Antireflux surgery in Sweden, 1987-1997: a decade of change

Population-based trend analysis of laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

BACKGROUND

The Nissen and Toupet fundoplications are the most commonly used techniques for surgical treatment of gastroesophageal reflux disease. To date, no population-based trend analysis has been reported examining the choice of procedure and short-term outcomes. This study was designed to analyze trends in the use of Nissen versus Toupet fundoplications, and corresponding short-term outcomes during a 10-year period between 1995 and 2004.

METHODS

A trend analysis was performed of 873 patients (Toupet: 254 patients, Nissen: 619 patients) prospectively enrolled in the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery.

RESULTS

The frequency of the performed techniques remained stable during the observation period (p value for trend 0.206). The average postoperative and total length of hospital stay both significantly decreased during the 10-year period from 5.6 to 4.0 days and 6.8 to 4.8 days, respectively (both p values for trend <0.001). The average duration of surgery decreased significantly from 141 minutes to 121 minutes (p value for trend <0.001). There was a trend towards less complications in later years (2000-2004) compared to early years (1995-1999, p = 0.058). Conversion rates were significantly lower in later years compared with early years (p = 0.004).

CONCLUSIONS

This is the first trend analysis in the literature reporting clinical outcomes of 873 prospectively enrolled patients undergoing Nissen and Toupet fundoplications during a 10-year period. The proportion of laparoscopic Nissen versus Toupet fundoplications remained stable over time, indicating that literature reports of the advantages of one procedure over the other had minimal influence on surgeons' choice of technique. Length of hospital stay, duration of surgery, morbidity, and conversion rate decreased over time, reflecting the learning curve. Clearly, patient outcomes have much improved during the 10-year observation period.

Nationwide survey of long-term results of laparoscopic antireflux surgery in Sweden

OBJECTIVE

Excellent results after laparoscopic antireflux surgery (LARS) have been reported from specialized clinics. These good results were not confirmed in a nationwide survey that studied procedures carried out in 1995-96 in Sweden. Critics pointed out that this study included the learning curve of laparoscopy. Therefore, we have repeated the survey after >5000 LARS procedures have been performed.

MATERIAL AND METHODS

A random sample of 236 patients operated on in 2000 was identified (Group I) and compared to the population operated on in 1995-96 (Group II). Both groups received a disease-specific questionnaire 4 years after surgery.

RESULTS

In Group I, 6.8% of patients had had a second procedure, 16.4% used antireflux medications regularly and 14.9% were dissatisfied. The results for Group II were 6.0%, 19.5% and 15.0%, respectively. Patients reporting any of these three conditions were classified as treatment failures. Treatment failure occurred in 25.4% and 29.0% of patients in Groups I and II, respectively.

CONCLUSIONS

The nationwide long-term outcome after LARS in Sweden demonstrates that approximately a quarter of patients experience some sort of treatment failure. The results seem to be consistent, even though the surgical technique ought to be well implemented after >8years of common use.

Medical or surgical management of GERD patients with Barrett's esophagus: the LOTUS trial 3-year experience

INTRODUCTION

The long-term management of gastroesophageal reflux in patients with Barrett's esophagus (BE) is not well supported by an evidence-based consensus. We compare treatment outcome in patients with and without BE submitted to standardized laparoscopic antireflux surgery (LARS) or esomeprazole treatment.

METHODS

In the Long-Term Usage of Acid Suppression Versus Antireflux Surgery trial (a European multicenter randomized study), LARS was compared with dose-adjusted esomeprazole (20-40 mg daily). Operative difficulty, complications, symptom outcomes [Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD)], and treatment failure at 3 years and pH testing (after 6 months) are reported.

RESULTS

Of 554 patients with gastroesophageal reflux disease, 60 had BE-28 randomized to esomeprazole and 32 to LARS. Very few BE patients on either treatment strategy (four of 60) experienced treatment failure during the 3-year follow-up. Esophageal pH in BE patients was significantly better controlled after surgical treatment than after esomeprazole (p = 0.002), although mean GSRS and QOLRAD scores were similar for the two therapies at baseline and at 3 years. Although operative difficulty was slightly greater in patients with BE than those without, there was no difference in postoperative complications or level of symptomatic reflux control.

