 821 patients, who were analyzed. 423 patients were included in the ED group, whereas 398 in the NED group. The mean regurgitation score of the ED group on the long-term follow-up was 0.25 compared to 0.20 for the NED group (P = 0.21). The heartburn score was 0.38 for the ED group compared to 0.33 for the NED group (P = 0.38). Long-term dysphagia was higher in the ED group. These findings were confirmed when ED patients were subclassified based on the degree of early post-operative dysphagia. Of the 821 patients, 599 underwent routine postoperative pH testing. The mean DeMeester score in the ED group (n = 308) was 11.7 compared to 13.2 for the NED group (n = 291; P = 0.54). The percentage of patients with abnormal pH testing was similar between the two groups. CONCLUSIONS Early postoperative dysphagia is not associated with worse long-term GERD symptom control after primary laparoscopic antireflux surgery.
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Toydemir T, Tekin K, Yerdel MA. Laparoscopic Nissen versus Toupet fundoplication: assessment of operative outcomes. J Laparoendosc Adv Surg Tech A 2011; 21:669-76. [PMID: 21859310 DOI: 10.1089/lap.2011.0038] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND This study was designed to analyze the outcomes of Nissen fundoplication (NF) versus Toupet fundoplication (TF) in patients undergoing laparoscopic antireflux surgery (LARS). METHODS All perioperative data, operative/postoperative complications, and follow-up data were prospectively recorded. All patients were seen on the 2nd month postoperatively and by yearly intervals thereafter. All patients have at least 12-month follow-up. Using SPSS software, groups were compared by t-test and chi-square tests as appropriate. RESULTS One thousand consecutive patients underwent primary LARS from May 2004 to August 2009. Six hundred eighty-four patients had NF and 316 had TF fundoplication. The mean follow-up of the NF (51.26 months) group was slightly longer than the TF group (43.53 months) (P=.018). There was no mortality and conversion. Esophageal perforation, jejunal perforation, and pulmonary emboli were the sole three major complications in separate patients. Dysphagia occurred in 15.4% and 9.9% in NF and TF, respectively (P=.001). Corresponding numbers for bloating were 19.6% and 10.8% in NF and TF, respectively (P=.001). Seventeen patients underwent reinterventions such as dilatation and re-do surgery and all 17 were in the NF group (P<.05). All other minor complications were similar except hiccups, which were seen in 30 patients and all were in the NF group (P<.05). Recurrence of reflux was observed in 1.8% and 2.2% of the NF and TF, respectively (P=.620). CONCLUSION Both NF and TF are effective procedures in controlling the acid-reflux symptoms. The functional side effects appear more often in the NF group. These side effects can be minimized and reinterventions for severe/prolonged dysphagia can be avoided with TF.
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Affiliation(s)
- Toygar Toydemir
- General Surgery Department, Istanbul Surgery Hospital, Nisantasi-Istanbul, Turkey.
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Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:2647-69. [PMID: 20725747 DOI: 10.1007/s00464-010-1267-8] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Laparoscopic tailored Nissen fundoplication. Surg Endosc 2010; 24:2221-5. [DOI: 10.1007/s00464-010-0936-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 05/01/2009] [Indexed: 12/31/2022]
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Is a bougie required for the performance of the fundal wrap during laparoscopic Nissen fundoplication? Surg Endosc 2009; 24:390-4. [DOI: 10.1007/s00464-009-0592-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 05/26/2009] [Accepted: 06/05/2009] [Indexed: 01/01/2023]
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45
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Omission of the calibration bougie in laparoscopic repair of paraesophageal hernia. Surg Endosc 2009; 23:2505-8. [DOI: 10.1007/s00464-009-0426-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 01/09/2009] [Accepted: 02/16/2009] [Indexed: 01/09/2023]
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Farah JFDM, Grande JCD, Goldenberg A, Martinez JC, Lupinacci RA, Matone J. Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation. Acta Cir Bras 2009; 22:422-9. [PMID: 18235928 DOI: 10.1590/s0102-86502007000600002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Accepted: 07/17/2007] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Evaluate short results after fundoplication procedure, concerning the division of short gastric vessels. METHODS A prospective randomization of 90 patients with indication for hiatoplasty and total fundoplication with fundus mobilization was performed. They were divided into two groups: no SGV division (group A, n= 46) and with SGV division (Group B, n=44), although in both groups the gastric fundus was mobilized to perform a floppy valve. Early outcome with clinical follow up (1 year) was observed. RESULTS Both groups were similar regarding preoperative parameters and severity of gastroesophageal reflux disease (GERD). No difference in morbidity was observed during hospital stay. Nevertheless, the median operating time was 80,2 minutes in group A and 94,1 minutes (p=0,021) in Group B. Transitory dysphagia during the first year was significantly lower in group B (46,6% versus 23,2%, p=0,012). However, in 12 months clinical outcome was similar in both groups (clinical symptoms of GERD, persistent dysphagia and reoperations). CONCLUSION There was no improvement in routine division of SGV in total fundoplication procedure when the gastric fundus was mobilized.
