Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.

METHODS

Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m²) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

RESULTS

The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.

CONCLUSION

Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

Complete vs partial fundoplication: a laboratory measurement of functionality and effectiveness

BACKGROUND

Complete or partial fundoplication remains controversial for the surgical treatment of GERD. While partial fundoplication is considered less effective, it is associated with less post-operative dysphagia and gas bloating compared with complete fundoplication.

AIM

To compare the mechanical efficiency of the three different types of fundoplication.

MATERIAL AND METHOD

Two studies of the LES were performed on explanted stomachs: distensibility and failure point. Measurements were taken before and after fundoplication.

RESULTS

There was no difference in distensibility between Nissen and Toupet fundoplication, however, the EGJ was more distensible following Dor fundoplication. According to failure point measurements, Nissen fundoplication was significantly more effective than Toupet, Toupet was significantly more effective than Dor (p = .016, p = .017, respectively).

CONCLUSIONS

There were significant differences in distensibility between Dor and both Nissen and Toupet, however no statistical difference between Toupet and Nissen. There was a significant difference in effectiveness between all three types of fundoplication according to the failure point. These laboratory findings demonstrate that the mechanical orientation of Nissen and Toupet have similar functionality suggesting that Toupet is as good as Nissen. While in clinical studies Toupet has fewer post-operative complications these findings support the proponents of Toupet for GERD. Abbreviation: GERD: Gastroesophageal reflux disease.

Tailoring Endoscopic and Surgical Treatments for Gastroesophageal Reflux Disease

The incidence of gastroesophageal reflux disease (GERD) remains on the rise. Pathophysiology of GERD is multifactorial, revolving around an incompetent esophagogastric junction as an antireflux barrier, with other comorbid conditions contributing to the disease. Proton pump inhibitors remain the most common treatment of GERD. Endoscopic therapy has gained popularity as a less invasive option. The presence of esophageal dysmotility complicates the choice of surgical fundoplication. Most literature demonstrates that fundoplication is safe in the setting of ineffective or weak peristalsis and that postoperative dysphagia cannot be predicted by preoperative manometry parameters. More data are needed on the merits of endoluminal approaches to GERD.

Laparoscopic anterior versus posterior fundoplication for gastro-esophageal reflux disease: a meta-analysis and systematic review

OBJECTIVES

Although laparoscopic posterior fundoplication (LPF) i.e., Nissen or Toupet have the proven efficacy for controlling gastro-esophageal reflux surgically, there remain problems with postoperative dysphagia and gas bloat syndrome. To decrease some of these postoperative complications, laparoscopic anterior fundoplication (LAF) was introduced. The aim of this study was to conduct a meta-analysis and systematic review of randomized controlled trials (RCTs) to investigate the merits and drawbacks of LPF versus LAF for the treatment of gastro-esophageal reflux disease (GERD).

DATA SOURCES, STUDY SELECTION, AND REVIEW METHODS

A search of Medline, Embase, Science Citation Index, Current Contents, PubMed, ISI Web of Science, and the Cochrane Database identified all RCTs comparing different types of LPF and LAF published in the English Language between 1990 and 2013. The meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. Data was extracted and analyzed on ten variables which include dysphagia score, heartburn rate, redo operative rate, operative time, overall complications, rate of conversion to open, Visick grading of satisfaction, overall satisfaction, length of hospital stay, and postoperative 24-h pH scores.

DATA SYNTHESIS

Nine trials totaling 840 patients (anterior = 425, posterior = 415) were analyzed. There was a significant reduction in the odds ratio for dysphagia in the LAF group compared to the LPF group. Conversely, significant reduction in the odds ratio for heartburn was observed for LPF compared to LAF. Comparable effects were noted for both groups for other variables which include redo surgery, operating time, overall complications, conversion rate, Visick's grading, patients' satisfaction, length of hospital stay, and postoperative 24-h pH scores.

CONCLUSIONS

Based on this meta-analysis, LPF compared to LAF is associated with significant reduction in heartburn at the expense of higher dysphagia rate on a short- and medium-term basis. We therefore conclude that LPF is a better alternative to LAF for controlling GERD symptoms.

Routine versus selective contrast imaging to identify the need for early re-intervention following laparoscopic fundoplication: A retrospective cohort study

BACKGROUND

The prompt recognition of complications is essential in reducing morbidity following anti-reflux surgery. Consequently, many centres employ a policy of routine post-operative contrast studies. The study aimed to examine whether routine contrast studies more effectively recognised early post-operative complications following anti-reflux surgery compared with selective use.

METHODS

This was a retrospective analysis of 240 adults who had undergone primary anti-reflux surgery. Selective use of water-soluble contrast swallows was employed for 115 patients (Group 1) while 125 patients (Group 2) had routine studies.

