Improvement in quality of life measures after laparoscopic antireflux surgery

Lap. Nissen fundoplication leads to better respiratory symptom control than Toupet in the long term of 20 years

INTRODUCTION

Having performed anti-reflux surgery for thirty years, it was important to reexamine our patients in the long term to enlarge the body of evidence concerning classical and extraesophageal symptoms that are differently controlled by Nissen or Toupet fundoplication.

OBJECTIVES

We report a cohort of 155 GERD patients who underwent fundoplication within a tailored approach between 1994 and 2000. Changes in the perioperative functional outcome, GERD symptoms, and quality of life are being analyzed 10 and 20 years after the operation.

RESULTS

The operation resulted in a superior quality of life compared to a patient cohort treated with PPI therapy. We found that both surgical methods (laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication) cure classical symptoms equally (heartburn, regurgitation, and dysphagia). GERD patients receiving a Toupet fundoplication seem more likely to suffer from extraesophageal GERD symptoms 10 and 20 years after surgery than patients with a Nissen fundoplication. On the other hand, some patients with Nissen fundoplication report dysphagia even 10 and 20 years after surgery.

CONCLUSION

Both the laparoscopic Nissen and Toupet fundoplications provide excellent symptom control in the long term. Moreover, the Nissen fundoplication seems to be superior in controlling extraesophageal reflux symptoms, but at the expense of dysphagia. In summary, tailoring the operation based on symptoms seems advantageous.

Assessment of quality of life after laparoscopic GERD surgery in children: a prospective study

The purpose of this study is to assess quality of life (QoL) after laparoscopic anti-reflux surgery (LARS) in children with gastroesophageal reflux disease (GERD) and to evaluate GERD symptoms and their impact on daily life and school. From June 2016 to June 2019, all children with GERD from 2 to 16 years of age, without neurologic impairment or malformation-related reflux, were prospectively included in a monocentric study. Patients (or their parents according to the age of the child) answered the Pediatric Questionnaire on Gastroesophageal Symptoms and QoL (PGSQ) before surgery and 3 and 12 months after surgery. Variables were compared by paired, bilateral Student t-test. Twenty-eight children (16 boys) were included. The median age at surgery was 77 months (IQR: 59.2-137) with median weight of 22 kg (IQR: 19.8-42.3). All had a laparoscopic Toupet fundoplication. Median duration of follow-up was 14.7 months (IQR: 12.3-22.5). One patient (4%) had a recurrence of GERD symptoms without abnormalities on follow-up examinations. Preoperative total PGSQ score was 1.42 (± 0.7) and decreased significantly 3 months (0.56 ± 0.6; p < 0.001) and 12 months after surgery (0.34 ± 0.4; p < 0.001). PGSQ subscale analysis revealed a significant decrease at 3 and 12 months for GERD symptoms (p < 0.001), impact on daily life (p < 0.001), and impact on school (p = 0.03).

CONCLUSION

There was a significant improvement in symptoms and their frequency after LARS in children, as well as an improvement of QoL, in the short and medium term. The impact of GERD should be taken into consideration in the treatment decision, given that surgery clearly improves the QoL.

WHAT IS KNOWN

• Laparoscopic anti-reflux surgery (LARS) is an established and effective treatment option in pediatric patients with severe GERD refractory to medical treatment. • Effect of LARS on the quality of life (QoL) has been mainly investigated in the adult population but there is very little data on the effect of LARS on the QoL in pediatric patients.

WHAT IS NEW

• Our prospective study was the first to analyze the effect of LARS on QoL in pediatric patients without neurologic impairment using validated questionnaires at two postoperative time points with a significant improvement in postoperative QoL at 3 and 12 months. • Our study emphasizes the importance of evaluating QoL and impact of GERD on all the aspects of daily life and of taking these into consideration in the treatment decision.

Long-Term Health-Related Quality of Life (HRQoL) After Redo-Fundoplication

BACKGROUND

We aim to shed light on long-term subjective outcomes after re-operations for failed fundoplication.

METHODS

1809 patients were operated on for hiatal hernia and/or gastroesophageal reflux disease (GERD) at the Helsinki University Hospital between 2000 and 2017. 111 (6%) of these had undergone a re-operation for a failed antireflux operation. Overall, HRQoL was assessed in 89 patients at the latest follow-up using the generic 15D© instrument. The results were compared to a sample of the general population, weighted to reflect the age and gender distribution of patients. Disease-specific HRQoL was assessed using the GERD-HRQoL questionnaire. We studied variation in the overall HRQoL with respect to disease-specific HRQoL and known patients' parameters using univariate and multivariable linear regression models.

RESULTS

The median postoperative follow-up period was 9.3 years. All patients were operated on laparoscopically (6% conversion rate), and 87% were satisfied with the re-operation. Postoperative complications were minimal (5%). Twelve patients (11%) underwent a second re-operation. The median GERD-HRQoL score was nine. In multivariable analysis, four variables were independently associated with the 15D score, suggesting a decrease in the 15D score with increasing GERD-HRQoL score, increasing Charlson Comorbidity Index (CCI) and the presence of chronic pain syndrome (CPS) and depression.

CONCLUSION

Re-do LF is a safe procedure in experienced hands and may offer acceptable long-term alleviation in patients with recurring symptoms after antireflux surgery. Decreased HRQoL in the long run is related to recurring GERD and co-morbidities.

