Laparoscopic refundoplications after failed antireflux surgery

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Re-operation for failed gastro-esophageal fundoplication. What results to expect?

The aim of this study is to evaluate short and medium term results of re-operation for failed fundoplication in a retrospective monocentric cohort of 47 patients.

PATIENTS AND METHODS

Between 1995 and 2011, 595 patients underwent a laparoscopic primary fundoplication (PFP) for gastroesophageal reflux disease (GERD). During the same period, 47 patients required a re-operative fundoplication (RFP). In 11 patients, the original wrap had herniated into the thorax. All these revisions consisted of a complete takedown of the original wrap before constructing a tension-free wrap using a standardized technique. Patients with a follow-up of at least 2 years were matched to patients who had been operated only once to assess satisfaction and quality of life.

RESULTS

Short term: All patients were operated by laparoscopy with no conversion. There was no mortality. Two postoperative complications necessitating re-operation were observed (morbidity 4.3%): one complete aphagia and one gastric perforation. Long term: 29 re-operated patients with a follow-up of at least 2 years (mean: 4,5 years) (Group RFP) were compared to a matched group of 29 patients operated only once (Group PFP). These groups were comparable in age, sex ratio, BMI and follow-up. In both groups, all patients were operated by laparoscopy without conversion. Morbidity was 3.5% in the RFP group, none in the PFP group. There was no mortality in either group. The length of stay and operative time were significantly higher in the RFP group (4.6 vs. 2.6 days, p<0.05). Two RFP patients (5%) required re-operation at three and seven months vs. none in the PFP group. The long-term satisfaction was comparable in the two groups (78% vs. 85%, p=NS). Quality of life assessed by the GIQLI was significantly better in the PFP group (104 vs. 84, p<0.05).

CONCLUSION

Re-do fundoplication is a safe procedure and is feasible by laparoscopy. In the long-term, patient satisfaction is comparable to primary intervention with, however, a slightly poorer quality of life.

Surgical reintervention after failed antireflux surgery: a systematic review of the literature

BACKGROUND

Outcome and morbidity of redo antireflux surgery are suggested to be less satisfactory than those of primary surgery. Studies reporting on redo surgery, however, are usually much smaller than those of primary surgery. The aim of this study was to summarize the currently available literature on redo antireflux surgery.

MATERIAL AND METHODS

A structured literature search was performed in the electronic databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

RESULTS

A total of 81 studies met the inclusion criteria. The study design was prospective in 29, retrospective in 15, and not reported in 37 studies. In these studies, 4,584 reoperations in 4,509 patients are reported. Recurrent reflux and dysphagia were the most frequent indications; intraoperative complications occurred in 21.4% and postoperative complications in 15.6%, with an overall mortality rate of 0.9%. The conversion rate in laparoscopic surgery was 8.7%. Mean(+/-SEM) duration of surgery was 177.4 +/- 10.3 min and mean hospital stay was 5.5 +/- 0.5 days. Symptomatic outcome was successful in 81.1% and was equal in the laparoscopic and conventional approach. Objective outcome was obtained in 24 studies (29.6%) and success was reported in 78.3%, with a slightly higher success rate in case of laparoscopy than with open surgery (85.8% vs. 78.0%).

CONCLUSION

This systematic review on redo antireflux surgery has confirmed that morbidity and mortality after redo surgery is higher than after primary surgery and symptomatic and objective outcome are less satisfactory. Data on objective results were scarce and consistency with regard to reporting outcome is necessary.