RESULTS

10 (0.9%) patients from Group 1 underwent contrast studies, four (40%) of which were abnormal. Routine studies in Group 2 identified thirty-two abnormalities (27%) however the inter-group difference was not significant (p = 0.32). Only one case from group 2 required immediate re-intervention. This was not statistically significant (p = 0.78). Multivariate analysis found no significant association between selective or routine imaging and re-intervention rates. One patient from group 2 presented three days following discharge with wrap migration requiring reoperation despite a normal post-operative study.

CONCLUSION

Routine use of contrast imaging following anti-reflux and hiatus hernia surgery is not necessary. It does not identify a significantly greater number of post-operative complications in comparison to selective use. Additionally, routine use of contrast studies does not ensure the diagnosis of all complications in the post-operative period.

Laparoscopic anti-reflux revision surgery after transoral incisionless fundoplication is safe and effective

BACKGROUND

Transoral incisionless fundoplication (TIF) treats gastroesophageal reflux disease (GERD) by creating a full-thickness esophagogastric plication using transmural fasteners. If unsuccessful, revision laparoscopic anti-reflux surgery (rLARS) may be performed. This study evaluated operative findings and clinical outcomes of rLARS in 28 patients with prior primary TIF.

METHODS

Intraoperative findings, complications, and symptomatic outcomes with GERD health-related quality of life (GERD-HRQL) were evaluated prospectively in patients having rLARS after TIF. Results are median with interquartile range (IQR).

RESULTS

Between 03/2009 and 08/2013, 28 patients underwent rLARS at 14 (13-50) months post-TIF for recurrent symptoms after initial improvement. Pre-rLARS endoscopies found hiatal hernia (9) and wrap disruption (12). All revisions were completed laparoscopically in 88 (70-90) min. Eight patients underwent partial fundoplication, the rest Nissen. No intraoperative or postoperative complications occurred. Operative findings included: No axial hernia in 65%; Dense adhesions in 14%; Fasteners incorporating the lateral crus in 95%; Traction diverticuli from esophagus to crura in 21%. Residual plication was noted anteriorly in 75%, posteriorly in 0%. Operative approaches: (1) Areas where the TIF fundoplication remained were left intact. This necessitated rolling the fundoplication over the fused area to prevent an endoscopic appearance of 'fold'. (2) Fasteners were cut and left to migrate into the lumen, rather than being pulled out. (3) In 8 patients with fusion of the lateral crus to TIF fundoplication and no axial hernia, revision fundoplication was performed without mediastinal mobilization but with posterior hernia repair. One patient required subsequent surgery for small paraesophageal hernia, one for refractory gas-bloat after rLARS. Dysphagia in 2 patients resolved with dilation. GERD-HRQL improved from a median of 20 (8-27) pre-TIF and 10 (1-20) pre-rLARS to 3 (0-4) at 28 months (12-40) post-rLARS (p = 0.020 for pre-rLARS to post-rLARS).

CONCLUSION

rLARS after TIF can be performed safely with excellent clinical outcomes.

A prospective nonrandomized comparison of laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication in Indian population using detailed objective and subjective criteria

BACKGROUND:

Laparoscopic Nissen fundoplication (LNF) is a commonly performed procedure for the treatment of gastro esophageal reflux disease (GERD) worldwide. However, unfavourable postoperative sequel, including gas bloat and dysphagia, has encouraged surgeons to perform alternative procedures such as laparoscopic Toupet fundoplication (LTF). This prospective nonrandomized study was designed to compare LNF with LTF in patients with GERD.

MATERIALS AND METHODS:

Hundred and ten patients symptomatic for GERD were included in the study after having received intensive acid suppression therapy for a minimum of 8 weeks. A 24-hour pH metry was done on all patients. Fifty patients having reflux on 24-hour pH metry were taken up for the surgery. Patients were further divided into group-A (LNF) and group-B (LTF).

RESULTS:

The median percentage time with esophageal pH < 4 decreased from 10.18% and 12.31% preoperatively to 0.85% and 1.94% postoperatively in LNF and LTF-groups, respectively. There was a significant and comparable increase in length of lower esophageal sphincter (LES), length of intraabdominal part of LES and LES pressure at respiratory inversion point in both the groups. In LNF-group, five patients had early dysphagia that improved afterwards. There were no significant postoperative complications.

CONCLUSION:

LNF and LTF are highly effective in the management of GERD with significant improvement in symptoms and objective parameters. LNF may be associated with significantly higher incidence of short onset transient dysphagia that improves with time. Patients in both the groups showed excellent symptom and objective control on 24-hour pH metry on short term follow-up.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease.

METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis.

RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients’ satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.

CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Short-term symptom and quality-of-life comparison between laparoscopic Nissen and Toupet fundoplications

Laparoscopic antireflux surgery is an established method of treatment of gastroesophageal reflux disease (GERD). This study evaluates the efficacy of Nissen versus Toupet fundoplication in alleviating the symptoms of GERD and compares the two techniques for the development of post-fundoplication symptoms and quality of life (QOL) at 12 months post-surgery. In this prospective consecutive cohort study, 94 patients presenting for laparoscopic antireflux surgery underwent either laparoscopic Nissen fundoplication (LN) (n = 51) from February 2002 to February 2004 or a laparoscopic Toupet fundoplication (LT) (n = 43) from March 2004 to March 2006, performed by a single surgeon (G. S. S.). Symptom assessment, a QOL scoring instrument, and dysphagia questionnaires were applied pre- and postoperatively. At 12 months post-surgery, patient satisfaction levels in both groups were high and similar (LT: 98%, LN: 90%; P = 0.21). The proportion of patients reporting improvement in their reflux symptoms was similar in both groups (LT: 95%, LN: 92%; P = 0.68), as were post-fundoplication symptoms (LT: 30%, LN: 37%; P = 0.52). Six patients in the Nissen group required dilatation for dysphagia compared with one in the Toupet group (LT: 2%, LN: 12%; P = 0.12). One patient in the Nissen group required conversion to Toupet for persistent dysphagia (P = 0.54). In this series, overall symptom improvement, QOL, and patient satisfaction were equivalent 12 months following laparoscopic Nissen or Toupet fundoplication. There was no difference in post-fundoplication symptoms between the two groups, although there was a trend toward a higher dilatation requirement and reoperation after Nissen fundoplication.

Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility

OBJECTIVE

To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication and to evaluate the success rate of these procedures. Nissen fundoplication (360 degrees ) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been recommended to use the Toupet procedure (270 degrees ) in these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia).

METHODS

200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview, endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry.

RESULTS

After two years 85% (Nissen) and 85% (Toupet) of patients were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication compared to Toupet (19 vs. 8, p < 0.05) and did not correlate with preoperative motility. Concerning reflux control the Toupet proved to be as good as the Nissen procedure.

CONCLUSION

Tailoring antireflux surgery according to the esophageal motility is not indicated, as motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation as it has a lower rate of dysphagia and is as good as the Nissen fundoplication in controlling reflux.

Esophagography predicts favorable outcomes after laparoscopic Nissen fundoplication for patients with esophageal dysmotility

BACKGROUND

We undertook this study to determine if clearance of a food bolus at preoperative esophagography predicts acceptable outcomes after laparoscopic Nissen fundoplication for patients with manometrically abnormal esophageal motility.

STUDY DESIGN

Patients with gastroesophageal reflux disease (GERD) or symptomatic hiatal hernia with evidence of esophageal dysmotility by stationary manometry underwent videoesophagography to document the ability of their esophagus to clear food boluses of varying consistencies. Sixty-six patients were identified who had manometric dysmotility yet were able to clear a food bolus at esophagography, and subsequently underwent laparoscopic Nissen fundoplication. These patients were compared with 100 randomly selected patients with normal motility who underwent laparoscopic Nissen fundoplication. Symptom reduction and satisfaction were assessed through followup. Patients with normal motility were compared with those with manometrically moderate and severe dysmotility.

RESULTS

Preoperative patient demographic data, symptoms, and symptom scores were similar among patients with normal motility and moderate or severe dysmotility. After fundoplication, symptom reduction was notable for all patients regardless of preoperative motility (p < 0.01, paired Student's t-test). There was no notable difference in postoperative symptom scores (p = NS, Kruskal-Wallis ANOVA) or in patient satisfaction (p = NS, chi-square analysis) among patients stratified by esophageal motility.

CONCLUSIONS

Patients with esophageal dysmotility documented by manometry who are able to clear a food bolus at contrast esophagography, have functional results after laparoscopic Nissen fundoplication similar to patients with normal motility. Preoperative esophagography predicts successful outcomes after laparoscopic Nissen fundoplication for patients with manometric esophageal dysmotility.