Clinical outcome after laparoscopic Nissen fundoplication in patients with GERD and PPI refractory heartburn

Typical reflux symptoms that respond well to proton pump inhibitor (PPI) therapy are key factors predictive of an excellent outcome with antireflux surgery for gastroesophageal reflux disease (GERD). Our aim was to evaluate whether poor preoperative heartburn (HB) relief with PPIs was associated with a worse outcome after Nissen fundoplication. Patients with a main symptom of HB and a positive pH-test who had a laparoscopic Nissen fundoplication between January 2008 and December 2014 were included. Prior to surgery, patients graded how effectively their HB symptoms were relieved by PPIs. Three groups were defined: good response (76-100% relief), partial response (26-75% relief) and poor response (0-25% relief). Outcomes and satisfaction were assessed at a minimum of 1 year after fundoplication. There were 129 patients who met inclusion criteria and 75 agreed to participate. The median follow-up was 48 months. Prior to Nissen fundoplication 13 patients had a good HB response to PPI-therapy, 36 had a partial response and 26 had a poor response. All patients were satisfied with their HB relief after fundoplication (mean satisfaction score: 9.5/10) and there was no difference in satisfaction score or heartburn relief between groups. Heartburn symptoms that respond poorly to PPI therapy are reliably relieved with a Nissen fundoplication in patients with objectively confirmed GERD. Patient satisfaction after Nissen fundoplication was excellent and was similar in patients with poor versus excellent HB relief with preoperative PPI therapy. Therefore, antireflux surgery is an option for patients with HB and confirmed GERD regardless of the degree of relief of HB symptoms provided by PPI medications.

Short-Term Health-Related Quality of Life After Abdominal Surgery: A Conceptual Framework

We sought to develop a conceptual framework of health-related quality of life (QOL) after abdominal surgery to assist in the development of a QOL measure suitable for use in clinical trials comparing laparoscopic and conventional surgery. We conducted semi-structured interviews with 21 patients within 2 weeks after an abdominal surgical procedure. Responses were transferred into an electronic spreadsheet and coded to facilitate analysis. We tabulated the frequency of similar responses and grouped response items into areas of QOL impairment. The patients ranged in age from 19 to 78 years. Six had laparoscopic procedures. Patients identified the following areas of QOL impairment (examples of specific items and frequency of response): (1) physical limitations (difficulty getting in and out of bed 52%, difficulty walking 48%), (2) functional impairment (inability to perform usual activities 100%, difficulty bathing 90%), (3) pain (pain in incision 48%, pain with coughing or movement 28%), (4) visceral function (inability to eat 48%, lack of appetite 43%), (5) sleep (frequent nighttime awakening 62%, difficulty falling asleep 33%), and (6) mood (helplessness 28%, anxiety 24%). Acute health status after abdominal surgery constitutes a unique, dynamic health state characterized by impairment in a number of different health domains. A measure of QOL after abdominal surgery should have adequate coverage of these health concepts.

Long term quality of life after laparoscopic antireflux surgery for the elderly

BACKGROUND

Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.

METHODS

Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

RESULTS

Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).

CONCLUSIONS

In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

Long term quality of life after laparoscopic antireflux surgery for the elderly

Background

Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.

Methods

Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

Results

Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).

There were 114 (36.6%) patients who filled out the SF36 questionnaire (98 in the younger group, rate: 37.4%; 16 in the elderly group, rate: 32.6%) pre- and post-operatively. There was no significant difference between the two age groups regarding preoperative PCS ( 45.6 ± 7.8 in YG vs. 44.2 ± 8.2 in EG; P = 0.51) and MCS ( 48.1 ± 10.7 in YG vs. 46.9 ± 9.2 in EG; P = 0.67). There was no significant difference between the two age groups regarding postoperative PCS (49.8 ± 11.9 in YG and 48.2 ± 9.5 in EG ; P = 0.61 and MCS (48.4 ± 10.7 in YG vs. 50.1 ± 6.9 in EG; P = 0.54).

Conclusions

In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

Impact of laparoscopic Nissen's fundoplication on response of disease specific symptoms and quality of life

The aim of this study is to establish responsiveness of gastroesophageal reflux disease (GERD) symptom score, quality of life SF-36 score in GERD with relation to oesophageal manometry and upper gastrointestinal endoscopy following laparoscopic Nissen's fundoplication (LNF). Interventional prospective study was done enrolling 77 patients of GERD who respond to proton pump inhibitor (PPI) and have undergone LNF, strict diagnostic criteria were followed with GERD score, upper gastrointestinal endoscopy, oesophageal manometry, and endoscopically negative patients have further undergone 24-h pH study. Follow-up was done at 12 and 24 months by GERD score, SF-36 score, endoscopy, oesophageal manometry. GERD score shows significant difference in pre-operative and post-operative score with P value <0.001 except dysphagia. Post-LNF improvement in GERD score is consistent with improvement in lower oesophageal sphincter (LES) pressure at 12 months. All dimensions in quality of life SF-36 show significant difference in pre-operative and post-operative score at 12 months with P value <0.001. Results are consistent at 24 months. Oesophagitis was decreased from 40.2 to 11.6 % as well as it showed down grading on endoscopy in post-operative period. Out of three patients of complete disruption of wrap, two patients underwent redo surgery and showed improvement. In properly diagnosed PPI respondent patients by GERD score, LNF has got improvement in GERD score, quality of life in all dimensions of SF-36 score in relation to improvement with LES pressure and oesophagitis.

Quality of life after Nissen-Rossetti fundoplication

BACKGROUND

We investigated Quality of Life (QoL) and Johnsson & DeMeester score of patients after Nissen-Rossetti fundoplication.

MATERIALS AND METHODS

From January 2007 to June 2008, 43 patients with chronic gastroesophageal reflux underwent laparoscopic Nissen-Rossetti fundoplication; 7 were lost during the follow-up. Patients underwent endoscopy, 24-hour pH-metry, Gastroesophageal Reflux Disease-Health-Related Quality-of-Life (GERD-HRQL), and Short Form 36 (SF-36) questionnaires preoperatively, 6 months, and 12 months after surgery.

