The laparoscopic Nissen fundoplication--a better operation?

Quality of Life in Gastroesophageal Reflux Disease Three Months After Laparoscopic Nissen's Fundoplication

INTRODUCTION

Gastroesophageal reflux disease (GERD) affects various elements of life including sleep, daily and social functioning, and physical and emotional activities. This study aims to determine the impact of laparoscopic Nissen's fundoplication (LNF) on health-related quality of life.

METHODS

This prospective study was conducted in a tertiary care hospital, Pakistan, from Jan 2019 to Feb 2020. Forty-seven participants completed the study. All patients completed the Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQoL) questionnaire both pre-operatively and three months after LNF.

RESULTS

There was significant difference in pre- and post-operative median Health-Related Quality of Life score (p value: 0.0073). There was improvement in items related to heartburn in HRQoL questionnaire, while questions related to swallowing and bloating either showed no change or worsening.

CONCLUSION

LNF has a significant impact on health-related quality of life. It is important for the physician to consider the impact of GERD in daily life. Management goals for GERD should also include improvement in quality of life of the patient.

Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication

Purpose

Laparoscopic total fundoplication is the standard surgery for gastroesophageal reflux disease. However, partial fundoplication may be a viable alternative. Here, we conducted a nationwide survey of partial fundoplication in Korea.

Methods

The Korean Anti-Reflux Surgery study group recorded 32 cases of partial fundoplication at eight hospitals between September 2009 and January 2016. The surgical outcomes and postoperative adverse symptoms in these cases were evaluated and compared with 86 cases of total fundoplication.

Results

Anterior partial fundoplication was performed in 20 cases (62.5%) and posterior in 12 (37.5%). In most cases, partial fundoplication was a secondary procedure after operations for other conditions. Half of patients who underwent partial fundoplication had typical symptoms at the time of initial diagnosis, and most of them showed excellent (68.8%), good (25.0%), or fair (6.3%) symptom resolution at discharge. Compared to total fundoplication, partial fundoplication showed no difference in the resolution rate of typical and atypical symptoms. However, adverse symptoms such as dysphagia, difficult belching, gas bloating and flatulence were less common after partial fundoplication.

Conclusion

Although antireflux surgery is not popular in Korea and total fundoplication is the primary surgical choice for gastroesophageal reflux disease, partial fundoplication may be useful in certain conditions because it has less postoperative adverse symptoms but similar efficacy to total fundoplication.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

Single-site Nissen fundoplication versus laparoscopic Nissen fundoplication

Background:

Advances in minimally invasive surgery have led to the emergence of single-incision laparoscopic surgery (SILS). The purpose of this study is to assess the feasibility of SILS Nissen fundoplication and compare its outcomes with traditional laparoscopic Nissen fundoplication.

Methods:

This is a retrospective study of 33 patients who underwent Nissen fundoplication between January 2009 and September 2010.

Results:

There were 15 SILS and 18 traditional laparoscopic Nissen fundoplication procedures performed. The mean operative time was 129 and 182 minutes in the traditional laparoscopic and single-incision groups, respectively (P = .019). There were no conversions in the traditional laparoscopic group, whereas 6 of the 15 patients in the SILS group required conversion by insertion of 2 to 4 additional ports (P = .0004). At short-term follow-up, recurrence rates were similar between both groups. To date, there have been no reoperations.

Conclusions:

SILS Nissen fundoplication is both safe and feasible. Short-term outcomes are comparable with standard laparoscopic Nissen fundoplication. Challenges related to the single-incision Nissen fundoplication include overcoming the lengthy learning curve and decreasing the need for additional trocars.

[Management of gastroesophageal reflux in children. Single centre experience in conventional and laparoscopic Nissen fundoplication in the last 15 years]

INTRODUCTION

Nissen fundoplication (NF) is the most used and effective technique for the treatment of gastroesophageal reflux in children. The laparoscopic approach (LNF) is safe, with low morbidity and high success rate, although some cases require a conventional approach (CNF). The aim of the study is to compare the results between LNF and CNF in our centre.

