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PubMed2003

Recurrence after laparoscopic and open Nissen fundoplication: a comparison of the mechanisms of failure.

BACKGROUND: Laparoscopic Nissen fundoplication as treatment for gastroesophageal reflux disease (GERD) in adults has a reported recurrence rate of 2-17%. We investigated the rates and mechanisms of failure after laparoscopic Nissen fundoplication in children. METHODS: All patients who underwent a laparoscopic Nissen fundoplication for GERD and who subsequently required a redo Nissen were reviewed (n = 15). The control group consisted of the most recent 15 patients who developed recurrent GER after an open Nissen, fundoplication. RESULTS: Between 1994 and 2000, laparoscopic Nissen fundoplication was performed in 179 patients. Fifteen patients (8.7%) underwent revision. The mechanisms of failure were herniation in four patients, wrap dehiscence in four, a too-short wrap in three, a loosened wrap in two, and other reasons in two. The reoperation was performed laparoscopically in five patients (33%). The failure mechanisms were different in the open patients: eight were due to slipped wraps; three to dehiscences; and two to herniations. CONCLUSION: The failure rate after laparoscopic Nissen is acceptably low. A redo laparoscopic Nissen can be performed safely after an initial laparoscopic approach.

Child↗
PubMed2003

Nissen fundoplication has a vagolytic effect on the lower esophageal sphincter.

BACKGROUND: Laparoscopic Nissen fundoplication is an increasingly utilized option for the treatment of gastroesophageal reflux disease (GERD). However, many questions remain as to the mechanism by which this operation prevents GERD in those without hiatal hernias or incompetent lower esophageal sphincters (LES). It is known that these patients experience reflux due to excess transient lower esophageal sphincter relaxations (TLESR), inappropriate and short-lived relaxation of the LES and crural diaphragm. The purpose of this study was to determine if Nissen fundoplication affects the neural pathways involved in the TLESR reflex. METHODS: Five dogs were anesthetized and intubated. Both vagal nerves and the right phrenic nerve were isolated. A continuous water perfusion manometric catheter was situated at the LES. The nerves were then electrically stimulated and the resultant pressure at the LES measured at baseline, and during and after an open Nissen fundoplication. RESULTS: The mean LES pressures before dissection, after esophago-gastric mobilization, and after fundoplication were 47 +/- 13 mmHg, 21 +/- 9 mmHg, and 14 +/- 4 mmHg, respectively. All differences were significant. There was no change noted in LES pressure with stimulation of either or both of the phrenic nerves without concomitant vagal stimulation. CONCLUSION: Nissen fundoplication may prevent GERD in those without a hiatal hernia or incompetent LES by disrupting the efferent vagal fibers to the LES. Such fibers mediate TLESR which are responsible for GERD in these patients.

Animals↗
PubMed2003

Complete fundoplication has similar long-term results in patients with and without esophageal body dysmotility.

BACKGROUND: Partial fundoplication is advocated for the treatment of gastroesophageal reflux disease in patients with poor esophageal body function. We hypothesized that a complete floppy wrap may be just as safe in patients with poor esophageal motility. METHODS: A retrospective, case-control study was performed on patients who underwent a complete fundoplication and had poor esophageal motility. Study patients were matched with controls with normal esophageal body pressures according to sex, age, and duration of reflux symptoms. Patients were followed up and interviewed using a modified symptom and life quality questionnaire. RESULTS: Twenty-two patients and 22 matched controls underwent a complete fundoplication. The mean esophageal body pressure was 42.1 and 87.5 mmHg in the study and control groups, respectively (p <0.05). Average time to resolution of dysphagia was 10.1 weeks in the study group and 12 weeks in the control group. All patients but 1 (control) graded their life quality improvement as good to excellent. CONCLUSION: Our data suggest that a 360 degrees fundoplication has similar long-term results regardless of esophageal body motility. We suggest that a partial fundoplication may be reserved for patients with severe esophageal body dysfunction. The role of manometry in the preoperative workup should be reassesed: it may be mandatory only in patients with preoperative dysphagia or when achalasia is suspected.

Case-Control Studies↗
PubMed2003

Multimedia article. Laparoscopic fundoplication in an infant.