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center. Data on patients undergoing antireflux surgery in our unit has been prospectively collected and includes more than 600 primary laparoscopic antireflux operations since 1993. Laparoscopic reoperations have been performed between 1996 and 2005 for patients suffering recurrent reflux, dysphagia or severe gas bloat symptomatic despite medical treatment. All patients underwent preoperative barium studies and endoscopy with selective manometry and pH studies. Symptomatic outcomes were evaluated at 6 weeks and 12 months with Visick scores. Anatomical results were assessed with barium studies at between 6 and 12 months. Thirty-five laparoscopic reoperations were performed in 20 women and 13 men (median age 56 years). Primary surgery had been performed in our unit in 27 (77%) and elsewhere in eight (23%). Median time from primary surgery was 28.5 months (5-360). Two patients underwent a second reoperation. Indication was recurrent reflux in 28 (80%), dysphagia in five (14%) and gas bloat in two (6%). Thirty-two of the 35 reoperations (91.4%) were completed laparoscopically, median operating time was 120.5 min (65-210) and median hospital stay 2 days. There was no mortality and there were only five minor complications. Twelve-month follow-up was available for 32 reoperations (91%). Overall good symptomatic outcomes were obtained in 26 (74%) Visick I or II at 6 weeks and 24 of 32 (75%) at 12 months. In reoperations for dysphagia/gas bloat there was a relative risk of 4.26 of a poor symptomatic outcome (Visick III or IV) at 12 months compared to those for recurrent reflux (P < 0.05, Fisher's exact test). Laparoscopic reoperation is feasible with low conversion rates and minimal morbidity for patients who have undergone previous abdominal or thoracic hiatal repair. Symptomatic outcomes are generally good, particularly if the indication is recurrent reflux.

Symptomatic and functional outcome after laparoscopic reoperation for failed antireflux surgery

BACKGROUND

The aim was to determine symptomatic and functional outcome after reoperative antireflux surgery for recurrent reflux, persistent dysphagia and severe gas bloat, using a primarily laparoscopic surgical approach.

METHODS

This was a retrospective analysis of prospectively collected data from 118 patients, of whom 70 had reoperative surgery for recurrent reflux, 35 for dysphagia and 13 for gas bloat. DeMeester scores before and 1 year after surgery, functional symptoms after surgery and overall patient satisfaction were analysed.

RESULTS

Reoperation was completed laparoscopically in 101 patients (85.6 per cent), in 28 after previous open hiatal surgery. The operation was converted from an initial laparoscopic approach to open surgery in 17 patients. One-year follow-up data were available for 104 patients (88.1 per cent). After reoperation for recurrent reflux, 84 per cent had a DeMeester heartburn score of zero or one, and 87 per cent had a regurgitation score of zero or one. After reoperation for dysphagia, 21 of 32 patients had a dysphagia score of zero or one, with improvement observed in 25. All patients undergoing reoperation for severe gas bloat were satisfied with the outcome 1 year after operation.

CONCLUSION

Revisional surgery for recurrent reflux using a laparoscopic approach offered high rates of success and patient satisfaction. Swallowing returned to normal in two-thirds of patients after reoperation.

Laparoscopic mesh repair antireflux surgery for treatment of large hiatal hernia

One of the most frequently occurring anatomic failures after laparoscopic fundoplication is migration of the wrap into the chest, with or without disruption. This so-called 'slipped' Nissen fundoplication may be the result of inadequate closure of the diaphragmatic crura or rupture of the sutures or disruption of the muscle fibers approached. From January 2000 to December 2002, a total of seven patients (four male) with a mean age of 56 years (range 22-72 years), were considered for laparoscopic antireflux procedure using DACRON mash to reinforce the crural hiatal closure. The patients were operated under general anesthesia; laparoscopy was performed by classical approach with five trocars. The mean operative time was 120 minutes (range 40-240 min). There were no deaths. The average of postoperative hospital stay was 3.5 days (range, 3-5). Patients returned to normal activities usually on postoperative day 10 (range, 7-15). The follow-up time was at least 2 years. There was only one late complication related to the use of DACRON mesh at the hiatus, due to migration of the mesh into the esophageal lumen causing disphagia. In conclusion the mesh repair antireflux surgery is a good alternative for closing the diaphragmatic defect in large hiatal hernias or to correct this problem in case of recurrence or Barrett's esophagus.

Austrian experiences with redo antireflux surgery

BACKGROUND

From 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results.

METHODS

A questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms).

RESULTS

Out of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach.

CONCLUSION

Laparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience.

Late laparoscopic reoperation of failed antireflux procedures

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.

Laparoscopic reoperative surgery after laparoscopic fundoplication: an initial experience

BACKGROUND

Primary fundoplication results are good to excellent. We explored failure patterns and results of redo fundoplication surgery.

STUDY DESIGN

Between January 1999 and July 2002, 10 redo laparoscopic fundoplications were attempted, 1 for the third time. Indications were large symptomatic hiatal hernia-2, hiatal hernia with reflux-2, hiatal hernia with reflux and dysphagia-1, hiatal hernia with dysphagia-2, bloating with dysphagia-1, dysphagia-1, and dysphagia for the third attempt.