MATERIAL AND METHODS

A retrospective review was performed on patients <14years after NF between 2000 and 2015. A comparison was made of the complications, hospital stay, and follow-up for both approaches.

RESULTS

Of the total 75 NF performed, 49 (65.3%) were LNF, 23 (30.7%) CNF, and 3 (4.0%) reconversions. Concomitant laparoscopic gastrostomy was performed in 10.7%, and open gastrostomy in 5.3% of cases. Prior to NF, 10.7% had a gastrostomy. The mean age was 4 years and 68.7% were male. Of the diagnoses, 36% had encephalopathy, 14.7% hiatal hernia, 5.4% oesophageal atresia, and 5.4% an acute life-threatening event. No differences were found in operation time. More than two-thirds (36%) had complications, which were more frequent in the CNF (OR=3.30, 95%CI: 1.1-9.6). The hospital-stay decreased by 9 days in the LNF (95%CI: 5.5-13.5). Mean follow-up was 26 months (95%CI: 20.9-31.6). Mortality during follow-up was of 5.3% (5 respiratory failure, 1 sudden cardiac death, and 2 due to complications of the encephalopathy), 4.2% required re-fundoplication, 15.8% had symptomatic improvement, and 64.0% had absence of symptoms.

CONCLUSIONS

The LNF is an effective technique for the treatment of gastroesophageal reflux, with lower morbidity and shorter hospital stay than CNF. It is recommended as the first surgical option.

Would you have laparoscopic Nissen fundoplication again? A patient satisfaction survey in a UK population

OBJECTIVE

Laparoscopic Nissen fundoplication (LNF) effectively reduces objective gastro-oesophageal reflux. It can however cause side effects which affect quality of life or fail to improve subjective reflux symptoms. This study aims to assess patient satisfaction following LNF by assessing whether patients would have the procedure again.

DESIGN

Telephone survey using a structured questionnaire. Participation was voluntary.

SETTING

UK Foundation Trust (two university hospitals).

PATIENTS

All patients who had LNF performed by a single surgeon between November 2008 and June 2012.

MAIN OUTCOME MEASURES

Primarily, current reflux symptoms, antiacid medication requirement and whether participants would choose to have the procedure again (should they still have their initial symptoms). Further measures were conversion to open procedure, need for redo or reversal, and mortality.

RESULTS

99 patients underwent LNF in the quoted period; 71 were contactable and willing to participate. Of the 99, two required redo operations (neither of whom was contactable), and one had a reversal (primary operation included). Median time since the operation was 33 months (range 5-48 months). Compared with preoperatively, 72% rated their current reflux-symptom severity as ≤2/10, 23% as 3-6/10 and 4% as 7-10/10. 75% were not taking any antiacid medication. 89% of patients said that they would have the procedure again.

CONCLUSIONS

This study provides supporting evidence that LNF improves reflux symptoms and decreases medication use at intermediate-term follow-up. These results will aid counselling and reassurance of patients regarding the risks and benefits of LNF as the majority of postoperative patients were sufficiently satisfied to choose the operation again.

Reoperation rates after laparoscopic fundoplication

INTRODUCTION

Current literature on redo antireflux surgery has limitations due to small sample size or single center experiences. This study aims to evaluate the reoperation rate of laparoscopic fundoplication in a large population database.

METHODS

A longitudinal version of the California Office of Statewide Health Planning and Development database from 1995 to 2010 was used. Inclusion criteria were patients who received a laparoscopic fundoplication for uncomplicated gastroesophageal reflux disease (GERD) or hiatal hernia. Patients were excluded if they had complications of GERD, esophageal or gastric cancer, prior esophageal or gastric surgery, vagotomy, esophageal dysmotility, and diaphragmatic hernia with gangrene or obstruction. The outcome was reoperation, specified as another fundoplication or reversal. Analysis was carried out via a Kaplan-Meier plot, hazard curve, and multivariate analysis adjusting for age, race, gender, comorbidities, insurance status, hospital teaching status, and year of procedure.