RESULTS

Endoscopic findings revealed complete healing of esophagitis in all patients. Barrett esophagus was still present. Six patients reported persistence of symptoms but postoperative pH-metry and endoscopy showed the absence of reflux; 2 patients (5.5%) were still on proton pump inhibitor therapy at 12 months. Seven patients (19.4%) reported dysphagia for solids for at least 3 months. Readmission for dysphagia was required for 2 (5.5%) and 1 patient underwent endoscopic dilatation. At 6 and 12 months, no dysphagia was reported. During the follow-up, no gas-bloat syndrome was reported. The Johnsson & DeMeester score and QoL measurement obtained from GERD-HRQL and SF-36 revealed a significant improvement in the related domain. At 6 months, 23 patients (63.8%) were completely satisfied and after 12 months, 30 patients (83.3%) were satisfied.

CONCLUSIONS

Nissen-Rossetti fundoplication is safe and effective for the treatment of GERD, improving QoL.

Gastrointestinal symptoms and patient satisfaction more than 1 year after laparoscopic Nissen fundoplication

BACKGROUND

Symptoms from poorly controlled gastroesophageal reflux disease (GERD) such as heartburn and regurgitation often resolve after laparoscopic Nissen fundoplication. Unfortunately, new gastrointestinal symptoms such as bloating may occur for some patients. Accurate data regarding the gastrointestinal symptoms experienced by patients who have had a laparoscopic fundoplication may help patients to make more informed decisions about pursuing surgery for their reflux disease.

METHODS

Patients more than 12 months after a laparoscopic Nissen fundoplication were mailed symptom surveys. Before surgery, all the patients had medically refractory esophageal symptoms (heartburn, regurgitation, or both). Surveys included the Gastrointestinal Quality of Life Index (GIQLI) and questions regarding satisfaction, reintervention, and medication use. Responses for individual GIQLI items were evaluated to determine the gastrointestinal symptoms experienced by fundoplication patients and the relationship of these symptoms to patient satisfaction.

RESULTS

Of the 76 patients eligible for inclusion in the survey, 48 returned complete surveys (63%). The mean time since surgery was 28±9 months. No patient experienced frequent regurgitation, and few (10%) reported frequent heartburn at follow-up assessment. No patient required redo fundoplication during the follow-up period. Acid reduction medications were resumed by 25% of the patients, but not all of these patients resumed medications for recurrent GERD symptoms (15% total). After surgery, frequent bloating (21%) and excessive flatus (46%) were often noted. Satisfaction with the results of surgery was high, including 83% of the patients.

CONCLUSIONS

Few patients report frequent regurgitation or heartburn after laparoscopic Nissen fundoplication. Although some patients resume acid reduction medications, many do so for reasons other than recurrent GERD symptoms. Most fundoplication patients are quite satisfied with the symptomatic results of surgery, although frequent functional gastrointestinal symptoms are common.

Hiatal hernia, lower esophageal sphincter incompetence, and effectiveness of Nissen fundoplication in the spectrum of gastroesophageal reflux disease

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett's esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett's esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication.

METHODS

From the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified 50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4) BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal esophageal pH monitoring; and were interviewed at least 1 year after operation.

RESULTS

One hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients in all GERD categories.

CONCLUSIONS

Compared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients.

Association between persistent symptoms and long-term quality of life after laparoscopic total fundoplication

BACKGROUND

We investigated which factors are significantly associated with long-term quality of life after laparoscopic total fundoplication in the treatment of gastroesophageal reflux disease.

METHODS

Patients (n = 144) were given a standardized frequency-intensity symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

RESULTS

At follow-up evaluation (n = 102), patients had a significant reduction in their symptoms score and no deterioration in quality of life. A significant association with postoperative dysphagia for solids and/or liquids was found in the physical component summary score of the Short-Form 36 administered to patients postoperatively (P = .003).

CONCLUSIONS

In this study, laparoscopic total fundoplication was a safe and effective surgical treatment for gastroesophageal reflux disease, generally offering an improved long-term quality of life, with the exception of a minority of patients (6 of 102 patients; 5.8%) who experienced persistent severe dysphagia.

Does laparoscopic antireflux surgery improve quality of life in patients whose gastro-oesophageal reflux disease is well controlled with medical therapy?

OBJECTIVE

Both medical therapy and laparoscopic antireflux surgery have been shown to improve quality of life in gastro-oesophageal reflux disease. Although patients with poor symptom control or side effects on medical therapy might be expected to have improved quality of life after surgery, our aim was to determine, for the first time, whether patients whose symptoms are well controlled on medical therapy but who decide to undergo surgery (patient preference) would experience improved quality of life.

METHODS

Retrospective analysis of our patient database (1998-2003, n=313) identified 60 patients who underwent laparoscopic antireflux surgery for the indication of patient preference. Two generic quality-of-life questionnaires (Short Form 36 and Psychological General Well-Being index) and a gastrointestinal symptom questionnaire (Gastrointestinal Symptom Rating Scale) were completed preoperatively, while on medical therapy, and 6 months after surgery.

RESULTS

Thirty-eight patients completed all three questionnaires at both time intervals: 31 males, seven females; mean age 42 (15-66) years. Preoperative scores while on medical therapy were significantly improved after surgery: Short Form 36 median physical composite scores 52.0 and 54.0 (P=0.034) and mental composite scores 51.0 and 56.0 (P=0.020); Psychological General Well-Being median total scores 78.0 and 90.0 (P=0.0001); Gastrointestinal Symptom Rating Scale median total scores 2.13 and 1.73 (P=0.0007) and reflux scores 2.50 and 1.00 (P<0.0001).