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Mathavan VK, Yuh JN, Marks JM. Long-Term Evaluation of Patients Undergoing Laparoscopic Antireflux Surgery Without Bougie Placement. J Laparoendosc Adv Surg Tech A 2009; 19:7-12. [DOI: 10.1089/lap.2007.0135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Jeffrey M. Marks
- Department of General Surgery, Case Medical Center, Cleveland, Ohio
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Mardani J, Lundell L, Lönroth H, Dalenbäck J, Engström C. Ten-year results of a randomized clinical trial of laparoscopic total fundoplication with or without division of the short gastric vessels. Br J Surg 2009; 96:61-5. [PMID: 19016274 DOI: 10.1002/bjs.6393] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Total fundoplication is the most common antireflux operation and can be performed with or without division of the short gastric vessels. There seems to be no difference in short-term outcomes with either approach. The aim of the study was to determine whether there were the long-term differences (after 10 years). METHODS Ninety-nine patients were enrolled in the study. Short gastric vessels were divided in 52 patients (group 1) and left intact in 47 (group 2). Ten patients were lost to follow-up and seven patients died, leaving 42 patients for analysis in group 1 and 40 in group 2. All patients were evaluated by standardized quality of life questionnaires. RESULTS Three patients underwent reoperation within 5 years. Thirty-eight of 42 patients with a completely mobilized fundus reported no reflux symptoms, compared with 31 of 40 patients with intact vessels. There were no differences between the groups in other symptoms reflecting post-fundoplication complaints and quality of life outcomes. CONCLUSION When total fundoplication is performed it makes no difference whether the fundus is mobilized or not. Both types of repair provide lasting control of reflux.
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Affiliation(s)
- J Mardani
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ravi N, Al-Sarraf N, Balfe P, Byrne PJ, Reynolds JV. On-table endoscopy following laparoscopic fundoplication. J Gastrointest Surg 2008; 12:991-6. [PMID: 17874274 DOI: 10.1007/s11605-007-0299-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Narayanasamy Ravi
- University Department of Surgery, Trinity Centre for Health Sciences, St. James' Hospital, Dublin 8, Ireland
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Abstract
BACKGROUND The report herein details a prospective audit of a unit's eight-year experience of the Rossetti-Nissen fundoplication using a predominantly laparoscopic technique, selective hiatal repair, no bougie and a standardised protocol of pre- and post-operative functional endoscopic and symptom assessment. METHODS Three hundred and seventy-eight patients underwent the Rossetti-Nissen fundoplication. All patients had documented data on endoscopy, health related quality of life (HR-QoL), surgical details and complications pre-operatively and at six months post-operatively. Repeat physiological testing was performed at six months. RESULTS At a median follow-up of six (range 3-13) months there was improved symptom scoring and HR-QoL after fundoplication with an 89% patient satisfaction rate. Ninety-five patients (25%) reported some early dysphagia, and 91 of these reported the outcome of surgery to be excellent or good. Thirty-eight patients (10%) had recurrent heartburn and 28 (7%) were back on medication at six months post-operatively. At follow-up pH study at a median of six months, 89% of patients had normalised acid reflux scores. CONCLUSIONS Rossetti-Nissen fundoplication, with no use of an oesophageal bougie and no division of short gastric vessels, is an effective procedure giving 89% patient satisfaction and significant improvement in QoL parameters and physiological measurements.
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