RESULTS

Two conversions (20%) were caused by dense adhesions at the crura and mediastinum. There were 8 recurrent hiatal hernia repairs. Fundoplication was left in place in 2 patients. Fundoplication was redone in 4 (2 were slipped), converted to Toupet in 2, or taken down in 1 (with esophageal myotomy). Pyloroplasty was performed in 2 patients and cruroplasty in 1. Laparoscopy operating room time was 140 (64 to 210) minutes and converted 210 and 295 minutes. Intraoperative complications occurred in 30% of patients (gastric perforation 1, bilateral chest tubes 2). Length of hospital stay was 3 (1 to 8) days for laparoscopic, 3 and 5 for converted. One patient was reoperated on acutely for a hiatal reherniation. Follow-up was 16 (1 to 40) months: 3 were symptom free, 2 had mild reflux symptoms, and were on prn H2 blockers, 1 mild bloating, 2 mild dysphasia, 2 moderate dysphagia, 1 had been dilated, and the other failed dilation and was redone.

CONCLUSIONS

Hiatal hernia was the most common cause of symptoms leading to redo surgery. Laparoscopic redo surgery is effective for dysphagia and recurrent heartburn. Results are not as good as for first-time fundoplication and morbidity is higher.

The management of patients who have "failed" antireflux surgery

Gastroenterologists may be called upon to manage patients who have had antireflux surgery that failed. The available literature on this topic comprises predominantly reports on retrospective, observational studies written by surgeons who often have focused on how technical deficiencies in performing the operation led to the failure. Such reports are of limited value to the gastroenterologist seeking guidance on patient management. Furthermore, comparisons among the reports are confounded by the lack of a standardized definition for failed antireflux surgery. This report critically reviews the available literature, and suggests a practical approach to the management of patients who have symptoms that were not completely relieved, that reappeared later, or that were caused by antireflux surgery.

Comparison of patient satisfaction after redo and primary fundoplications

BACKGROUND

Although much has been written about the results and patient satisfaction with fundoplication for the treatment of gastroesophageal reflux disease, the reports have focused primarily on surgical successes. With the growing number of fundoplications being performed, more patients are requiring reoperation because of recurrent symptoms or side effects. Reports of success rates for reoperation are available, but information regarding patient satisfaction is limited.

METHODS

All the patients undergoing fundoplication at our institution were sent short-form health surveys (SF-12), Gastroesophageal reflux disease-specific quality-of-life questionnaires (QOLRAD), and queries regarding long-term satisfaction.

RESULTS

Between November 1992 and July 2000, 221 patients (198 primary and 23 redo) underwent fundoplication. There were 19 open cases (3 primary and 16 redo). In the primary group, 173 patients underwent Nissen, 23 underwent Toupet, and 2 underwent Collis fundoplications. In the redo group, 12 patients underwent Nissen, 9 underwent Toupet, 1 underwent Collis, and l underwent Belsey fundoplications. Follow-up surveys were completed for 130 patients (112 primary and 18 redo) at a mean of 32.6 months (range, 0.8-98 months). In the primary group, 87% of the patients were satisfied with their operation, as compared with 75% in the redo group. There was a trend toward higher SF-12 mental scores (46 +/- 12 vs 40 +/- 14; p = 0.07) and QOLRAD scores (6.2 +/- 1.3 vs 5.2 +/- 2.0; p = 0.07) in the primary fundoplication group. There was a significant difference in the SF-12 physical scores between the groups (32 +/- 13 for the primary group vs 18.5 +/- 11 for the redo group; p = 0.0002). Additionally, 61% of the patients in the redo group were again using antireflux medications, whereas only 24% of the patients in the primary group were using medications again.

CONCLUSION

Gastroesophageal reflux disease symptom scores and quality-of-life scores for patients undergoing redo fundoplication are lower than the scores of patients having primary fundoplication. Quality of life is similar between primary and redo fundoplication patients in the mental component. However, redo patients do not do as well physically more than 2 years after surgery.