CONCLUSION

Laparoscopic antireflux surgery significantly improved quality of life in reflux patients whose symptoms were well controlled on medical therapy. Although on the basis of a noncomparative trial with a relatively short follow-up period, we believe such patients should be considered for laparoscopic antireflux surgery.

Comparison of patient-centered outcomes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernia

BACKGROUND

Patients undergoing laparoscopic Nissen fundoplication (LNF) with paraesophageal hernias (PEH) are not only older and less healthy than those with gastroesophageal reflux disease (GERD), but in addition the repair is more complicated. We evaluated whether outcomes relating to GERD symptoms and quality of life (QOL) were impacted by the presence of PEH.

METHODS

Prospectively entered data from 149 patients (109 GERD and 40 PEH) were evaluated prior to and one year after LNF with standardized and validated symptoms scores. Scores for heartburn, dysphagia, disease-specific QOL (GERD-HRQL), and general health-related QOL (SF-12 physical and mental component scores) were compared between patients undergoing LNF for PEH or for GERD alone, at baseline and one year after surgery. p < 0.05 was considered statistically significant.

RESULTS

Preoperative data for GERD-HRQL, heartburn, and dysphagia were available for 134 patients, with 96% one-year follow-up. SF-12 data were collected for 98 patients with 100% follow-up. PEH patients were older and had greater comorbidity. Preoperative GERD-HRQL and heartburn were significantly worse in the GERD group. One year after surgery, both GERD and PEH patients showed significant improvement in GERD-HRQL, heartburn and dysphagia scores, with no difference in any of these disease or symptom measures between the two study groups. Postoperative PCS and MCS scores showed improvement in GERD patients, while PEH patient scores remained at or below the population mean.

CONCLUSIONS

LNF is equally effective as an antireflux procedure in both GERD and PEH patients, prevents symptoms of reflux in PEH patients that have none preoperatively, and does not increase dysphagia in either group. Despite the increased complexity of the procedure, LNF provides an effective control of reflux symptoms in patients undergoing PEH repair.

Robotic foregut surgery

BACKGROUND

Computer-assisted surgical systems, or surgical robots as they are more commonly called, are complex new devices which may be used to perform minimally invasive surgical procedures. There are certain technical limitations to a traditional laparoscopic approach that these devices can help a surgeon to overcome. Several surgical teams have applied these new devices to surgical procedures of the upper gastrointestinal tract and foregut.

METHODS

A retrospective review of the currently published literature on robotic foregut surgery.

RESULTS

Robotic foregut surgery appears to be feasible and safe. These procedures may be associated with increased operative time and cost when compared to their traditional laparoscopic counterparts. Procedures that require complex manoeuvres, delicate dissection, or a magnified high-definition image may be best suited to a computer-assisted approach.

CONCLUSIONS

Robotic foregut surgery is an exciting new field with tremendous potential for growth and dissemination.

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.

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility.

METHODS

A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions.

RESULTS

In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 +/- 5.2 mmHg (range, 6.0-30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% +/- 8.3% (range, 70-100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett's progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1-46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results.

CONCLUSION

The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360 degrees fundoplication should not be contraindicated for patients with severe esophageal dysmotility.

Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial)

BACKGROUND

Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs. Both focus on a faster recovery and shorter hospital stay. The randomized controlled multicenter LAFA-trial (LAparoscopy and/or FAst track multimodal management versus standard care) was conceived to determine whether laparoscopic surgery, fast track perioperative care or a combination of both is to be preferred over open surgery with standard care in patients having segmental colectomy for malignant disease.

METHODS/DESIGN

The LAFA-trial is a double blinded, multicenter trial with a 2 x 2 balanced factorial design. Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be randomized to either open or laparoscopic colectomy, and to either standard care or the fast track program. This factorial design produces four treatment groups; open colectomy with standard care (a), open colectomy with fast track program (b), laparoscopic colectomy with standard care (c), and laparoscopic surgery with fast track program (d). Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days. Secondary outcome parameters are quality of life two and four weeks after surgery, overall hospital costs, morbidity, patient satisfaction and readmission rate. Based on a mean postoperative hospital stay of 9 +/- 2.5 days a group size of 400 patients (100 each arm) can reliably detect a minimum difference of 1 day between the four arms (alfa = 0.95, beta = 0.8). With 100 patients in each arm a difference of 10% in subscales of the Short Form 36 (SF-36) questionnaire and social functioning can be detected.

DISCUSSION

The LAFA-trial is a randomized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease.

Gastroesophageal reflux: prevalence of psychopathological disorders and quality of life implications

There is evidence in the literature that psychosocial aspects affect the symptoms and results of surgery for gastroesophageal reflux. The purpose of this study was to estimate the prevalence of psychopathological disorders measured using the General Health Questionnaire (GHQ-28) in a sample of patients with gastroesophageal reflux, and to assess the influence of such disorders on their quality of life. A prospective study was conducted in 74 consecutive patients before gastroesophageal reflux surgery; patients answered the GHQ-28, the health questionnaire SF-36, and the Gastrointestinal Quality of Life Index (GIQLI). The convergent validity of the GHQ-28 questionnaire as compared to the other two questionnaires and preoperative quality of life was tested. A pathological result of the GHQ-28 questionnaire was found in 38.3% of patients. A correlation was seen between the results of the GHQ-28 questionnaire and all categories of the SF-36 and GIQLI questionnaires. Patients with pathological results in the GHQ-28 questionnaire had poorer results in all dimensions of the SF-36 and GIQLI quality of life questionnaires as compared to patients with a normal result in the GHQ-28 questionnaire. In conclusion, 38.3% of patients with gastroesophageal reflux showed psychopathological disorders when administered the GHQ-28 questionnaire. These patients also had poorer results in quality of life studies.