Laparoscopic cardial calibration and gastropexy for treatment of patients with reflux esophagitis: pathophysiological basis and result

Laparoscopic antireflux surgery is the gold standard procedure for treatment of patients with reflux esophagitis. The current results of the laparoscopic approach are absolutely comparables with the results obtained during the open surgery era. The Nissen, Nissen-Rossetti, or Toupet techniques are the more frequently used. We have performed cardial calibration and posterior gastropexy or Nissen fundoplication by the open approach with similar results. The purpose of this article is to present the anatomo-physiological basis for employing cardial calibration and posterior gastropexy in patients with reflux esophagitis. This study includes 108 symptomatic patients, 12 of them with associated extraesophageal manifestations ( posterior laryngitis). Endoscopic mild or moderate esophagitis was confirmed in 83 patients, Barrett's esophagus in 12 patients, and type I or II hiatal hernia in 13 patients. All patients were also submitted to manometry, 24 hour intraesophageal pH monitoring, and barium swallow before and after surgery. Follow-up ranged from 12 to 36 months. There were no conversion, major intraoperative, or postoperative complications; nor were there any deaths. Postoperative dysphagia was present in 5% of cases. Symptomatic recurrence of reflux was observed in 10.3% and endoscopic presence of esophagitis in 12.3% of cases . Lower esophageal sphincter pressure increased significantly after surgery, even in patients with endoscopic recurrence. 24-hour intraesophageal monitoring improved after surgery, except in patients with objective recurrence of esophagitis. In conclusion, laparoscopic cardial calibration with posterior gastropexy presents comparable results to those reported after Nissen fundoplication and therefore could be another excellent therapeutic option in patients with reflux esophagitis.

Gastroesophageal reflux disease: then and now

Although Galen first described esophagitis almost 2000 years ago, its relation to acid was only recognized in the 19th century by Rokitansky. Considerably more interest in the symptoms and complications of esophagitis has been evident over the last century, as gastroesophageal reflux disease displaced peptic ulceration and became the principal acid-related disease of our times. Of particular interest has been the recognition of the clinical significance of the previously overlooked extraesophageal manifestations of the disease such as laryngitis, asthma, and sleep disturbance. The evolution of highly effective medical therapy has over the last decade drastically reduced the need for surgical intervention for control of symptoms except under select conditions, especially volume-related reflux and children with refractory symptoms. The proton pump inhibitor class of drugs is indisputably the most effective overall form of management, while individual proton pump inhibitors appear to be equivalent in their efficacy. Issues that remain to be resolved include the management of nonerosive gastroesophageal reflux disease, the long-term dependence of many patients on acid-suppressing medication, and the recognition of atypical manifestations and rare but serious complications of gastroesophageal reflux disease. In this respect, Barrett's esophagus still presents a major biologic and management conundrum for the physicians and scientists alike.

Nissen vs Toupet laparoscopic fundoplication

BACKGROUND

Nissen fundoplication (360 degrees ) is the standard operation for the surgical management of gastroesophageal reflux disease (GERD). To avoid postoperative dysphagia, it has been proposed that antireflux surgery be tailored according to the degree of preexisting esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and the Toupet procedure (270 degrees ) has been recommended for these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques in terms of reflux control and complication rate (dysphagia). Our objective was to determine the impact of preoperative esophageal motility on the clinical and objective outcome, following Toupet vs Nissen fundoplication and to evaluate the success rate of these procedures.

METHODS

From May 1999 until May 2000, 200 patients with GERD were included in a prospective randomized study. After preoperative examinations (clinical interview, endoscopy, 24-h pH study and esophageal manometry), 100 patients underwent either a laparoscopic Nissen (50 with and 50 without motility disorders), or a Toupet procedure (50 with and 50 without motility disorders). Postoperative follow-up after 4 months included clinical interview, endoscopy, 24-h pH study and esophageal manometry.

RESULTS

Interviews showed that 88% (Nissen) and 90% (Toupet) of the patients, respectively, were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication than after a Toupet (30 vs 11, p <0.001) and did not correlate with preoperative motility. In terms of reflux control, the Toupet proved to be as effective as the Nissen procedure.

CONCLUSION

Tailoring antireflux surgery to esophageal motility is not indicated, since motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation because it has a lower rate of dysphagia and is as effective as the Nissen fundoplication in controlling reflux.

Surgical management of gastroesophageal reflux and outcome after laryngectomy in patients using tracheoesophageal speech

BACKGROUND

Gastroesophageal reflux disease (GERD) is common in patients with head and neck carcinoma. The impact of laparoscopic fundoplication on laryngectomy patients with tracheoesophageal prostheses for voice restoration is unknown.

METHODS

Nine laryngectomy patients who use tracheoesophageal speech underwent laparoscopic fundoplication for documented reflux. Preoperative and postoperative symptoms were recorded. Quality of speech was documented before and after fundoplication.

RESULTS

Although 88% of patients had resolution of GERD symptoms, all developed bloating and hyperflatulence. There was no difference in quality of esophageal speech after laparoscopic fundoplication.