CONCLUSION

In a well-controlled surgical environment, the success of LARS is similar in patients with or without BE and matches optimized medical therapy.

Subjective results and symptomatic outcome after fundoplication revision

OBJECTIVE

In a small proportion of patients, fundoplication fails and a reoperation is required. However, there are few reports on the symptomatic outcome after reoperative antireflux surgery. The aim of this study was to evaluate the results after fundoplication revision.

MATERIAL AND METHODS

All patients (n=71) undergoing fundoplication revision between 1997 and 2005 were included in this study. The follow-up data were collected both from the hospital records and during postoperative control visits, including a personal interview using a structured questionnaire; follow-up was completed by 61 patients (88.4%).

RESULTS

The primary fundoplications included both open (n=21) and laparoscopic (n=40) approaches; 92% (n=56) of the reoperations were open procedures. The morbidity rate was 21% and the reoperation rate 16%. Fifty-six percent (n=34) of the patients regarded the result of their reoperative surgery as excellent, good or satisfactory at a mean follow-up of 51 months; 66% of the patients had no significant reflux symptoms after re-fundoplication. With the benefit of hindsight, 77% of the patients would again choose to undergo re-fundoplication, but only 48% of the patients would again primarily choose surgical treatment. Mortality rate was 1.4% (n=1) and in three patients the reoperative treatment required total gastrectomy.

CONCLUSIONS

These suboptimal results show that surgical treatment for gastro-oesophageal reflux disease in general is far from being perfect and this is even more marked after reoperative antireflux surgery, as fundoplication revision can result in severe complications. This emphasizes the importance of proper patient selection for both initial and reoperative antireflux surgery.

Late subjective results and symptomatic outcome after laparoscopic fundoplication

Laparoscopic fundoplication is generally accepted as a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are few reports on the long-term results after this procedure. Between 1996 and 2001, 468 patients underwent laparoscopic Nissen fundoplication of which 464 patients were available for follow-up. The follow-up data were collected both from the hospital records and by a structured questionnaire, which were completed by 441 patients (95%). Eighty-nine percent (n=394) of the patients regarded the result of their surgery excellent, good, or satisfactory at a median follow-up of 51 months. With the benefit of hindsight 83% of the patients would again choose surgical treatment. Eighty-seven percent of the patients had no significant reflux symptoms. Bloating or increased flatulence were the most common side-effects. One hundred thirty-two patients (30%) had started to use antireflux medications postoperatively, but only 51 of them used it daily. Laparoscopic Nissen fundoplication provides a good and effective alternative to a life-long use of antireflux medication.

Surgeons' experience with laparoscopic fundoplication after the early personal experience: does it have an impact on the outcome?

BACKGROUND

The adverse outcomes of laparoscopic fundoplication are more likely during the initial 20 cases performed by each individual surgeon. This study aimed to evaluate the impact of substantial surgical experience versus experience beyond the learning curve on the early and late objective and subjective results.

METHODS

The patients were divided into two groups according to the surgeon. In group 1 (n = 230), all the patients underwent surgery by a surgeon with substantial experience in laparoscopic fundoplication. In group 2 (n = 118), the patients were treated by a total of seven surgeons whose personal experience exceeded the individual learning curve, but was distinctively less than that of the group 1 surgeon.

RESULTS

The conversion rate was 2.2% in group 1 and 4.4% in group 2. The median operating time was 65 min in group 1 and 70 min in group 2 (p = 0.0020). The occurrence of immediate complications was 3.5% in group 1 and 7.6% in group 2 (p = 0.0892). At 6 months after surgery, 7.4% of the patients in group 1 and 16.1% of the patients in group 2 reported that dysphagia disturbed their daily lives (p = 0.0115). The late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in the two groups.