Long-term, health-related, quality of life comparison in patients undergoing single stage vs staged resection for complicated diverticular disease

OBJECTIVE

To evaluate long-term health-related quality of life, for single-staged and staged resections following reversal, for complicated diverticular disease.

PATIENTS AND METHODS

Between 1981 and 2003, 188 patients undergoing single stage (n = 158) or staged resection (n = 30) completed the SF-36 questionnaire. Health-related quality of life (HRQL) was compared between the two groups and the US normal population based on the eight domains of the SF-36. HRQL analysis was also performed at various time intervals. The effect of age and postoperative complications on HRQL was also determined. Functional and postoperative outcomes were also assessed.

RESULTS

The single and staged resection groups differed in the presence of comorbidity, degree of peritoneal contamination and operative urgency. No difference in functional outcomes or HRQL was found, even after analysing time-interval subgroups. Social functioning and general health was substantially worse in both groups when compared to US norms. Ageing was found to significantly reduce physical functioning (P < 0.001) and physical and emotional role limitations (P < 0.001 for both). Post-operative complications significantly reduced scores when compared to patients without complications, for physical functioning (63.57 vs 78.7, respectively; P < 0.001), physical role limitation (80.65 vs 86.9, respectively; P < 0.001) and bodily pain (66.67 vs 74.81, respectively; P < 0.01).

CONCLUSIONS

No significant difference in long-term HRQL was found in patients undergoing single staged or staged resection for complicated diverticular disease. There was significant impact of ageing and postoperative complications on physical health. Prospective studies that include pre-operative data on HRQL are required to compare the two operative techniques, with emphasis on quality of life of patients left with a permanent stoma.

Quality of life in GERD patients: medical treatment versus antireflux surgery

Medical and surgical treatments are able to improve symptoms in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the outcome in GERD patients without therapy, under continuous medical treatment, and after laparoscopic antireflux surgery. Five hundred seventy-nine consecutive patients underwent medical or surgical treatment for GERD-induced symptoms. Patients were studied in detail before and after treatment by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI) and the Health-Related Quality of Life (HRQL) questionnaire. Surgery was indicated and performed in 351 patients with persistent or recurrent GERD symptoms and/or complications, and in patients preferring surgery to medical treatment, despite the use of an adequate medication. The remaining 228 patients were treated with proton pump inhibitors (PPI) in the standard dose, or if required, the double dose. The outcome was assessed 3 and 12 months after treatment. While symptoms and quality of life were highly impaired in GERD patients without therapy compared with normal people, a significant improvement was obtained by PPI therapy. Following surgery, quality of life was normalized in all subsections and was significantly higher compared with the medically treated group. These results stayed constant in short-term and intermediate follow-up. Medical and surgical therapies are both able to improve symptoms and quality of life in GERD patients. Nevertheless, the outcome is significantly better following surgery. It can be suggested that surgical treatment may be the more successful therapy in the long-term.

[Quality of life after laparoscopic fundoplication for gastroesophageal reflux disease]

OBJECTIVE

To evaluate our results in terms of satisfaction and quality of life in patients who underwent laparoscopic 360 degrees fundoplication for gastroesophageal reflux disease.

PATIENTS AND METHOD

We performed a cross-sectional study of 49 consecutive patients who underwent laparoscopic 360 degrees fundoplication for gastroesophageal reflux disease. All patients had been operated on more than 6 months previously by the same surgeon. Postoperative morbidity was recorded. Patients were sent the SF-36 and GIQLI quality of life questionnaires and were also asked about their degree of satisfaction with the surgery.

RESULTS

The mean age was 40.5 years (range, 23-71). There were nine women and 40 men. All patients underwent a floppy 360 degrees fundoplication and crural closure. There were no conversions. The complication rate was 8.2% (one case each of fever of unknown origin, acute urinary retention, self-limiting bleeding and hernia from a port). Forty-three patients completed the questionnaires (87.7%). Satisfaction with surgery was 8.7 points (out of 10), 89.5% would undergo surgery again and 94.6% would recommend it to a relative. The results of the SF-36 questionnaire were similar to population-based reference values except in the domains of physical functioning and bodily pain where statistically significant differences were found. The mean global GIQLI score was 110.8, which was similar to other studies published in the medical literature.

CONCLUSIONS

Although this is a cross-sectional study, these preliminary results indicate a high degree of satisfaction with laparoscopic fundoplication, which was reflected in the results of the quality of life questionnaires.

Complications and antireflux medication use after antireflux surgery

BACKGROUND & AIMS

Although antireflux surgery is increasingly common, few studies have assessed the associated complications and health care use after surgery. The aim of this study was to estimate postoperative complications and continued use of antireflux medications and to identify predictors of complications.

METHODS

Through a review of the Department of Veterans Affairs administrative databases, all patients undergoing antireflux surgery from October 1, 1990, through January 29, 2001, were identified. Of 3367 patients identified, 222 were excluded as a result of a diagnosis of esophageal cancer, achalasia, or because there was no diagnosis related to gastroesophageal reflux disease. Medication use was determined for 2406 patients who had a minimum of 1 year of follow-up, including 1 or more outpatient visits at least 6 months after surgery and during the time when national pharmacy records were available.