Short esophagus: literature incidence

There are controversies regarding existence and incidence of short esophagus. The authors reviewed the literature incidence of short esophagus among operated patients due to gastroesophageal reflux disease in the last 3 years. The overall incidence of short esophagus was 1.53%. The proposed risk factors (paraesophageal hernia, Barrett's esophagus, reoperation, esophageal strictures and access route) do have a higher incidence of short esophagus, with the exception of the Barrett's esophagus. Although several biases can be associated with the review, the authors identified the short esophagus incidence in the literature.

Determining an appropriate threshold for referral to surgery for gastroesophageal reflux disease

BACKGROUND

Persistent symptomatic gastroesophageal reflux disease (GERD) can be treated with medication or surgery. The purposes of this study were (1) to determine how poor the quality of life on medication would need to be to justify assuming the risks of surgery, and (2) to estimate the proportion of patients currently on medication whose quality of life is below this value.

METHODS

We developed a Markov decision analysis model to simulate health outcomes (measured in quality adjusted life years [QALY]) over 10 years for medication and surgery in patients with typical GERD symptoms. We included probabilities of events obtained from a systematic literature review. Quality of life adjustments, expressed as utilities, were drawn from a survey of 131 patients 1 to 5 years after antireflux surgery. By using this model, we calculated what quality of life on medications would change the optimal strategy from medication to surgery (threshold). To determine the proportion of patients below this value, we prospectively surveyed 40 medically treated GERD patients at our hospital.

RESULTS

Surgery resulted in more QALYs than medical therapy when the utility with medication use was below 0.90. Sensitivity analysis showed this value to be relatively insensitive to reasonable variations in surgical risks (mortality, failures, reoperation) and quality of life after surgery. Among those surveyed on medications, 48% fell below this threshold and would be predicted to benefit from surgery.

CONCLUSION

Our model suggests that surgery would likely benefit a high proportion of medically treated GERD patients. Individual assessment of quality of life with GERD should be considered to aid clinical decision making.

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: quality of life, symptomatic outcome, and patient satisfaction

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluated using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery.

Minimally Invasive Surgical Techniques in Reoperative Surgery for Gastroesophageal Reflux Disease in Infants and Children

Fundoplication is commonly performed in children suffering from complications of gastroesophageal reflux disease (GERD). Recently laparoscopic fundoplication has become a standard of care for GERD in children. Published reports show that 2.3 to 14 per cent of children require reoperation after failed fundoplication. The purpose of this study is to show the feasibility of minimally invasive surgical (MIS) techniques to treat children after failed fundoplication. A retrospective chart review was performed for all patients who underwent laparoscopic redo fundoplication at Children's Healthcare of Atlanta at Egleston from July 1998 to July 2000. The patients' records were reviewed for age, diagnosis, type and time of initial operation, type and time of redo operation, operative time for redo operation, and complications. Seventeen children (age 3 months to 18 years) had operations for failed fundoplication attempted using MIS techniques. Six of these children were referred after their initial operation performed elsewhere. Nine (53%) were neurologically impaired. Ten (59%) have respiratory complications of GERD. The initial procedures were as follows: One open Nissen fundoplication, two open Thal fundoplications, 13 laparoscopic Nissen fundoplications, and one laparoscopic Toupet fundoplication. The reoperative procedures performed were revision of fundoplication and hiatal hernia repair (13) or hiatal hernia repair only (four). Two patients had concurrent gastric emptying procedures. One procedure was converted to open for technical reasons. One patient developed a pelvic abscess secondary to leakage around the gastrostomy tube. One child had erosion into the esophagus of a Dacron® patch that was used to close a large hiatal defect. Thirteen patients began feeding by the first postoperative day. We conclude that MIS techniques can be applied to reoperative surgery for the treatment of GERD with an acceptable complication rate in this difficult group of patients. Reoperative patients appear to have the same benefits from MIS as patients undergoing their initial procedure.

Mid- and long-term quality of life assessments after laparoscopic fundoplication and refundoplication: a single unit review of more than 500 antireflux procedures

BACKGROUND

For the evaluation of surgical interventions, quality of life data are being increasingly used as an efficacy endpoint.

AIMS

To evaluate impact of laparoscopic fundoplication and laparoscopic refundoplication on quality of life as well as on patient satisfaction with the procedure for at least 5 years after surgical intervention.