BACKGROUND: Laparoscopic fundoplication in infants and children is rapidly becoming the procedure of choice for surgical correction of symptomatic gastroesophageal reflux because of the advantages of reduced discomfort and decreased hospitalization. In addition, there may be a hidden benefit of an earlier return to work by the parents. METHODS: This video depicts the salient operative features for performing a laparoscopic fundoplication in an infant who presented with an acute life-threatening event, which was felt secondary to gastroesophageal reflux. In this operation, a 5 mm cannula was placed in the umbilicus through which insufflation was achieved and a 5 mm, 45 degrees angled telescope was inserted into the peritoneal cavity. The four instruments were placed directly through the abdominal wall using a stab incision technique rather than using cannulas. Moreover, the operation was performed using AESOP, the voice-activated telescopic holder, which provides a steady and consistent view. RESULTS: The operative technique was straightforward in that the short gastric vessels were divided, the crura were closed, and the esophagus was secured to the crura to keep the esophagus in an intraabdominal position and to prevent transmigration of the fundoplication wrap in the postoperative period. The length of the fundoplication should be around 2.0 cm and was measured to ensure that the fundoplication approximates this length. CONCLUSION: This patient made an eventful recovery and was discharged the following day. No complications have developed. [The full text of this article is a video computer file.]

Fundoplication↗
PubMed2004

Outcome of laparoscopic redo fundoplication.

BACKGROUND: To date, there has been no objective evidence for the effectiveness of laparoscopic redo fundoplication. We therefore reviewed our experience and based our analysis on a number of objective parameters. METHODS: We prospectively followed 28 consecutive patients (five men and 23 women; mean age, 48.64 +/- 2.57 years) who required redo fundoplication. These patients were part of a series of laparoscopic Nissen fundoplications done between 1992 and 2001. The indications were recurrent symptoms of gastroesophageal reflux disease (GERD) (21 patients), acute herniation of the wrap (three patients), and chronic paraesophageal hernia (four patients). A diagnosis of recurrent GERD was based on endoscopy, 24-h pH study, manometry, and symptom score evaluation. A diagnosis of paraesophageal and acute herniation was based on contrast swallow studies and/or gastroscopy. RESULTS: Twenty-six redo fundoplications were completed laparoscopically; two were converted to open. The mean operative time was 55.43 +/- 3.81 min. There were no intraoperative complications. The mean hospital stay was 3.0 +/- 0.35 days. Postoperative complications included postoperative pneumonia in one patient. Two patients from the laparoscopic group required a third operation-one for acute herniation of the redo wrap, which was fixed laparoscopically, and the other for acute recurrent paraesophageal hernia, which was fixed via an open transthoracic approach. The mean follow-up after revision is 25.14 +/- 3.48 months, with a significant decrease in acid reflux from 5.01% +/- 0.99 to 0.48% +/- 0.23 ( p < 0.0001), a significant decrease in symptom score from 28.96 +/- 2.93 to 10.75 +/- 2.61 ( p < 0.0001), and a small but significant increase in lower esophageal sphincter (LES) pressure from 13.71 +/- 1.79 to 16.69 +/- 1.50 ( p = 0.04). CONCLUSIONS: Laparoscopic redo fundoplication is technically feasible and clinically effective over a 2-year objective follow-up. Conversion and complication rates are low.

Equipment Failure↗
PubMed2006

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.

Contraindications↗
PubMed2006

Therapeutic effects of laparoscopic fundoplication for nonerosive gastroesophageal reflux disease.

PURPOSE: Surgical treatments for nonerosive gastroesophageal reflux disease (NERD) have not been investigated sufficiently. We examined the results of laparoscopic fundoplication for patients with NERD. METHODS: We performed laparoscopic fundoplication for NERD in 22 patients. The severity of esophageal hiatal hernia, morphology of the cardiac orifice, and results of 24-hour continuous esophageal and gastric pH were evaluated. We used a four-point scale for the improvement rating of postoperative symptoms. RESULTS: There were 20 patients (91%) with a sliding hiatal hernia, and 21 patients (95%) with a loose cardiac orifice. Seven patients had acid reflux with 4.0% or higher esophageal fraction of time pH below 4. The surgical techniques used were Nissen fundoplication in 10 patients and Toupet fundoplication in 12 patients. Improvement of postoperative heartburn was rated as excellent in 16 patients, good in 5, and fair in 1. The overall efficacy rating was 95%, and discontinuation of proton pump inhibitor (PPI) was possible in 21 patients. CONCLUSION: Our results of performing laparoscopic fundoplication in patients with NERD were excellent. Even if abnormal acid reflux cannot be confirmed preoperatively, sufficient therapeutic efficacy can be expected for patients with esophageal hiatal hernia or a loose cardiac orifice.