CONCLUSIONS

Substantial experience with the procedure is associated with a shorter operating time and somewhat fewer complications, conversions, and early dysphagia episodes. This supports the provision of expert supervision even after the initial learning phase of 20 individual procedures. The patients' long-term subjective symptomatic outcome was similar in the two groups. Substantial experience does not provide better late results than surgical experience beyond the learning curve.

Gastroesophageal reflux disease as a cause of death is increasing: analysis of fatal cases after medical and surgical treatment

OBJECTIVES

The population impact of modern treatment on complicated gastroesophageal reflux disease (GERD) is not well understood. Our aim was to determine the current mortality from GERD in Finland and compare this with the use of health resources.

METHODS

In this population-based retrospective study, Finland's administrative databases provided figures on the nationwide use of antireflux medication, rate of antireflux surgery, and mortality from GERD. Any deceased person included had classic symptoms as well as objective findings of GERD.

RESULTS

After analysis of the medical records of 306 patients, 213 were included. Annual mortality from GERD increased (P < 0.001) from 0.18/100,000 in 1987 to 0.46/100,000 in 2000. During that time, use of H2-blockers and proton pump inhibitors and the annual rate of antireflux surgery increased significantly (P < 0.001). Mortality from antireflux surgery, including fundoplication and gastric and esophageal resection, remained around 1.9/1,000 operations. Of the 213 patients whose cause of death was considered to be GERD, 180 (85%) had received medical treatment, including 4 patients whose death was related to either diagnostic or therapeutic endoscopy. Early complications of antireflux surgery caused 24 (11%) deaths; 9 (4%) were late failures of antireflux surgery. Causes of death in the medical group were hemorrhagic esophagitis (82, 47%), aspiration pneumonia (41, 23%), ulcer perforation (25, 14%), rupture with esophagitis (15, 9%), and stricture (13, 7%).

CONCLUSIONS

Regardless of the increased use of health resources, mortality from GERD, especially with medical treatment, rose. Surgery for GERD was also associated with early mortality and usually could not prevent the fatal outcome.

Techniques and results of laparoscopic antireflux surgery in Germany

BACKGROUND

This study aimed to evaluate the development and outcomes of laparoscopic antireflux surgery in Germany using a nationwide representative survey.

METHODS

A written questionnaire including 34 detailed questions and 288 structured items about diagnostic and therapeutic approaches, number of procedures, complications, and mortality was sent to 546 randomly selected German surgeons (33% of the registered general surgeons) at the end of 2000.

RESULTS

The response rate was 72%, and a total of 2,540 antireflux procedures were reported. According to the survey, 81% of all procedures were performed laparoscopically, and 0.1% were performed thoracoscopically. As reported, 65% were total fundoplications, 31% were partial fundoplications, and 4% were other procedures. Of the surgeons who had experience with laparoscopic antireflux techniques (29%), 71% preferred a 5-trocar technique, and 91% used the Harmonic Scalpel for dissection. There were significant technical variations among the surgical procedures (e.g., use and size of the bougie, length of the wrap, additional gastropexy, fixation of the wrap). The overall complication rate for laparoscopic fundoplication was 7.7% (5.7% surgical and 2% nonsurgical complications), including rates of 0.6% for esophageal perforations and 0.6% for splenic lesions. The conversion rate was 2.9%; the reoperation rate was 1.6%; and the overall hospital mortality rate was 0.13%. The authors observed a striking learning curve difference in complication rates between hospitals performing fewer than 10 laparoscopic antireflux techniques annually and those performing more than 10 fundoplications per year (14% vs 5.1%, p < 0.001). Long-term dysphagia and interventions occasioned by dysphagia occurred significantly more often after total fundoplications than after partial fundoplications (6.6% vs 2.4%; p < 0.001). Similar findings were reported for Nissen versus floppy Nissen procedures. The overall failure rate, however, was similar for both groups (Nissen 8.7%; partial 9%, difference not significant).