RESULTS

Dysphagia was recorded in 19.4%, dilation was performed in 6.4%, and a repeat antireflux surgery was performed in 2.3%. The surgical mortality rate was .8%. Prescriptions were dispensed repeatedly for H2 receptor antagonists in 23.8%, proton pump inhibitors in 34.3%, and promotility agents in 9.2% of patients. Overall, 49.8% of patients received at least 3 prescriptions for one of these medications.

CONCLUSIONS

A moderate proportion of patients undergoing antireflux surgeries experienced complications and approximately 50% of patients received multiple prescriptions for antireflux medications at a median of 5 years of follow-up evaluation. Therefore, before surgery is performed, patients considering surgery should be counseled fully about the risk for complications and the likelihood of continued antireflux medication use.

Surgical therapy for Barrett's esophagus

Given the anatomic and functional defects almost universally present in patients who have BE, antireflux surgery is the most reliable means of stopping acid and nonacid (alkaline) reflux. Because patients who have BE have end-stage GERD, they require durable and reliable control of reflux, and the Hill procedure and partial fundoplication are associated with unacceptably high failure rates. In addition, there is mounting evidence that the success rates for Nissen fundoplication are lower in patients who have BE than in patients who have less severe GERD. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, patients who have BE must be considered at risk for having a short esophagus. The failure rate may be reduced by the liberal addition of a Collis gastroplasty, but the long-term consequences of acid-secreting mucosa left above the fundoplication in patients who have BE remain unclear. Patients suspected of having a short esophagus on the basis of a large hiatal hernia, stricture, or long-segment BE should be considered for a transthoracic approach to their fundoplication, as this affords good esophageal mobilization and may obviate the need for a gastroplasty. Surgeons must pay particular attention to their own and published results and continue to refine the operation to maximize the likelihood of a good outcome in this difficult group of patients. It is only with excellent control of reflux that any differences in the risk of progression to dysplasia and cancer become apparent, and significant, between medically and surgically treated patients.

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome

BACKGROUND

It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients.

METHODS

From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 +/- 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 +/- 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients' satisfaction with surgery. The data of a complete 5-year follow-up are available.

RESULTS

There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients' satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 +/- 11.6 points/EGD-negative vs 93.8 +/- 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 +/- 8.5 for EGD-negative vs 120.9 +/- 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 +/- 8.5).

CONCLUSION

We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.

Hand-assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomosis: a randomized trial

OBJECTIVE

The aim of the study was to evaluate postoperative recovery after hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis in a randomized controlled trial.

METHODS

Sixty patients were randomized for hand-assisted laparoscopic (n = 30) or open surgery (n = 30). Primary outcome parameter was postoperative recovery in the 3 months after surgery, measured by quality of life questionnaires (SF-36 and GIQLI). Secondary parameters were postoperative morphine requirement and surgical parameters, viz. operating time, morbidity, hospital stay, and costs.

RESULTS

There was no difference between the 2 procedures in quality of life assessment in the 3 months after surgery. There was a significant decline in quality of life on all scales of the SF-36 (P < 0.001) and total GIQLI score (P < 0.001) in the first 2 weeks in both groups (no significant difference between the groups). Quality of life returned to baseline levels after 4 weeks. Operating times were longer in the laparoscopic group compared with the open group (210 and 133 minutes, respectively; P < 0.001). No significant differences were found in morphine requirement. Neither morbidity nor postoperative hospital stay differed between the laparoscopic and open group (20% versus 17%, in 10 versus 11 days, respectively). Median overall costs were 16.728 for the hand-assisted laparoscopic procedure and 13.406 for the open procedure (P = 0.095).

CONCLUSIONS

Recovery measured using quality of life questionnaires is comparable for hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis. The laparoscopic approach is as safe, but more costly than the open procedure.

Robotic Laparoscopic Fundoplication

Gastroesophageal reflux disease is a very common disorder, and both medical and surgical treatments have shown outstanding results. Whereas proton pump inhibitors are the mainstay of treatment, laparoscopic fundoplication has become a very attractive alternative due to its efficacy and low morbidity. There are defined patient categories that may benefit more from laparoscopy than medical therapy, but a conclusive comparison between the two is lacking. Robotic laparoscopic fundoplication can be performed safely without increased morbidity. Potential advantages include enhanced precision, improved dexterity, and remote telesurgical applications. Disadvantages include increased cost and prolonged operative times. Further studies and more long-term outcome data are needed to fully evaluate the procedure. Robotic surgery is currently in its infancy and not cost effective but has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.

Treatment of Achalasia

Achalasia is a primary motility disorder of the esophagus that causes dysphagia. Normal esophageal motility and lower esophageal sphincter (LES) function can not be restored; thus treatment is directed at decreasing the pressure or disrupting the muscle fibers of the LES to allow passage of ingested material. Effective therapy for achalasia can be broadly characterized as surgery based or endoscopy based. Medications (calcium channel blockers and nitrate derivatives) do not provide adequate relief of dysphagia and have substantial side effects, and thus are rarely used as long-term therapy. Botulinum toxin injection, a recently introduced endoscopic therapy, enjoyed much enthusiasm initially but was shown to have only transient effect and is now recommended only for poor operative candidates. The mainstay of therapy remains endoscopic dilation or laparoscopic esophagomyotomy (LEM) combined with an antireflux procedure. We have found that patients who can tolerate a laparoscopic abdominal surgery are best served with an LEM and Toupet (270 degrees ) posterior fundoplication. This provides good or excellent relief of dysphagia in 90% to 95% of patients with very little morbidity.

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 quality of life of gastroesophageal reflux disease patients waiting for an antireflux operation

BACKGROUND

The purpose of this trial was to measure the health-related quality of life (HRQL) of gastroesophageal reflux disease (GERD) patients waiting for an antireflux operation.