PATIENTS

After more than 500 laparoscopic antireflux procedures, quality of life data have been prospectively reviewed and data compared with healthy individuals, untreated gastro-oesophageal reflux disease patients (n = 150) and successfully treated patients (n = B4) under adequate omeprazole therapy.

METHODS

Gastrointestinal Quality of Life Index has been used in all patients and evaluated the day before surgery and 5 times after surgery. Moreover, the SF-36 questionnaire has been used up to 2 years after surgical intervention, but only in patients who underwent laparoscopic redo-surgery (n = 49).

RESULTS

In both surgical groups, mean preoperative Gastrointestinal Quality of Life Index showed a significant (p < 0.01) impairment (before laparoscopic antireflux surgery: 90.4 +/- 10.3 points; before redo-surgery: 84.3 +/- 8.1 points) when compared with healthy individuals (mean: 122.6 +/- 8.5 points) and successfully treated patients with acid-suppressive therapy (mean: 121.4 +/- 9.2 points). After surgery, the mean Gastrointestinal Quality of Life Index increased significantly and remained stable for at least 5 years after laparoscopic antireflux surgery (120.8 +/- 8.6 points) or for at least 2 years after redo-proce-dure (120.9 +/- 7.2 points). Before laparoscopic refundoplication, 6 out of 8 SF-36 scores were significantly p < 0.05) decreased. Redo-surgery influenced these 6 scores significantly (p < 0.05-0.01), resulting in values comparable to those of general population. Patients' satisfaction with surgery was excellent or good in 95%.

CONCLUSION

Both, laparoscopic fundoplication as well as laparoscopic refundoplication are able to improve patients' quality of life significantly for at least 5 years. Therefore, quality of life data provide useful information to discuss different treatment options with patients.

Laparoscopic antireflux surgery with routine mesh-hiatoplasty in the treatment of gastroesophageal reflux disease

One of the most frequent complications after laparoscopic antireflux surgery is intrathoracic migration of the wrap ("slipped" Nissen fundoplication). The most common reasons for this are inadequate closure of the crura or disruption of the crural closure. The aim of this prospective study was to evaluate surgical outcomes in patients who underwent laparoscopic antireflux surgery with simple nonabsorbable polypropylene sutures for hiatal closure in comparison to patients who underwent routine mesh-hiatoplasty. Between 1993 and 1998, a group of 361 patients underwent primary laparoscopic Nissen or Toupet fundoplication with the use of simple nonabsorbable polypropylene sutures for hiatal closure. Since December 1998, in all patients (n = 170) who underwent laparoscopic antireflux surgery, a 1 x 3 cm polypropylene mesh was placed on the crura behind the esophagus to reinforce them. Functional outcome, symptoms of gastroesophageal reflux disease, and postoperative complications such as recurrent hiatal hernia with or without intrathoracic migration of the wrap have been used for assessment of outcomes. In the initial series of 361 patients, postoperative herniation of the wrap occurred in 22 patients (6.1%). Of these 22 patients, 17 of them (4.7%) had to undergo laparoscopic redo surgery. The remaining five patients were free of symptoms. In comparison to these results, in a second group of 170 patients there was only one (0.6%) who had postoperative herniation of the wrap into the chest. There have been no significant differences in objective data such as DeMeester scores or lower esophageal sphincter pressure between the two groups. Postoperative dysphagia was increased during the early period after surgery in patients undergoing mesh-hiatoplasty but resolved without any further treatment within the first year after laparoscopic antireflux surgery. We concluded that routine hiatoplasty with the use of a polypropylene mesh is effective in preventing postoperative herniation of the wrap and leads to a significantly better surgical outcome than closure of the hiatal crura with simple sutures, without any additional long-term side effects.

Dysphagia and quality of life after laparoscopic Nissen fundoplication in patients with and without prosthetic reinforcement of the hiatal crura

BACKGROUND

Recurrent hiatal hernia with or without intrathoracic wrap migration ("slipping Nissen") is one of the most common complications after laparoscopic Nissen fundoplication (LNF). Therefore, we decided to reinforce the hiatal crura using a prosthetic mesh prosthesis in an attempt to reduce recurrent hiatal hernia.

METHODS

The current nonrandomized study compares the surgical outcome, including quality of life data [Gastrointestinal Quality of Life Index (GIQLI)] and subjective degree of dysphagia, in a total of 200 patients with (n = 100) or without (n = 100) mesh prosthesis for a follow-up for at least 1 year.