Adult↗
PubMed2004

Teflon pledget reinforced fundoplication causes symptomatic gastric and esophageal lumenal penetration.

BACKGROUND: Nissen fundoplication has become the standard operative procedure for the treatment of severe gastroesophageal reflux disease. The use of Teflon pledgets in Nissen fundoplications by our unit has been associated with a number of complications that has led to a change of technique in performing these operations. METHODS: We reviewed our database of all patients who had fundoplications that involved the use of pledgets and identified those who had represented with postoperative complications related to pledget erosion/migration. RESULTS: We identified 11 patients to date from a total of 1,175 fundoplications who had symptomatic pledget erosion occurring between 2 and 85 months after surgery (mean time 33.3 months). Symptoms included dysphagia, recurrent symptomatic gastroesophageal reflux, chest pain, and melaena, and in some cases significant morbidity was associated with the erosion. No common factor predisposing these patients to pledget erosion was identified. In the majority of cases removal of the pledget was associated with resolution of the symptoms. A review of the literature does not reveal any similar studies but problems associated with the erosion and migration of Teflon prostheses are described. CONCLUSIONS: The use of Teflon pledgets in fundoplication is associated with a small but significant risk of complications that has led to our unit abandoning this technique.

Adult↗
PubMed2004

Failed fundoplications.

BACKGROUND: Five percent of patients who undergo fundoplication will require reoperation. The cause of this high failure rate and the best management for these patients remains poorly understood. The aim of this study was to identify patterns and causes of failure of primary antireflux procedures. METHODS: Retrospective review of the medical records of patients who underwent revisional antireflux surgery at 2 tertiary referral centers. RESULTS: Between 1998 and 2003, 39 patients underwent laparoscopic revisional antireflux surgery. The time between primary and revisional surgery was 5.9 +/- 0.4 years. Primary operations included 26 laparoscopic and 13 open fundoplications. All of the 39 revisional operations were attempted laparoscopically, and there was 1 open conversion. Revisional procedures included 31 Nissen and 8 partial fundoplications. The duration of surgery was 138 +/- 10 minutes. Length of hospital stay was 2.1 +/- 0.3 days. At a mean follow-up of 6 months, reflux resolved in 94% of patients. Morbidity occurred in 23% of patients. Four types of failure were identified: type 1 = herniation of the gastroesophageal junction through the hiatus with or without the wrap (n = 21); type 2 = paraesophageal hernia (n = 9); type 3 = malformation of the wrap (n = 2). Six patients had primary wrap failure, and 1 had esophageal dysmotility. CONCLUSIONS: Laparoscopic revisional antireflux surgery is effective treatment for patients with failed primary fundoplications. Successful revisional surgery depends on identification and correction of the reason for primary fundoplication failure.

Adolescent↗
PubMed2006

Surgical fundoplication in laryngopharyngeal reflux unresponsive to aggressive acid suppression: a controlled study.

BACKGROUND & AIMS: In patients with persistent laryngeal symptoms despite aggressive proton pump inhibitor therapy, gastroesophageal reflux disease (GERD) continues to be implicated. The role of surgical fundoplication as the definitive therapy for these patients is uncertain. METHODS: In this prospective concurrent controlled study, 72 patients with suspected GERD-related laryngeal symptoms received aggressive acid-suppressive therapy. Four-month symptomatic nonresponders (<50% improvement) with continued laryngeal inflammation and normalized esophageal acid exposure were offered laparoscopic Nissen fundoplication. The primary outcome was symptom improvement/resolution at 1 year after surgery. RESULTS: Twenty-five of 72 (35%) patients remained unresponsive after 4 months of acid-suppressive therapy. Ten patients (40%) underwent surgical fundoplication (median age, 54 y; men, 4) and 15 patients (60%) continued medical therapy (median age, 52; men, 4). The most common laryngeal symptoms were sore throat, hoarseness, and cough. pH studies at 3 and 12 months were normal in all patients after fundoplication (median % time pH < 4, .0% and .3%; respectively). One of 10 (10%) patients in the surgery group reported improvement of laryngeal symptoms at 1 year compared with 1 of 15 in the control group (6.7%) (P = 1.0). Treatment of causes other than GERD improved symptoms in an additional 2 of 10 (20%) patients in the surgical group, and 10 of 15 (66%) patients in the nonsurgical cohort. CONCLUSIONS: Surgical fundoplication does not improve laryngeal symptoms reliably in patients unresponsive to aggressive proton pump inhibitor therapy. The argument of low volume or intermittent reflux as the cause of persistent laryngeal symptoms needs to be replaced with evaluation and therapy for other potential non-GERD causes.