METHODS

A total of 120 patients waiting for a laparoscopic fundoplication were sent questionnaires measuring their symptoms and quality of life.

RESULTS

Ninety-five of the patients still needing an operation returned the questionaires and were included in the analysis. Thirty-one of 84 patients (37%) felt that the symptoms had worsened, and 51/90 (57%) were unsatisfied. Thirty percent suffered from throat or airway infections, 25% from swallowing difficulties, 48% from retrosternal pain, and 18% had asthma. The mean GERD HRQL score (0-45) was 21.7 (95% confidence interval, 19.7-23.7). Short Form-36 scores of this population were significantly worse when compared to patients with inguinal hernia or moderate asthma.

CONCLUSIONS

Patients waiting for a fundoplication seem to have a significantly decreased health-related quality of life due to poor symptom control regardless of continuous medical treatment.

Telerobotic foregut and esophageal surgery

Computer-assisted telerobotic surgery has many potential advantages over standard laparoscopy in foregut and esophageal surgery. The high-definition, three-dimensional images produced by the optics of these systems can facilitate identification of anatomy and dissection during surgery. The full range of motion afforded by the multiarticulated instruments can be beneficial in completing complex laparoscopic tasks such as suturing and intracorporeal knot tying. Tremor filtration and motion scaling allows for more precise movements during surgery. The remote console provides the operating surgeon with a comfortable ergonomic position during the sometimes long and complex procedures. Despite the many advantages of these systems, however, several limitations still exist. It is expected that the development and refinement of these technologies will address many of these issues. With continued progress, it is likely that this technology will disseminate widely throughout the surgical community.

Review of the quality of life and burden of illness in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is associated with a range of symptoms (typically heartburn, acid regurgitation and dysphagia), which may or may not be accompanied by endoscopically evident esophagitis. A number of studies have demonstrated that health-related quality of life (HRQoL) in reflux disease patients is significantly impaired in comparison to the general population, regardless of the endoscopic findings. Furthermore, this impairment is comparable to or greater than that observed in other chronic conditions, such as diabetes, arthritis or congestive heart failure. Impaired HRQoL in GERD patients is a result of features such as disturbed sleep, reduced vitality, generalized body pain, an impaired sex life and anxiety about the underlying cause of the symptoms. Nocturnal symptoms of reflux disease appear to have a particularly marked impact on HRQoL. The burden of illness imposed by reflux disease on HRQoL also has an impact on productivity, both at and outside work. The impact of reflux disease on productivity is significant and comparable to that caused by headache or back pain. Effective treatment is available for reflux disease, and there is evidence that this can quickly restore HRQoL to levels observed in the general population. However, poor communication between physicians and patients is contributing to unacceptable levels of patient dissatisfaction. Understanding patients' experience of GERD and its treatment through the study of HRQoL is one way to address this problem.

Laparoscopic Nissen Fundoplication Improves Quality of Life in Patients with Atypical Symptoms of Gastroesophageal Reflux

Laparoscopic Nissen fundoplication has been shown to improve overall quality of life (QOL) in patients with gastroesophageal reflux, but most studies have not addressed patients with atypical symptoms. We investigated the effect of laparoscopic Nissen fundoplication on QOL using the Gastrointestinal Quality of Life Index (GIQLI) survey modified to address both typical (heartburn, regurgitation, dysphagia) and atypical (hoarse voice, chronic cough, adult-onset asthma, vocal cord polyps) symptoms. One-hundred forty-eight patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) at UCLA Medical Center from January 1, 1995 to May 1, 2002. Surveys evaluating pre- and postoperative QOL were administered after surgery: 55 per cent of patients responded (82/148). Forty-eight per cent of all patients (72/148) had atypical symptoms. Perioperative morbidity and mortality were 8.8 per cent and 0.7 per cent, respectively. Mean length of postoperative stay was 2.96 ± 1.5 days. Mean follow-up for the entire cohort was 18.5 months. Postoperative dysphagia not present before surgery occurred in 4.7 per cent of patients. Eighty per cent of patients were medication-free following surgery. QOL scores for all participants increased significantly from 52.5 ± 15.3 preoperatively to 72.0 ± 14.9 postoperatively ( P < 0.0001). Patients with atypical symptoms or typical symptoms alone showed significant mean QOL score increases from 48.3 ± 17.6 preoperatively to 71 ± 15.7 postoperatively ( P < 0.0001) and from 55.7 ± 12.6 to 72.8 ± 14.4 ( P < 0.0001), respectively. Laparoscopic Nissen fundoplication can effectively improve overall QOL for patients with GERD. Patients with atypical GERD symptoms can experience increases in QOL similar to those with only typical gastrointestinal symptoms.

Antireflux surgery for Barrett's oesophagus

Barrett's oesophagus is usually the result of severe reflux disease. Relief of reflux symptoms is the primary aim of treatment in patients with Barrett's oesophagus who do not have high-grade dysplasia. Some studies with medium-term (2-5 years) follow up show that antireflux surgery can provide good or excellent symptom control, with normal oesophageal acid exposure, in more than 90% of patients with Barrett's oesophagus. Antireflux surgery, but not medical therapy, can also reduce duodenal nonacid reflux to normal levels. There is no conclusive evidence that antireflux surgery can prevent the development of dysplasia or cancer, or that it can reliably induce regression of dysplasia, and patients with Barrett's oesophagus should therefore remain in a surveillance programme after operation. Some data suggest that antireflux surgery can prevent the development of intestinal metaplasia (IM) in patients with reflux disease but no IM. The combination of antireflux surgery plus an endoscopic ablation procedure is a promising treatment for patients with Barrett's oesophagus with low-grade dysplasia.