CONCLUSIONS

Fundoplication in laryngectomy patients that use tracheoesophageal speech eliminates symptoms of gastroesophageal reflux and resolves regurgitation associated prosthesis erosion. Although nearly all patients are satisfied with outcome, there is a high incidence of postfundoplication bloating and hyperflatulence that may be life limiting. Poor quality tracheoesophageal speech should not be used as an indication for antireflux surgery.

Characterization of long-term outcomes after Toupet fundoplication: symptoms, medication use, and health status

GOALS AND BACKGROUND

Fundoplication is increasingly used for the treatment of gastroesophageal reflux disease (GERD). Few studies have tracked patient outcomes of the Toupet method for more than 1 year. Further clinical, physiologic, and patient-based outcome measures have not been well characterized for this method. The current study conducts a long-term, comprehensive outcome evaluation in patients receiving Toupet fundoplication.

STUDY

Fifty-five patients who had previously undergone fundoplication were examined. In a subset of 24 patients, esophagogastroduodenoscopy was used to assess the severity of reflux esophagitis. Manometry and ambulatory pH monitoring also were performed.

RESULTS

Patients were studied 2.9 (+/- 0.7) years after surgery. Sixty-seven percent of the sample reported heartburn, 51% reported postoperative bloating, 33% reported regurgitation, and 20% reported dysphagia. Thirty-three percent reported the use of prescription medications for GERD-related symptoms. Health status was diminished relative to population norms. Degree of GERD severity was associated with symptom reports and medication use.

CONCLUSIONS

Although fundoplication is thought to be a curative procedure, the current findings suggest that many patients take symptomatic therapies and report symptoms and diminished health status up to 2 years after the procedure. These outcomes are associated with physiologic findings. Thus, these findings suggest that symptom-free status and absence of medication use cannot be assumed for all patients after Toupet fundoplication.

Quality of life and symptomatic outcome three to five years after laparoscopic Toupet fundoplication in gastroesophageal reflux disease patients with impaired esophageal motility

BACKGROUND

Many centers practice a tailored approach to laparoscopic antireflux surgery in attempt to prevent postoperative side effects in gastroesophageal reflux disease (GERD) patients with an impaired esophageal motility. As a result of controversial findings reported in literature no worldwide accepted consensus exists regarding the appropriate indication for this tailored approach. The aim of this prospective study was to evaluate quality of life and symptomatic outcome in selected patients for a follow-up of 3 to 5 years.

METHODS

A total of 155 patients with esophageal dismotility underwent laparoscopic Toupet fundoplication (LTF). Basic requirements for surgery included in all patients a detailed evaluation of symptoms and quality of life (Gastrointestinal Quality of Life Index [GIQLI]), esophagogastroduodenoscopy, 24-hour pH monitoring, and esophageal manometry. Patients were evaluated 6 weeks, 3 months, 1 year, and 3 to 5 years after LTF.

RESULTS

GERD-related symptoms such as heartburn, regurgitation, dysphagia, or chest pain showed a significant improvement (P <0.05 to 0.001) in all gradings immediately after surgery. During the complete follow-up, a total of 4 patients (2.6%) required laparoscopic redo surgery because of recurrent GERD symptoms. Two patients (1.3%) were adequately maintained on short-term proton pump inhibitor therapy because of mild symptoms. All these patients have shown a pathological DeMeester score within the early period after surgery (3 months or 1 year control). Severe and persistent side effects have been present in 7 patients (4.5%), mild to moderate side effects in 11 patients (7.1%). Other side effects have been temporary and resolved spontaneously. GIQLI improved significantly (P <0.05 to 0.01) in all dimensions and persisted for at least 5 years with mean values comparable with healthy individuals.

CONCLUSIONS

LTF is effective, well tolerated, and improves quality of life, improving long-term outcome with an acceptable rate of long-term side effects in GERD patients with moderate to severe esophageal dismotility for a follow-up period of 3 to 5 years.

Laparoscopic fundoplication for symptomatic but physiologic gastroesophageal reflux