CONCLUSIONS

Until now, no unique laparoscopic antireflux technique has been accepted, and a number of different antireflux procedures with numerous modifications have been reported. The morbidity and mortality rates reported in this article compare very well with those in the literature, and 1-year-follow-up results are promising.

Surgery of gastroesophageal reflux disease: a competitive or complementary procedure?

The management of chronic gastroesophageal reflux disease (GERD) has both been simplified and immensely improved by the development of modern medical therapies. These are built entirely on the concept of profound acid inhibition, which is very successful in a substantial proportion of GERD patients. Despite the efficacy of proton pump inhibitors (PPIs) some failures are unavoidable, and some patients experience incomplete control of major GERD symptoms on ordinary dosing of PPIs. Although the safety profile of PPIs is very reassuring, some people express some concern about the safety of drug treatment extending beyond 10 years especially when alternative therapeutic strategies are available. Some patients complain of alleged respiratory complications to severe reflux, and in those situations as well as in cases with e.g. Barrett's esophagus, a complete control of reflux also incorporating the duodenal components in the refluxate may be warranted. In all those situations antireflux surgery can be considered indicated for the treatment of chronic GERD and thus be looked upon as complementary to medical therapy. Furthermore, some patients who have their GERD symptoms under control on PPIs still want to have an operation to avoid dependency on drugs. Hence in none of these clinical situations does antireflux surgery play a competitive role in relation to medical therapy. However, in the very few randomized clinical trials in which a head-to-head comparison has been completed between medical and surgical therapy, the latter has been found to be somewhat more effective in terms of reflux control. The other side of the coin is that antireflux surgery has some side effects that signify the importance of this surgery being performed in specialized centers.

Long-term results of antireflux surgery indicate the need for a randomized clinical trial

Background

Well conducted, comparative trials of laparoscopic versus open antireflux surgery with an adequate patient enrolment are few and they do not demonstrate obvious advantages for the laparoscopic approach except for a marginal gain in shorter hospital stay. The aim of this study was to compare the effectiveness of laparoscopic and open procedures.

Methods

Two unselected groups of 230 patients were identified through a register of all inpatient public care in Sweden. Outcomes of laparoscopic and open antireflux surgery were compared using a disease-specific questionnaire 4 years after operation.

Results

Failure and dissatisfaction were significantly more common in the laparoscopy group than among patients having conventional open surgery. Treatment failure rates were 29·0 and 14·6 per cent respectively (P = 0·004). Dissatisfaction rates were 15·0 and 7·0 per cent respectively (P = 0·005). There was no other questionnaire item for which the proportion of failures differed significantly between the two groups.

Conclusion

This study does not support the presumption that laparoscopic antireflux surgery is to be preferred to the open procedure. It is strongly recommended that a randomized controlled trial be conducted.

The cost of gastro-oesophageal reflux disease, dyspepsia and peptic ulcer disease in Sweden

BACKGROUND AND OBJECTIVE

Dyspepsia, peptic ulcer disease (PUD) and gastro-oesophageal reflux disease (GORD) involve a substantial cost to Swedish society. There is a lack of up-to-date nationwide cost estimates after 1985. This study was conducted to present a comprehensive and updated cost analysis and study the change over time of the national cost of these disorders.

DESIGN AND SETTING

Primarily, data from National Swedish databases and secondly, data from databases from the County of Uppsala for 1997 were used for the calculations and estimations.

PERSPECTIVE

Swedish societal perspective.

RESULTS

The total cost to Swedish society of dyspepsia, PUD and GORD in 1997 was $US424 million, or $US63 per adult. Direct costs totalled $US258 million (61%) while indirect costs totalled $US166 million (39%). The highest proportions of costs were due to drugs and sick leave, these being 37 and 34%, respectively.

CONCLUSIONS

The cost of dyspepsia and GORD is substantial for patients, health providers and society. Since 1985, drug costs have increased substantially while the cost of sick leave has decreased.

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