Severe gastroesophageal reflux disease

Laparoscopic antireflux surgery

BACKGROUND

The purpose of this paper is to review the experience of a community surgeon performing laparoscopic antireflux procedures (LAP). The experience has been difficult and at times unsettling, and underscores the need for advanced laparoscopic expertise not normally obtained performing laparoscopic cholecystectomies.

METHODS

Sixty-one consecutive patients underwent attempted LAP. The preoperative evaluation is reviewed, and the length of operative times, conversion rates, complications, and patient satisfaction is discussed.

RESULTS

Four patients were converted to an open procedure, and two more patients required later reoperation for dysphagia. While the operative times are shorter now, the technical difficulty in performing the procedure does not seem to be appreciatively decreasing. No deaths or esophageal perforations occurred; however, there were a large number of patients with varying degrees of troubling dysphagia that did not require reoperation but frequently required endoscopic gastroduodenoscopy (EGD) dilatation. No recurrence of reflux has been documented in the short 2-year follow-up period.

CONCLUSIONS

LAP is still the most difficult procedure that I perform, and the learning curve is at least 60 cases. Patient satisfaction is quite good as only three have mild "heartburn." Dysphagia is a significant problem that has led to takedown of several short gastric vessels to obtain looser fundoplications around larger and larger bougies. Appropriate patient preoperative selection is paramount and the antireflux procedure should be tailored to the individual patient. Major complications have been reported elsewhere, but have not been seen in this review.