Esophageal pH monitoring identifies some patients who have physiologic amounts of esophageal acid exposure but have a strong correlation between symptoms of esophageal reflux events. These patients with symptomatic physiologic reflux probably have enhanced sensory perception of reflux events and may be difficult to control with acid-suppressive therapy. Little is known about the role of fundoplication in such patients. Patients with no endoscopic evidence of gastroesophageal reflux disease and a normal 24-hour pH composite score (<22.4 in our laboratory), but a symptom index (SI = number of symptoms with pH <4/total number of symptoms) greater than 50% were offered laparoscopic fundoplication if acid-suppressive therapy was unsatisfactory. This group comprised 18 (4%) of 459 patients undergoing fundoplication at our institution. Heartburn, dysphagia, and reflux symptoms were scored on a scale of 0 to 10 with patients on and off medicine preoperatively, and at a mean of 7.2 months (range 1 to 32 months) postoperatively. The 18 patients with symptomatic physiologic reflux (6 males and 12 females) had heartburn as a major complaint. Preoperative response to proton pump inhibitors for heartburn was 72% and for all symptoms was 60%. The group had a mean pH composite score of 14 (range 4 to 22). The symptom used to calculate the symptom index was heartburn in 12 patients, regurgitation in three, chest pain in two, and cough in one. An average of 18 symptoms (range 2 to 56) were recorded. The mean symptom index was 82% (range 50% to 100%). A Nissen fundoplication was performed in nine patients and a Toupet fundoplication in nine. Surgery was successful (>90%) in alleviating reflux symptoms in 14 patients and partially successful (>75%) in three of the remaining four patients. Gas bloat and dysphagia were seen in one patient each. Fundoplication is effective at relieving reflux symptoms in carefully selected patients with symptomatic physiologic reflux, with minimal side effects.

Predictors of outcome in 100 consecutive laparoscopic antireflux procedures

BACKGROUND

Published success rates for surgical intervention in gastroesophageal reflux disease exceed 90%. The goal of this study was to determine if any preoperative factors could accurately predict postoperative symptom relief.

METHODS

One hundred consecutive patients undergoing laparoscopic antireflux surgery completed a detailed preoperative questionnaire, and underwent endoscopy, manometry, and 24-hour esophageal pH monitoring. Two surgeons performed all procedures in a standardized fashion. At least 2 months following operative intervention, a single interviewer, blinded to all preoperative information and procedure performed, recorded Visick and Gastroesophageal Reflux Disease-Health-Related Quality of Life scores for all patients. All follow-up was performed within 3 years of antireflux procedure.

RESULTS

The surgical success rate, as defined by Visick scores of 1-2, was 91%. Three variables were predictive of postoperative success: age <50, presence of typical symptoms at presentation, and complete resolution of symptoms with acid suppression therapy.

CONCLUSION

The study shows that surgical strategies can reproducibly control gastroesophageal reflux disease symptoms in more than 90% of patients. The optimal surgical candidate is a patient under the age of 50 whose typical symptoms completely resolve with acid suppression therapy.

Evaluation of 142 consecutive laparoscopic fundoplications in children: effects of the learning curve and technical choice

PURPOSE

This retrospective study describes the 5-year experience of a single surgeon with 142 consecutive laparoscopic fundoplications in children and analyzes the results in terms of the surgeon's learning curve and the choice of technique.

METHODS

The patients were 44 girls (40%) and 98 boys (60%) with an age range of 3 months to 18 years (mean, 5.35 years). Indications for surgery included medically refractory reflux associated with vomiting, pneumopathy, otorhinolaryngologic pathology, failure to thrive, esophagitis, apnea and bradycardia, or anemia. The laparoscopic surgery used 5 trocars of 5 mm or 3 mm, with a 30 degrees telescope.

RESULTS

Laparoscopic fundoplication was successful in 139 cases. The authors performed 13 Nissen techniques without short gastric vessel division (SGVD), 47 Toupets without SGVD, 9 Toupets with SGVD, and 70 Nissens with SGVD. Mean operating time was 105 minutes (range, 45 to 300). Mean time was 125 minutes for the first 60 cases and 93 minutes for the other 79 cases). Intraoperative and postoperative complication rates were 0.5% and 2%, respectively, and the complications occurred in the first 60 cases. Mean postoperative hospital stay was 3 days (range, 2 to 14).

CONCLUSIONS

The rate of complication caused by the laparoscopic procedure was acceptable, and it decreased with the surgeon's experience. Complications and conversions to open technique occurred only in the beginning of the operator's experience. Dysphagia, epigastric pain, gas bloating, and early reflux recurrences were noted among the first 60 cases but seemed to be consecutive to the fact that the gastric vessels were not divided. J Pediatr Surg 36:921-926.

Dysphagia after antireflux surgery

BACKGROUND

Dysphagia is experienced by many patients after antireflux surgery. This literature review examines factors associated with the development, prediction and management of postoperative dysphagia.

METHODS

Published studies examining issues related to dysphagia, gastro-oesophageal reflux and fundoplication were reviewed.

RESULTS

Postoperative dysphagia is usually temporary but proves troublesome for 5--10 per cent of patients. Technical modifications, such as a partial wrap, division of short gastric vessels and method of hiatal closure, have not conclusively reduced its incidence. There is no reliable preoperative test to predict dysphagia.