Adult↗
PubMedDate not supplied

Obesity is not a contraindication to laparoscopic Nissen fundoplication.

Obesity has been shown to be a significant predisposing factor for gastroesophageal reflux disease (GERD). However, obesity is also thought to be a contraindication to antireflux surgery. This study was undertaken to determine if clinical outcomes after laparoscopic Nissen fundoplications are influenced by preoperative body mass index (BMI). From a prospective database of patients undergoing treatment for GERD, 257 consecutive patients undergoing laparoscopic Nissen fundoplication were studied. Patients were stratified by preoperative BMI: normal (<25), overweight (25-30), and obese (>30). Clinical outcomes were scored by patients with a Likert scale. Overweight and obese patients had more severe preoperative reflux, although symptom scores for reflux and dysphagia were similar among all weight categories. There was a trend toward longer operative times for obese patients. Mean follow-up was 26+/-23.9 months. Mean heartburn and dysphagia symptom scores improved for patients of all BMI categories (P<0.001). Postoperative symptom scores and clinical success rates did not differ among BMI categories. Most patients undergoing laparoscopic Nissen fundoplication are overweight or obese with moderate dysphagia and severe acid reflux. Clinical outcomes after laparoscopic Nissen fundoplication did not differ among patients stratified by preoperative BMI. Obesity is not a contraindication to laparoscopic Nissen fundoplication.

Body Mass Index↗
PubMed2006

Long-term control of gastroesophageal reflux disease symptoms after laparoscopic Nissen-Rosetti fundoplication.

Laparoscopic fundoplication is the gold standard surgical treatment for gastroesophageal reflux disease, although some patients develop recurrence or collateral symptoms related to surgery. The aims of this study were to describe the long-term symptoms control in patients undergoing laparoscopic fundoplication, to analyze the patterns of failure and to correlate postoperative symptoms with anatomic and physiologic findings. Extensive preoperative and postoperative work-up including symptom questionnaire, barium meal, endoscopy, manometry, and 24-hour pH-metry were performed in 130 consecutive patients undergoing laparoscopic fundoplication. Mean follow-up was 52 months. After laparoscopic fundoplication, 117 patients (90%) were asymptomatic with Visick grade I and II symptoms reported by 124 patients (95%). On evaluation, 119 (92%) patients were satisfied and willing to repeat surgery. Two failure patterns, anatomic abnormalities (wrap migration into the chest or down onto the stomach with or without repair disruption) and functional (incompetence of antireflux mechanism), were reported in 17 patients. Reflux can be controlled in up to 90% of patients with gastroesophageal reflux disease with relatively few complications and a high degree of patient satisfaction. The most common cause of recurrent symptoms is an anatomic failure of the fundoplication.

Female↗
PubMed2004

Esophagogastric separation for failed fundoplication in neurologically impaired children.

PURPOSE: Recurrent gastroesophageal reflux (GER) after a fundoplication in severely neurologically impaired children is a frustrating problem without an effective solution: redo fundoplications carry a significant recurrence rate and gastrojejunostomy (GJ) tube feedings are associated with frequent tube dislodgment. The authors report a series of esophagogastric separation (EGS) procedures aimed at the management of failed fundoplication in neurologically impaired children. METHODS: Medical records of 10 patients who underwent EGS for recurrent GER were reviewed retrospectively. Variables examined included diagnosis, preoperative problems, operative and perioperative data, and outcomes. RESULTS: None of the patients were feeding orally and all were dependent on tube feedings. A median of 1.5 (range, 1 to 3) fundoplications had been performed previously and failed. All had preoperative emesis and feeding intolerance. Eight had failure to thrive and 5 recurrent pneumonias. Median age at the time of the procedure was 7.5 years (range, 2 to 22). Median postoperative length of stay was 9 days (range, 5 to 17), and there were no leaks from the anastomosis. Salivary secretion intolerance was the most common postoperative problem (5 of 10 patients). Repeat exploration was required for perforation of the colon in one and paraesophageal hernia in another. Recurrent GER was not noted. All 9 currently surviving children are tolerating bolus gastrostomy feedings, which was an advantage to the parents. CONCLUSIONS: EGS is an attractive alternative for failed fundoplication in severely neurologically impaired children.