RESULTS

There are no significant differences between groups in postoperative DeMeester score or lower esophageal sphincter pressure. In the group without mesh prosthesis, in 6 cases laparoscopic redo surgery was necessary due to severe and persistent dysphagia (n = 2) or a slipping Nissen (n = 4). Additionally, in 5 patients we found recurrent hiatal hernia, but patients have been without symptoms for at least 1 year. In the group with mesh prosthesis, laparoscopic refund application was performed in only 1 patient due to a slipping Nissen. In this group, recurrent hiatal hernia was not found in endoscopy. After laparoscopic antireflux surgery, GIQLI showed an equal improvement in both groups with an outcome comparable to that for healthy individuals. Postoperative dysphagia was significantly higher in the group with mesh prothesis within the 3 first months after surgery. One year after surgery no differences could be found.

CONCLUSIONS

Our findings suggest that LNF with reinforcement of the hiatal crura reduces the risk of recurrent hiatal hernia with or without wrap migration. In addition, LNF with mesh prosthesis improves patient's quality of life significantly to the same level as that in patients without mesh prosthesis. Postoperative dysphagia is higher in the early period after surgery, but this is only temporary. Long-term results of a randomized trial must be obtained before a general standardization can be discussed.

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.

Prospective randomized trial comparing Nissen to Nissen-Rossetti technique for laparoscopic fundoplication

BACKGROUND

It has been suggested that division of the short gastric vessels (SGV) provides a more floppy Nissen fundoplication, for the treatment of reflux disease. The aim of the study was to assess whether Nissen fundoplication with division of SGV is associated with improved clinical outcome and laboratory findings.

METHODS

Fifty-six consecutive patients with gastroesophageal reflux disease (GERD) were randomly assigned to have a laparoscopic Nissen fundoplication either with division (24 patients; 15 men; mean age 51 +/- 15 years) or without division (32 patients; 23 men, mean age 47 +/- 14 years) of the SGV. Preoperative and postoperative investigation included clinical assessment, esophagoscopy, esophagogram, esophageal manometry, and 24-hour ambulatory esophageal pH monitoring.

RESULTS

Division of the SGV resulted in a significant increase of the operating time (P <0.0001). The operation abolished reflux in both groups. Also, both types of Nissen fundoplication significantly increased the amplitude of peristalsis at distal esophagus (division group: from 56 +/- 20 mm Hg to 64 +/- 25 mm Hg, P = 0.01; nondivision group: from 65 +/- 27 mm Hg to 75 +/- 26 mm Hg, P <0.001) and the lower esophageal sphincter pressure (division group: from 16 +/- 10 mm Hg to 24 +/- 7 mm Hg, P <0.001; nondivision group: from 22 +/- 8 mm Hg to 28 +/- 5 mm Hg, P <0.001). No differences in the incidence of postoperative severe dysphagia (division group: 5 of 24; nondivision group: 3 of 32) and overall esophageal transit were accounted between groups. However, division of the SGV was associated with a significant increased incidence of gas-bloating syndrome (division group, 13 of 24, versus nondivision group, 9 of 32, P = 0.02).

CONCLUSIONS

Division of the SGV at laparoscopic Nissen fundoplication for GERD does not improve clinical outcome and laboratory findings, while it is associated with prolongation of the operating time and increased incidence of gas-bloating syndrome.

Laparoscopic antireflux surgery at an outpatient surgery center

BACKGROUND

Laparoscopic fundoplication (LF) procedures have been shown to be safe and effective for the control of gastroesophageal reflux disease (GERD). Preliminary reports suggest that LF can be performed safely in an ambulatory surgery center. We report on our extensive experience with outpatient LF.

METHODS

Since May 1995, we have performed laparoscopic antireflux procedures in 557 consecutive patients at a freestanding outpatient surgery center. All patients had esophageal manometrics and esophagogastroduodenoscopy (EGD) within 1 year of their surgical procedure. This series included 16 patients with large paraesophageal hernias (mostly type III) and 22 patients with prior antireflux procedures. Most patients (n = 494) underwent Nissen fundoplication.

RESULTS

Patients were typically given clear liquids 6 hs postoperatively and discharged home in