CONCLUSION

It is uncertain whether postoperative dysphagia arises from patient predilection or is largely a consequence of mechanical changes created by fundoplication. Anatomical errors account for a significant proportion of patients referred for correction of dysphagia but these are uncommon in large single-institution studies. Abnormal manometry cannot predict dysphagia and, on current evidence, 'tailoring' the operation does not prevent its occurrence.

[Laparoscopic posterior fundoplication in gastroesophageal reflux: mid-term results]

STUDY AIM

The aim of this study was to report the mid-term results of the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic posterior partial fundoplication (Toupet technique) in 100 patients, and to evaluate their post-operative quality of life.

PATIENTS AND METHOD

Between November 1993 and January 2000, 100 patients were surgically treated for a medically refractory GERD. Laparoscopic posterior partial fundoplication was performed by the Toupet technique. In the postoperative period, the patients were asked to answer a questionnaire by telephone. The aim of this survey was three-fold: to identify clinical symptoms indicative of recurrence; to evaluate postoperative functional impairment; to assess the postoperative quality of life. pH monitoring was also proposed in asymptomatic patients at a minimum follow-up of two years, and in all patients with clinical symptoms of GERD recurrence.

RESULTS

Six laparotomy conversions were necessary. The mean duration of follow-up was 18 months (range: 6 to 57 months). The rate of clinically diagnosed recurrence was 7.6%. Intermittent dysphagia was observed in 2.3% of cases. Postoperative digestive functional disorders were noted in 53% of patients without clinical recurrence, and 95.3% of them were satisfied or very satisfied with the results of surgery.

CONCLUSION

Laparoscopic posterior partial fundoplication by the Toupet technique can satisfactorily treat GERD without mid-term recurrence in about 94% of cases. Patient satisfaction seems mainly to depend on the disappearance of clinical symptoms of GERD. It was found that postoperative functional disorders frequently occurred, but were well tolerated. Their etiology has not yet been determined, and it is considered that factors other than the surgical procedure may also play a role.

Advances in minimally invasive esophageal surgery

Advances in minimally invasive techniques have substantially expanded the role of surgery in the treatment of esophageal disease. In many cases this expansion has made more effective treatment available to a larger number of patients. Gastroesophageal reflux disease, paraesophageal hernias, and achalasia are now routinely treated laparoscopically, and laparoscopy is beginning to be used for total esophagectomy as well. The introduction of this technology has created new controversies and revitalized existing ones in the surgical treatment of esophageal disease. The indications, techniques, and outcomes of videoendoscopic approaches to the esophagus, as well as the controversies surrounding them, are discussed in this review.

Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication

BACKGROUND

In the operative management of gastro-oesophageal reflux, a balance must be achieved between adequate control of reflux and excessive dysphagia. The ideal technique is not known. A randomized study was performed to determine whether laparoscopic anterior fundoplication is associated with a lower incidence of postoperative dysphagia than laparoscopic Nissen fundoplication, while achieving equivalent control of reflux.

METHODS

Patients presenting for laparoscopic antireflux surgery were randomized to undergo either a Nissen fundoplication (n = 53) or an anterior 180 degrees hemifundoplication (n = 54). Patients were blinded to which procedure had been performed, and follow-up was obtained by a blinded independent investigator. Standardized clinical grading systems were used to assess dysphagia, heartburn and patient satisfaction 1, 3 and 6 months after operation. Objective measurement of lower oesophageal sphincter pressure, oesophageal emptying time, distal oesophageal acid exposure and endoscopic healing of oesophagitis was also performed.

RESULTS

Operating time was similar for the two procedures (58 min for the Nissen procedure versus 60 min for anterior fundoplication). Resting and residual lower oesophageal sphincter pressures were lower following anterior fundoplication (29 versus 18 mmHg, and 13 versus 6 mmHg), and oesophageal emptying times were faster (92 versus 116 s). Acid exposure times and ability to heal oesophagitis were similar. At 3 months' follow-up clinical outcomes were similar for the two procedures. At 6 months, however, patients who had undergone anterior fundoplication experienced significantly less dysphagia for solid food and were more likely to be satisfied with the clinical outcome.

CONCLUSION

Laparoscopic anterior fundoplication achieved equivalent control of reflux, more physiological postoperative manometry parameters, and an improved clinical outcome at 6 months. Continued follow-up remains necessary to confirm the long-term efficacy of the partial fundoplication procedure.

