Open Nissen fundoplication and highly selective vagotomy as a treatment for gastro-oesophageal reflux disease

A Novel, Dynamic Statistical Model for Predicting Patient Satisfaction with Fundoplication Based on Pre-Operative Symptom Patterns

BACKGROUND

Fundoplication provides excellent control of gastro-oesophageal reflux disease (GORD), but there remain a number of unsatisfied patients who have proven difficult to identify pre-operatively. We hypothesised that pre-operative symptom patterns can predict of the risk of post-operative dissatisfaction.

METHODS

Pre-operative symptoms and post-operative satisfaction were measured using standardised questionnaires along with routine investigations. These data were used to calculate our novel pre-operative risk of dissatisfaction (PROD) score. Potential pre-operative prognostic markers were tested against the post-operative satisfaction data, including the objective investigations and the PROD score. The prognostic utility of the PROD score and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline was tested using receiver operating characteristic analysis to determine the area under the curve (AUC).

RESULTS

An association was found between our PROD score and each of the satisfaction measures (n = 225, p < 0.001) which is likely to be of prognostic utility (AUC = 0.67-0.79). No such association was found between the routine investigations and post-operative satisfaction. The PROD score was found to be of greater prognostic utility than the SAGES guideline (n = 166, p < 0.001).

CONCLUSIONS

The PROD score is a novel, easy-to-use test that can predict individual patient satisfaction with fundoplication.

Barrett's esophagus: surgical treatments

The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.

Vagotomy during hiatal hernia repair: a benign esophageal lengthening procedure

INTRODUCTION

This study describes the use of vagotomy in patients during complex laparoscopic esophageal surgery (e.g., reoperative antireflux surgery (rLARS) or paraesophageal hernia (PEH) repair) when, after extensive esophageal mobilization, the gastroesophageal junction cannot be made to reach the abdomen without tension. In doing so, we hope to understand the risk incurred by vagus nerve division in this setting in order to evaluate its role in managing the short esophagus.

METHODS

One hundred and sixty-six patients underwent rLARS or PEH repair between 1/1998 and 6/2003 at our institution. Clinical data was obtained from a prospectively maintained database and systematic patient questionnaires administered for this study. Follow-up was available for 102 (61%) of these patients, at a median of 19 months (range 6-69 months).

RESULTS

Fifty-two patients underwent rLARS while 50 patients underwent PEH repair. Thirty patients had a vagotomy during the course of their operation (Vag Group; 20 anterior, six posterior, four bilateral), 13 in the rLARS group (25%), and 17 in the PEH group (34%). The primary presenting symptoms for rLARS and PEH repair patients were improved in 89% in the Vag Group and 91% in the No Vag Group. Similarly, there was no difference in the severity of abdominal pain, bloating, diarrhea, or early satiety between the Vag and No Vag groups at follow-up. No patient required a subsequent operation for gastric outlet obstruction.

CONCLUSIONS

Vagotomy during rLARS and PEH repair does not lead to a higher rate delayed gastric emptying, dumping syndrome, or other side effects. Thus, we propose vagotomy to be a legitimate alternative to Collis gastroplasty when extensive mobilization of the esophagus fails to provide adequate esophageal length.

Laparoscopic highly selective vagotomy with nissen fundoplication: is there any role?

INTRODUCTION

Nissen fundoplication (NF) has not been a uniformly successful treatment for gastroesophageal reflux disease (GERD). Acid lowering procedures such as highly selective vagotomy (HSV) have not yet been fully evaluated as an adjunctive treatment. NFHSV was evaluated in GERD.

MATERIALS AND METHODS

Between June 2003 and June 2005, 8 women with a history of 6 months of GERD unrelieved by medication, preprandial pain, peptic ulcer disease, or severe gastritis underwent laparoscopic NFHSV. They have been followed for a mean 12 months. Preoperative and postoperative Heartburn Severity scores (HSS) were obtained.

RESULTS

Mean operative time was 110 minutes. There were no complications. One patient needed postoperative proton pump inhibitor, which was discontinued after smoking cessation 5 months after NFHSV. All 8 patients showed marked improvement in symptoms and HSS.

CONCLUSIONS

This series lends credence to the notion that NFHSV was effective. Several studies need to be performed to demonstrate the full efficacy and safety of this approach.

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.

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.