Adolescent↗
PubMed2004

Computer-assisted robot-enhanced laparoscopic fundoplication in children.

BACKGROUND/PURPOSE: Robotic surgery improves laparoscopic surgery through a more natural interface, tremor filtration, motion scaling, and additional degrees of freedom of the instruments. Here, the authors report that experience with robot-assisted fundoplication in children. METHODS: The authors have performed 15 laparoscopic fundoplications with the Zeus Robotic Surgery System and retrospectively reviewed prospectively collected data on set-up time, operating time, and outcome. RESULTS: All cases were completed successfully: one Heller myotomy with Dor fundoplication and 14 Nissen fundoplications. Patients ranged from 2 months to 18 years old (mean, 4.3 years) and from 3.4 kg to 37.7 kg (mean, 13.0 kg). There were no technical errors, equipment errors, or conversions. There were no complications in the first 30 days after surgery. The operating time declined from 323 minutes for the first case to 180 minutes for the last (mean, 195 minutes). The 14th case was the shortest at 123 minutes. Setting up the robotic surgery system took an average of 11 minutes. The surgeons perceived benefits of greater ease and confidence in suture placement and knot tying. CONCLUSIONS: The authors have successfully used surgical robots for gastric fundoplication at a pediatric teaching hospital. Our experience with this operation has shown the additional dexterity that the robot provides and will pave the way to more complex procedures.

Adolescent↗
PubMed2005

Esophagogastric dissociation in the neurologically impaired: an alternative to fundoplication?

BACKGROUND/PURPOSE: Gastroesophageal reflux is common in children with severe neurological impairment. Fundoplication may produce symptomatic improvement but has a high failure rate. Esophagogastric dissociation (EGD) is an alternative procedure for treatment of gastroesophageal reflux. The aim of this study is to evaluate the results of EGD in our institution and compare them with a neurologically matched group of children who had Nissen fundoplication. METHODS: Twenty consecutive patients who had EGD were retrospectively evaluated and the results were compared with a neurologically matched group of 20 consecutive patients who had Nissen fundoplication. RESULTS: Twenty patients had EGD, 17 as a primary procedure. There was no operative mortality but 5 have died of other causes. Resolution of reflux-associated symptoms occurred in all patients. Of the 15 survivors, 5 remain on antireflux medication. Twenty patients had fundoplication. There was no operative mortality, but 8 patients have died of other causes. Failure occurred in 5 patients necessitating further surgery. Of the 10 unreoperated survivors, 6 remain on antireflux medication. CONCLUSIONS: Esophagogastric dissociation is an effective antireflux procedure when compared with fundoplication. It has a lower failure rate. We recommend EGD as a primary procedure in selected children with severe neurological impairment.

Adolescent↗
PubMed2005

Effect of different types of fundoplication on the gastric emptying of liquids and gastric compliance in rats.

BACKGROUND/PURPOSE: The aim of this study is to evaluate the early and late effects of partial fundoplication (PFp) and total fundoplication (TFp) on gastric emptying (GE) and on gastric compliance (GC) in rats. METHODS: One hundred fifty-nine male Wistar rats, 6 to 8 weeks of age and weighing 150 to 250 g underwent sham operation, PFp or TFp. They were randomly divided into early group (group E) and late group (group L), evaluated on the 7th and 28th postoperative days, respectively. Gastric emptying studies were performed with and without short-term induction of GE delay. RESULTS: Gastric emptying studies: In group E, TFp altered gastric retention when compared with sham subgroup in rats with GE delay. In group L, neither PFp nor TFp produced changes in GE. Gastric volume-gastric compliance studies: In group E, only TFp reduced significantly gastric volume, but both PFp and TFp caused a significant decrease in GC. A trend toward normalization of gastric volume and GC was perceived in group L. Partial fundoplication did not change the intragastric pressure response in either group E or group L. Total fundoplication increased the intragastric pressure significantly in group E, but this difference disappeared on the 28th postoperative day. CONCLUSIONS: Partial fundoplication induces less change in gastric motor physiology than TFp. These findings provide background to explain some differences in the postoperative course after PFp and TFp.