Antireflux surgery in the laparoscopic era

BACKGROUND

The recent development of laparoscopic techniques for fundoplication has created renewed interest in surgery for gastro-oesophageal reflux disease, leading to reports of large clinical series from many centres. However, controversy remains about technical aspects of laparoscopic antireflux surgery, with no consensus yet reached about a standard operative technique. It is important, therefore, to reassess critically the results of laparoscopic surgery for reflux disease, so that its current status can be determined.

METHODS

Published outcome studies for laparoscopic antireflux surgery, as well as selected studies from the era of open antireflux surgery, were reviewed to assess outcomes.

RESULTS

The results of case series for laparoscopic antireflux surgery with short- and medium-term follow-up, as well as the early results of randomized trials, confirm that this approach reduces the early overall morbidity of surgery for reflux disease. However, certain complications may be more common, for instance paraoesophageal hiatus herniation, pneumothorax and oesophageal perforation, requiring surgeons to use specific strategies which can help to avoid these problems. Published studies and trials do not support the routine or selective application of a posterior partial fundoplication technique or routine division of the short gastric vessels during Nissen fundoplication.

CONCLUSION

At present, a short loose Nissen fundoplication performed laparoscopically, with or without division of the short gastric vessels, is an appropriate surgical approach for gastro-oesophageal reflux disease. However, long-term outcomes following laparoscopic antireflux surgery will not be available for some years, and must be awaited before the final status of the various laparoscopic techniques can be confirmed.

Efficacy of anterior, posterior and total fundoplication in an experimental model

BACKGROUND

This study examined the effect of different types of laparoscopic fundoplication on an incompetent lower oesophageal sphincter to test their effectiveness at preventing gastro-oesophageal reflux in the early postoperative period.

METHODS

An experimental porcine model was used. Initial oesophageal myotomy ensured an incompetent lower oesophageal sphincter with free reflux of 'intragastric fluid'. Anterior, posterior or total fundoplication was then performed laparoscopically in 15 laboratory pigs (five in each group). Fundoplication competence and efficacy were determined 2 weeks after laparoscopic antireflux surgery by inflating the stomach with liquid through a gastrostomy cannula. Some animals were also studied at 4 and 6 weeks. Lower oesophageal sphincter pressure was determined using a water-perfused oesophageal manometry catheter incorporating a Dent sleeve.

RESULTS

All three types of fundoplication produced similar increases in postoperative resting lower oesophageal sphincter pressure and restored adequate competence to the gastro-oesophageal junction.

CONCLUSION

All three variants of laparoscopic fundoplication restore gastro-oesophageal competence in the early postoperative period.

The surgical management of Barrett's esophagus

Barrett's esophagus is an increasing health concern in most Western countries. The diagnosis is usually made during investigation of patients with symptoms of gastroesophageal reflux disease. The appropriate antireflux procedure, performed in properly selected patients, provides long-term symptomatic relief in 80% to 90% of patients. The effect of reliable and complete control of gastroesophageal reflux on the natural history of Barrett's metaplasia once it has developed and on its prevention in symptomatic patients who have not yet developed Barrett's changes is one of the most important areas of study over the next decade.

A randomized, prospective comparison of the Nissen fundoplication versus the Toupet fundoplication for gastroesophageal reflux disease

OBJECTIVE

A prospective, randomized trial was performed to determine which of two antireflux procedures, a complete wrap (Nissen) or a 200N wrap (Toupet), was more effective with fewer sequelae.

SUMMARY BACKGROUND DATA

Laparoscopic procedures for gastroesophageal reflux disease appear to be as effective as those done by open laparotomy. The Nissen fundoplication is used most frequently, but postoperative bloating, inability to belch, and dysphagia occur. The partial wrap has been said to be as effective with less unfavorable postoperative symptoms.

METHODS

Patients with reflux esophagitis were approached laparoscopically using a six-port technique. After division of the short gastric vessels and dissection of the terminal esophagus and fundus of the stomach to allow performance of either procedure, patients randomly were assigned one of the procedures by a card drawn in the operating room.

RESULTS

Forty patients underwent operation, but 1 was excluded when an open procedure became necessary. Twenty-three patients received a complete wrap and 16 received a partial wrap. The average operating time was 155 minutes for the Nissen procedures and 162 minutes for the Toupet procedures. The postoperative stay averaged 2.7 days for the Nissen procedures and 2.5 days for the Toupet procedures. There were no deaths. Including the patient converted to an open procedure, three patients had operative complications. At follow-up, Visick scores after the complete wraps were I-13, II-8, III-2 and after the partial wrap were I-12 and II-3. Two patients indicated they would not have the operation again.

CONCLUSIONS

A partial or a complete wrap after division of the short gastric vessel offers effective therapy for reflux esophagitis with > 90% patient satisfaction. The authors' study shows no clear advantage of one wrap (partial or complete) over the other.