RESULTS

13,050 patients were included in the study. The 5 and 10-year cumulative reoperation rates were 5.2 % (95 % CI 4.8-5.7%) and 6.9 % (95 % CI 6.1-7.9%), respectively. Of these reoperations, 30 % were performed at a different hospital from that of the initial fundoplication. Reoperation rate was highest at 1 year post-operatively (1.7 % per year), and steadily declined until 4 years post-operatively, after which it remained at approximately 0.5 % per year. Multivariate analysis demonstrated significantly higher rates of reoperation among younger patients (HR = 3.56 for <30yo; HR = 1.89 for 30-50yo; HR = 1.65 for 50-65yo) and female patients (HR = 1.35).

CONCLUSIONS

Nearly one third of reoperations after failed laparoscopic fundoplication occur at a hospital different from the initial operation, which raises concern that existing literature does not reflect the true reoperation rate. The reoperation rate is highest in the first year postoperatively. The reasons for the higher rate of reoperation in females and younger patients remain unclear and warrant further study.

The barrier-free trocar technique in three laparoscopic standard procedures

BACKGROUND:

Numerous technical and surgical innovations took place in laparoscopic surgery in the recent past. It is debatable whether single-access surgery or natural orifice surgery (NOS) will establish for several standard procedures. Most of the NOS-procedures are controversial and single-access surgery still has to prove its equality in controlled trials. In the intention to reduce the ingress incisons and to facilitate instrumentation, we decided to test the barrier-free AirSeal^®-trocar in clinical practice.

MATERIALS AND METHODS:

Laparoscopically we performed a cholecystectomy, gastric wedge-resection and a fundoplication using the barrier-free AirSeal^® 12-mm-trocar. This trocar works without any mechanical barrier so that via this trocar the use of two instruments is possible.

RESULTS:

All three operations were successful.

CONCLUSION:

Laparoscopic standard procedures are feasible using this barrier-free trocar without a higher degree of difficulty. Because of the facilitated instrumentation, it is possible to work more efficiently and to maintain the focus on the surgical field.

Fundoplication combined with mediogastric plication

BACKGROUND

The purpose of this pilot study was to demonstrate the feasibility and procedural safety of laparoscopic fundoplication combined with mediogastric plication in patients with a body mass index of 32-35 kg/m(2).

METHODS

Sixteen patients underwent laparoscopic fundoplication combined with mediogastric plication. All procedures were performed with the patient under general anesthesia. The 1-year follow-up results encompassed gastroesophageal reflux disease recovery and excess weight loss.

RESULTS

The procedure time varied from 65 to 95 minutes. No serious procedure-related complications occurred. Gastroesophageal reflux disease-related symptoms resolved in all patients (P = .000). The excess weight loss was 10 ± 4 kg (58%) 1 year after the procedure. The 1-year follow-up excess weight was significantly less than the baseline excess weight (P = .000). The average body mass index decreased from 33.8 ± 1.9 kg/m(2) at baseline to 27.2 ± 1.7 kg/m(2) at 1 year (P = .02). Of the 16 patients, 14 had an excess weight loss of 62%, and 2 sweet-eaters had an excess weight loss of 33%. At 1 year of follow-up, the excess weight in those who smoked (n = 10) was greater than that of nonsmokers (n = 6; P = .02). However, smoking did not seem to significantly affect excess weight loss (P = .065).

CONCLUSION

Fundoplication combined with mediogastric plication produced a total recovery from gastroesophageal reflux disease and an excess weight loss of 62% in 87.5% of patients after 1 year of follow-up. This procedure is technically feasible, and no serious procedure-related complications occurred. The follow-up is ongoing to investigate the efficacy and long-term durability of the procedure.