Animals↗
PubMed2007

Use of esophagocrural sutures and minimal esophageal dissection reduces the incidence of postoperative transmigration of laparoscopic Nissen fundoplication wrap.

OBJECTIVES: Herniation of the fundoplication wrap through the esophageal hiatus is a common reason for surgical failure in children who have undergone laparoscopic Nissen fundoplication. Extensive mobilization of the gastroesophageal junction in combination with decreased adhesions after laparoscopy may contribute to the development of this complication. In an attempt to decrease the incidence of wrap migration, we changed our technique to minimal mobilization of the intraabdominal esophagus and to placement of esophageal-crural sutures. In this study, we investigate the impact of these modifications on outcome. METHODS: A retrospective analysis was performed on all patients undergoing laparoscopic fundoplication by the senior author (GWH) from January 2000 through December 2004. Those undergoing operation with extensive esophageal mobilization and without esophagocrural sutures (January 2000 to March 2002) (group I) were compared with those in whom there was minimal esophageal dissection with placement of these esophagocrural sutures (April 2002 to December 2004) (group II). RESULTS: Two hundred forty-nine patients underwent laparoscopic Nissen fundoplication during the study period. One hundred thirty patients were in group I, and 119 patients were in group II. The rate of transmigration decreased from 12% in group I to 5% in group II (P = .072). The relative risk of transmigration with extensive esophageal mobilization and without the esophagocrural sutures was 2.29. CONCLUSIONS: This retrospective study has shown that placement of esophagocrural sutures and minimization of the dissection around the esophagus results in a more than 2-fold reduction in the risk of wrap transmigration after laparoscopic Nissen fundoplication.

Child, Preschool↗
PubMed2001

Prospective randomized trial comparing Nissen to Nissen-Rossetti technique for laparoscopic fundoplication.

BACKGROUND: It has been suggested that division of the short gastric vessels (SGV) provides a more floppy Nissen fundoplication, for the treatment of reflux disease. The aim of the study was to assess whether Nissen fundoplication with division of SGV is associated with improved clinical outcome and laboratory findings. METHODS: Fifty-six consecutive patients with gastroesophageal reflux disease (GERD) were randomly assigned to have a laparoscopic Nissen fundoplication either with division (24 patients; 15 men; mean age 51 +/- 15 years) or without division (32 patients; 23 men, mean age 47 +/- 14 years) of the SGV. Preoperative and postoperative investigation included clinical assessment, esophagoscopy, esophagogram, esophageal manometry, and 24-hour ambulatory esophageal pH monitoring. RESULTS: Division of the SGV resulted in a significant increase of the operating time (P <0.0001). The operation abolished reflux in both groups. Also, both types of Nissen fundoplication significantly increased the amplitude of peristalsis at distal esophagus (division group: from 56 +/- 20 mm Hg to 64 +/- 25 mm Hg, P = 0.01; nondivision group: from 65 +/- 27 mm Hg to 75 +/- 26 mm Hg, P <0.001) and the lower esophageal sphincter pressure (division group: from 16 +/- 10 mm Hg to 24 +/- 7 mm Hg, P <0.001; nondivision group: from 22 +/- 8 mm Hg to 28 +/- 5 mm Hg, P <0.001). No differences in the incidence of postoperative severe dysphagia (division group: 5 of 24; nondivision group: 3 of 32) and overall esophageal transit were accounted between groups. However, division of the SGV was associated with a significant increased incidence of gas-bloating syndrome (division group, 13 of 24, versus nondivision group, 9 of 32, P = 0.02). CONCLUSIONS: Division of the SGV at laparoscopic Nissen fundoplication for GERD does not improve clinical outcome and laboratory findings, while it is associated with prolongation of the operating time and increased incidence of gas-bloating syndrome.

Deglutition Disorders↗