Psychological and emotional aspects of gastroesophageal reflux disease

A synergy exists between the psychological and physiological aspects of esophageal and other gastrointestinal symptoms. Based on a biopsychosocial model of disease, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) has been under study. This article reviews psychological and emotional factors influencing GERD symptoms and treatment.

The effect of chronic pain syndromes and psychoemotional disorders on symptomatic and quality-of-life outcomes of antireflux surgery

Psychoemotional disorders (PED) and chronic pain syndromes (CPS) are common problems. Many patients with these disorders also suffer from gastroesophageal reflux disease (GERD). It is unclear how PED/CPS affect outcomes of antireflux surgery; therefore, the purpose of this study was to determine if PED/CPS adversely affects the results of surgical therapy for GERD. All patients referred for surgical therapy for GERD completed both the GERD-HRQL symptom severity instrument and the SF-36 generic quality-of-life instrument prior to surgery. To be candidates for surgery, patients must have symptomatic GERD and objective evidence of pathologic reflux by upper endoscopy, esophageal manometry and 24-hour pH monitoring. Patients underwent either laparoscopic or open Nissen or Toupet fundoplication. Six to 24 months postoperatively, patients were evaluated for satisfaction and quality-of-life. Ninety-three percent of control patients compared to 25% of PED/CPS patients were satisfied with surgery (P < 0.001). Dissatisfaction in PED/CPS patients was generally due to persistent or new somatic complaints. Median total GERD-HRQL scores improved for both groups, although postoperative scores were worse in the PED/CPS group. PED/CPS patients had significantly worse SF-36 scores both preoperatively and postoperatively compared to control patients. SF-36 scores improved in four of eight domains in control patients and none in the PED/CPS patients. In conclusion, PED/CPS patients are generally dissatisfied with antireflux surgery. Although some patients do benefit from surgery, careful patient selection is required.

Surgical and endoscopic treatment of gastroesophageal reflux disease

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.

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.

Excellent quality of life after Nissen fundoplication depends on successful elimination of reflux symptoms and not the invasiveness of the surgical approach

BACKGROUND

Quality of life, poor in patients with reflux disease, improves significantly after an antireflux operation. The aim of this study was to determine the relative importance of the operative approach used for a fundoplication, as well as the successful elimination of reflux symptoms on long-term quality of life in patients with gastroesophageal reflux disease.

METHODS

A questionnaire, including the medical outcome study short-form health survey (SF-36), was completed by 105 patients who had undergone either a laparoscopic Nissen fundoplication (n = 72) or a transthoracic Nissen fundoplication (n = 33); median follow-up was 25 and 31 months, respectively. Patients were classified as completely or incompletely relieved of reflux symptoms based on the frequency of reflux symptoms and the use of acid-suppression medication.

RESULTS

Patients selected for transthoracic Nissen fundoplication had significantly worse preoperative gastroesophageal reflux disease based on the presence of a large hiatal hernia, Barrett's esophagus, or stricture. Long-term quality of life was similar for the two approaches, but was significantly decreased in patients with recurrent reflux symptoms. Compared with laparoscopic Nissen fundoplication patients, transthoracic Nissen fundoplication patients were less likely to use acid-suppression medication and tended to be more satisfied with their operation.

CONCLUSIONS

Long-term quality of life was independent of the invasiveness of the procedure, but significantly dependent on successful elimination of reflux symptoms and the necessity for acid suppression medication. Patients who underwent a transthoracic Nissen fundoplication, despite having more advanced disease preoperatively, tended to have less reflux symptoms and less long-term acid-suppression medication usage after their procedure. These findings support the continued use of a transthoracic antireflux procedure in patients with advanced gastroesophageal reflux disease.

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.

Influence of functional bowel disease on outcome of surgical antireflux procedures

Patients with gastroesophageal reflux disease (GERD) have a coexisting diagnosis of functional bowel disease (FBD) in approximately 30% of cases. Symptom improvement after surgical therapy for GERD may be less in patients with FBD when compared to patients without this coexisting problem. A retrospective review of patients undergoing Nissen fundoplication between 1996 and 2000 evaluated patients with documented FBD or FBD symptoms to determine operative outcome. Poor postoperative outcome included recurrent heartburn, gas bloat syndrome, dysphagia requiring reoperation or dilation, or delay in resumption of normal diet. Bivariate comparison and multivariate logistic regression evaluated the independent impact of a documented diagnosis of FBD or preoperative symptoms of FBD on outcome. This study examined 155 patients: 32% reported having symptoms of FBD and 10% had a confirmed diagnosis of FBD. Poor postoperative outcomes occurred in 27%. Patients with a documented diagnosis of FBD were significantly more likely to have a poor outcome when compared to patients without symptoms of FBD (53% vs. 23%, P = 0.01). Patients with preoperative symptoms of FBD (but without a documented diagnosis of FBD) also had a higher incidence of poor outcome (5% vs. 23%, P = 0.09). Patients with FBD are at increased risk of poor results after antireflux surgery. Patients with these conditions should be counseled preoperatively regarding the potential for recurrent postoperative symptoms.

Clinical and histologic follow-up after antireflux surgery for Barrett's esophagus

There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett's esophagus, as defined by the recently standardized criteria. We report the clinical, endoscopic, and histologic results of patients with Barrett's esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett's esophagus required preoperative endoscopic evidence of columnar-lined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic [n = 84] or open [n = 6] nissen, laparoscopic Toupet [n = 11], laparoscopic Collis-Nissen [n = 1], Collins-Toupet [n = 1] or open Dor [n = 1]). Short-segment Barrett's esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic-type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett's esophagus. A substantial number of patients with Barrett's esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy.