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PubMed2001

[Laparoscopic fundoplication. A prospective assessment of 100 operations for gastroesophageal reflux].

INTRODUCTION: Laparoscopic fundoplication was assessed in a prospective study. METHOD: One hundred patients with gastroesophageal reflux (GORD) were treated by a 360 degrees fundoplication. The number of operations completed as a laparoscopic procedure, the complication rate, the length of hospital stay and time of work and the effect on GORD symptoms were used as endpoints. RESULTS: The operations could be performed as a laparoscopic procedure in 97 cases. Complications were few: A left-sided pneumothorax in two patients. Median operating time was 100 min and postoperative hospital stay two days. Sufficient reflux control was obtained in 93 patients. Only minor side effects were encountered in three patients (dysphagia two, flatulence one). At three-month control 91 were satisfied. After 3-49 mo (median 19 mo) two have needed a re-operation for dysphagia (one due to tight suture and one for a rotated fundoplication). One patient had the fundoplication taken down for embarrassing flatulence in spite of successful reflux control. CONCLUSION: Laparoscopic fundoplication offers a good immediate control of GORD during a short hospitalization with few complications or side effects. No long term results are available at present.

Adult↗
PubMed2001

Effectiveness of laparoscopic fundoplication for gastro-oesophageal reflux.

BACKGROUND: Gastro-oesophageal reflux (GERD) is a common condition. Many patients respond to conservative therapy. Severe symptomatic cases and those who fail medical treatment are referred to surgery. The long-term results of open fundoplication surgery have been good with a more than 90% response after 10 years of follow-up. The introduction of laparoscopic fundoplication achieved the same results with shorter hospital stay, a better cosmetic result and less cost to the health care providers. PATIENTS AND METHODS: 74 patients who failed medical treatment for GERD were treated by laparoscopic fundoplication. The Toupet procedure was performed in 66 of these patients, the others patients had a Nissen-type fundoplication. The patients were followed up for a mean period (+/- SD) of 14.8 +/- 8.8 months (range 3-33 months). RESULTS: Most of the patients were males (n = 65). The mean age (+/- SD) of all the patients was 36.1 +/- 9.5 years (range 17-60 years). The majority (93.8%) reported disappearance of symptoms and are not using any antireflux medications. Five patients (6.7%) are considered failures of the procedures. Of these, three patients developed recurrence of reflux symptoms during the follow-up period. The other two patients developed complications, i.e. gas bloat, persistent vomiting and dysphagia which warranted taking down the wraps laparoscopically. Two patients developed a small incisional hernia at the site of the 10 mm port. The mean of hospital stay (+/- SD) was 3.1 +/- 1.3 days (range 1-7 days). CONCLUSION: Laparoscopic fundoplication is safe and effectively relieves reflux symptoms in patients who fail medical treatment.

Adolescent↗
PubMedDate not supplied

Causes of long-term dysphagia after laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic fundoplication has revolutionized the surgical treatment of gastroesophageal reflux disease. Despite improvements in the technique of fundoplication, persistent dysphagia remains a significant cause of postoperative morbidity. METHOD: Causes of persistent postoperative dysphagia were analyzed in a consecutive series of 167 patients after laparoscopic Nissen fundoplication. Short gastric vessel division and its effect on postoperative dysphagia were analyzed. RESULTS: Follow-up was possible in 139 patients (83%). The mean follow-up period was 27 +/- 21 months. Nine patients (6%) had persistent (moderate to severe) dysphagia, and 33 patients (24%) had mild dysphagia. The satisfaction score among patients with persistent dysphagia was significantly lower than that in patients with mild dysphagia (P < 0.0002). On the other hand, the satisfaction rate among patients with mild dysphagia and those who are asymptomatic was similar. Manometry, performed in 7 of 9 persistent dysphagia patients revealed no difference in postoperative lower esophagus sphincter (LES) pressure and relaxation as compared with that in the control group (n = 52). Six of 9 patients with persistent dysphagia underwent a re-do antireflux procedure. Dysphagia as related to fundic mobilization (complete vs. partial) or bougie size (< 58 Fr. vs. > or = 58 Fr.) revealed no difference in the dysphagia ratings. CONCLUSIONS: Laparoscopic short Nissen fundoplication with or without fundic mobilization achieved an acceptable long-term dysphagia rate. Careful patient selection, identification of the short esophagus, and accurate construction of the fundoplication can lead to a decrease in the incidence of persistent postoperative dysphagia.

Adult↗
PubMed2003

[Laparoscopic treatment of gastro-esophageal reflux by fundoplication].

The aim of this retrospective study was to evaluate the results of the laparoscopic fundoplication for gastroesophageal reflux disease. From January 1997 to February 2001, we performed 8 laparoscopic fundoplication. They are 5 men and 3 women with mean age of 45 [30-67 years]. The delay of apparition the symptoms varied from 6 months to 14 years. Seven patients had a heart burn. The preoperative evaluation included endoscopy, gastrointestinal contrast radiography, 24 hour pH monitoring and esophageal manometry. The surgical procedures were partial fundoplication (Toupet) in 7 cases and complete fundoplication (Nissen) in 1 case. There was no postoperative mortality. Two patients had a postoperative dysphagia. Two patients had persistent epigastric pain without gastroesophageal reflux in endoscopy and esophageal manometry. Laparoscopic fundoplication for treatment of gastroesophageal reflux disease is a safe and effective procedure with satisfying results.

Adult↗
PubMedDate not supplied

Postoperative chylous ascites: a rare complication of laparoscopic Nissen fundoplication.

The accumulation of chylous fluid in the abdominal cavity is an infrequent, yet alarming, complication in abdominal surgery. Laparoscopic fundoplication has assumed a central role in the surgical treatment of gastroesophageal reflux disease and is significantly altering the balance of therapy toward more common and earlier surgical intervention. We report the case of a 67-year-old woman with gastroesophageal reflux disease and intense esophagitis who underwent a laparoscopic Nissen fundoplication in February 2000. The procedure was performed without apparent complications. Twenty days later, the patient complained of abdominal pain and distension. Ultrasonography showed ascites, whereas endoscopic and radiological exploration of the fundoplication demonstrated no abnormalities. A paracentesis was performed, which showed a milky fluid with high concentrations of triglycerides (1024 ng/dL) and cholesterol (241 ng/dL). The patient was treated successfully with total parenteral nutrition for 3 weeks, followed by a low-fat diet. To our knowledge, this is the third reported case of chylous ascites after a Nissen fundoplication and the second case after laparoscopic fundoplication. The development of chylous ascites seems to be related to the injury of lymphatic vessels, including the thoracic duct, during the retroesophageal window dissection. The careful dissection and judicious use of diathermy is proposed to prevent this rare complication.

Aged↗
PubMedDate not supplied

Laparoscopic Nissen fundoplication; results of a prospective pilot study.

Laparoscopic fundoplication is rapidly becoming the surgical procedure of choice in western countries for the management of gastro-oesophageal reflux disease (GERD). Experience with this technique is limited in India. Most operations continue to be performed through the traditional open technique, thus denying the advantage of a minimal invasive approach to patients. This study was done to evaluate the feasibility and short term results of laparoscopic Nissen fundoplication. Between June 2000 and March 2002, a total of 10 patients with GERD refractory to medical therapy or requiring daily treatment underwent laparoscopic Nissen fundoplication. Preoperative evaluation included scoring of symptoms, oesophagogastroduodenoscopy, barium swallow and nuclear scan. The intraoperative and post-operative course of the patients was recorded. At 3 months post-surgery, patients were re-evaluated using pre-operative symptom scores and investigations to assess the benefit of and complications associated with surgery. Laparoscopic nissen fundoplication was successfully completed in all the patients. Follow up ranged from 3 to 18 months with a mean of 5.9 months. The mean symptom score decreased from 10.1 pre-operatively to 1.7 (p value < 0.001). Eight out of 9 patients (88%) had endoscopic resolution of oesophagitis. Seven patients (70%) were off medication following surgery while the remaining 3 (30%) were taking medication intermittently. Overall, 80% of the patients were satisfied with the surgery. One patient required re-exploration due to bleeding from a short gastric vessel. The most frequent post-operative complication was temporary dysphagia in 60% of patients, which improved with conservative management over 2 to 3 weeks. We concluded that laparoscopic Nissen fundoplication is a safe and effective procedure to treat patients with GERD.

Adult↗
PubMedDate not supplied

Preservation of an aberrant left hepatic artery during laparoscopic nissen fundoplication.

OBJECTIVE: Laparoscopic Nissen fundoplication is performed in neonates and children for significant gastroesophageal reflux. An aberrant left hepatic artery encountered during laparoscopic Nissen fundoplication makes dissection around the esophageal hiatus more difficult if the artery is not transected. Although some suggest division of the aberrant left hepatic artery, this is associated with risk of significant hepatic injury from ischemia. We routinely preserve the aberrant left hepatic artery and sought to determine (1) the incidence of aberrant left hepatic artery and (2) the results following preservation of the aberrant left hepatic artery. METHODS: Between January 2000 and October 2002, 195 laparoscopic Nissen fundoplications were performed. We documented intraoperative findings of each procedure, and reviewed postoperative radiographic studies and clinic visits. RESULTS: In 30 patients (15%), an aberrant left hepatic artery was identified. All dissections were performed laparoscopically with the Nissen fundoplication positioned cephalad to the aberrant left hepatic artery. Postoperatively, 2 patients (6%) have had evidence of wrap failure. The remainder of the patients has had normal radiographic studies or no clinical evidence of reflux during clinic visits. CONCLUSION: During laparoscopic Nissen fundoplication in neonates and children, an aberrant left hepatic artery may be encountered in approximately 15% of patients. When an aberrant left hepatic artery is identified, it should be preserved to avoid the potential risk of hepatic ischemic injury.

Child↗
PubMed2006

Nissen fundoplication and gastrostomy in severely neurologically impaired children with gastroesophageal reflux.

OBJECTIVES: To study the effect of Nissen fundoplication and gastrostomy in severely neurologically impaired children. DESIGN: Prospective observational study. SETTING: Developmental Disabilities Unit of a regional medical centre in Hong Kong. PATIENTS: Children with severe neurological impairment and gastroesophageal reflux who were institutionalised between 1999 and 2004 inclusive. MAIN OUTCOME MEASURES: Incidence of vomiting, gastro-intestinal bleeding, and pneumonia in the baseline year and consecutive years following surgery; 24-hour oesophageal pH monitoring; recurrence rate (determined by 24-hour oesophageal monitoring); body weight; complications of surgery; and mortality. RESULTS: Twenty children, with a mean age at surgery of 8.5 (standard deviation, 3.5) years, were recruited. Nissen fundoplication was performed in nine children and 11 children underwent laparoscopic fundoplication. Children were monitored for 1.3 to 5.7 years (median, 3.5 years) after surgery. The incidence of vomiting and gastro-intestinal bleeding was significantly decreased following surgery (P < 0.001 and P = 0.001, respectively; Friedman's test). There was no difference between the preoperative and postoperative incidence of pneumonia (P = 0.973, Friedman's test). The median reflux index was reduced from 5.7% to 0.15% after surgery but six (30%) patients had recurrent gastroesophageal reflux. The mean body weight was 17.4 kg (standard deviation, 4.7 kg) at baseline and 22.8 kg (standard deviation, 4.4 kg) at the end of follow-up (P < 0.05, Student's t test). One patient had mild dumping syndrome soon after fundoplication. One patient had one episode of intestinal obstruction. Four patients died 1.9 to 5.0 years following surgery due to respiratory disease. CONCLUSION: Our results indicate that in severely neurologically impaired children with gastroesophageal reflux, vomiting, gastro-intestinal bleeding, and reflux indices based on 24-hour oesophageal pH monitoring were significantly reduced following fundoplication and gastrostomy. The incidence of pneumonia was unchanged. The recurrence rate of reflux was 30% and mortality rate was 20%.

Adolescent↗
PubMed1995

Nissen fundoplication for gastro-oesophageal reflux disease: long-term results.

Since its introduction by Rudolph Nissen in 1956, fundoplication has become the most commonly used antireflux procedure. Following fundoplication the majority (80 to 90%) of the patients become symptomfree or have only mild and occasional reflux symptoms in the long run. With a short and loose fundic wrap postoperative dysphagia is not a clinical problem, providing that preoperative manometry shows adequate peristalsis. Flatus is increased after fundoplication, but rarely to a disturbing extent. Patients who have problems with flatus preoperatively are also prone to have complaints postoperatively. Bloating is decreased rather than increased after fundoplication. At endoscopy as intact seen fundic wrap (the main determinant of the long-term outcome) is observed in 70% to 80% of the cases 10 to 20 years after the operation. Oesophageal 24-hour pH-recording is normal and oesophagitis cured in similar number of patients. In conclusion, Nissen fundoplication gives effective cure of symptoms of gastro-oesophageal reflux disease and reliably corrects reflux oesophagitis. Postoperative adverse effects are rare and well tolerable and do not detract from the success of the operation in correctly selected patients.

Esophagitis, Peptic↗
PubMed1995

Excessive competence of the lower oesophageal sphincter after Nissen fundoplication: evaluation by three-dimensional computerised imaging.

OBJECTIVE: To compare the competence of the lower oesophageal sphincter after Nissen fundoplication with that in a control group of healthy volunteers using a new computerized manometric device that integrates the pressure and length of the entire sphincter into one measurement, called the vector volume. DESIGN: Open study. SETTING: University hospital, Italy. SUBJECTS: 18 patients, 6-52 months (mean 10 months) after they had undergone Nissen fundoplication for gastro-oesophageal reflux, and 14 healthy volunteers. INTERVENTIONS: Oesophageal computerised manometric system comprising a catheter with eight side holes radially oriented to each other at 45 degrees on one level and 24-hour oesophageal pH monitoring. MAIN OUTCOME MEASURES: Differences in percentage time of oesophageal acid exposure, number of episodes of gastro-oesophageal reflux, and lower oesophageal sphincter vector volume. RESULTS: The pH of the oesophagus was returned to the normal range in all patients after the Nissen fundoplication. There was a significant reduction in both the percentage time of acid exposure and the number of episodes of gastro-oesophageal reflux compared with the control group (p < 0.001). The vector volume of the intra-abdominal part of the lower oesophageal sphincter was significantly increased compared with the control group (p < 0.04). Lower oesophageal sphincter pressure measured at the respiratory inversion point, and lower oesophageal length, both increased after fundoplication to become similar to control values. When sphincter pressure was measured as a mean of the sphincter pressure curve there was a clear difference postoperatively compared with controls (p < 0.02). CONCLUSIONS: Nissen fundoplication corrects abnormal gastro-oesophageal reflux but abolishes normal physiological postprandial reflux; this is caused by the gastric fundus that encircling the intra-abdominal oesophagus, restores sphincter pressure and length, and modifies its shape.

Adult↗
PubMed1996

Laparoscopic fundoplication: a three-year review.

Laparoscopic treatment of gastroesophageal reflux disease provides decreased postoperative pain and shortens hospitalization. Experience with this procedure continues to grow. The charts of patients who had laparoscopic fundoplication for the treatment of symptomatic refractory gastroesophageal reflux over a three year period were reviewed. Age, sex, preoperative evaluation, surgical technique, length of procedure, length of hospitalization, time to regular diet, conversion to laparotomy, complications, and long-term outcome were analyzed. Eighty-eight patients, 39 females and 49 males, underwent laparoscopic gastric fundoplication. All patients has symptomatic gastroesophageal reflux. Preoperative evaluation including upper endoscopy demonstrated esophagitis in 71 patients (81%) with changes of Barrett's esophagitis in 12 patients (14%). Decreased lower esophageal sphincter pressures were found in 33 of 73 patients (45%) and none had abnormal motility identified. A 2-3 cm fundoplication with nonabsorbable suture was performed over a large dilator. Mean operative time was 109 minutes. The mean length of hospitalization was 1.9 days in patients completed laparoscopically and six days in the 3 patients that required conversion to celiotomy for completion of their fundoplication. A clear liquid diet was offered the evening of surgery and advanced to regular as tolerated. Mild dysphagia was found in most patients for the first week and full liquid or soft diet was prescribed. All but seven patients advanced to regular diet by two weeks. Operative complications occurred in four patients and included two pneumothoraces and two esophageal perforations. Follow-up to 40 months has identified one partial wrap disruption and one crural breakdown both repaired laparoscopically. Seventy-seven patients (88%) have remained asymptomatic and off all medication. Laparoscopic fundoplication is safe and effective, allowing the benefits of minimal access surgery, including decreased postoperative pain and disability.

Adolescent↗
PubMed1996

[Computed tomography patterns in patients treated with laparoscopic Nissen fundoplication for gastroesophageal reflux].

This work was aimed at investigating the CT anatomy in patients submitted to Nissen's fundoplication. Forty patients (mean age: 61 years) with peptic esophagitis (9 patients), refractory gastroesophageal (GE) reflux (11 patients) and hiatal hernia (20 patients) were examined. CT studies were performed with a third generation unit (CT Pace, General Electric, USA) with the patients in the prone position, after Gastrovison (Schering) and barium paste administration. In 34 patients, CT demonstrated surgery-related anatomical changes, such as the presence of a soft tissue mass at the distal third of the esophagus. In 4 patients, functional incompetence of the fundoplication (3 patients) and a recurrent hyatal hernia (1 patient) were demonstrated. In conclusion, CT studies performed with a dedicated technique permitted the accurate assessment of the anatomy of the GE junction after Nissen's fundoplication. In our study, CT demonstrated the presence of postoperative fluid collections and specific signs related to fundoplication incompetence. Our results suggest a possible application of CT to the postoperative follow-up of the patients submitted to Nissen's fundoplication, with a complementary role that of to endoscopy and functional exams.

Adult↗
PubMed1996

Laparoscopic fundoplication in children: our first 30 cases.

We report our experience performing 30 laparoscopic fundoplications in children (24 using the Nissen Rossetti technique and 6 using the Toupet fundoplication). Special instruments adapted to the young children are used: first, a miniature parietal suspender to decrease the intra-abdominal pressure and to provide more space; second, a retractable losenge-shaped liver retractor; and third, a Babcock forceps articulated at 60 degrees. In the Nissen Rossetti procedure, the wrap is fixed to the anterior face of the esophagus, the anterior wall of the fundus, and the upper right crus. In the Toupet procedure, the wrap is a retroesophageal partial fundoplication: the first suture attaches the wrap to the right crus, the second attaches the wrap to the esophagus, and the third recreates the oesogastric angle. We do not use gastrostomy. Patients have no gastric tube after the intervention. Thirty children from 2 to 15 years have undergone laparoscopic fundoplications. One conversion to open procedure was necessary. An average follow-up of 12 months was observed for 18 children with 3 complications: dysphagia for a psychotic girl, intrathoracic valve without any trouble, and recurrent episodes of digestive bleedings during 6 months. Laparoscopic fundoplication is a feasible extension of minimally invasive surgery in the hands of experienced surgeons; however limitations must be recognized to do a safe operation.

Adolescent↗
PubMed1998

[Good results of laparoscopic Thal fundoplication for treatment of gastroesophageal reflux in children].

OBJECTIVE: Evaluation of the results of laparoscopic fundoplication according to Thal as a treatment for gastro-oesophageal reflux in children. DESIGN: Prospective, descriptive. SETTING: Department of paediatric surgery, Wilhelmina Children's Hospital, Utrecht, the Netherlands. METHODS: Between November 1993 and May 1996, 53 children with reflux and an average age of 6 years underwent laparoscopic fundoplication according to Thal; in 23 of them a gastrostomy was created as well. The most important symptoms were vomiting and lack of growth. There were 18 children with primary reflux and 35 with secondary reflux, 28 of whom had psychomotor retardation. Preoperatively all patients were subjected to 24-hour oesophageal pH-monitoring, upper GI series and oesophagogastroscopy. Pathological reflux was defined as a pH < 4 during 5% or more of the total time measured (24 hours). pH-monitoring was repeated three months postoperatively to evaluate the effect of the fundoplication and esophagogastroscopy was repeated in case of preoperative oesophagitis. RESULTS: In one patient the laparoscopic approach was converted peroperatively because of bleeding that had stopped on exploration. Enteral feeding could be recommenced on day one in 49 of 53 children. The mean hospitalisation time was 4.4 days. One patient was reoperated for a too tight fundoplication and two patients died of unrelated causes. The mean follow-up period for the other 50 patients was 11 months (1-35). On follow-up, 42 of them (84%) were free of symptoms, while 31 of 41 children (76%) in whom pH-monitoring could be done 3 months postoperatively displayed no recurrence of pathological reflux. CONCLUSION: Thal fundoplication can be performed laparoscopically in children. Enteral feeding becomes possible again quickly and the period of hospitalisation is short.

Adolescent↗
PubMedDate not supplied

Results of laparoscopic Nissen fundoplication.

BACKGROUND/AIMS: Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations. METHODOLOGY: Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation. RESULTS: Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%). CONCLUSIONS: The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.

Adolescent↗
PubMed1991

Prospective randomized trial of Nissen fundoplication and Angelchik prosthesis in the surgical treatment of medically refractory gastro-oesophageal reflux disease.

Fifty patients with gastro-oesophageal reflux disease refractory to multiple courses of medical therapy were entered into a prospective randomized trial comparing Nissen fundoplication with the Angelchick prosthesis as a primary surgical procedure. The two groups were matched for age, sex, duration of symptoms before surgery, type of medical therapy, pattern of symptom presentation, endoscopic grade of oesophageal inflammation, manometric lower oesophageal pressure and 24-h pH profile. Twenty-five patients were randomized to each of the Nissen fundoplication and Angelchik prosthesis groups. Operation time and hospital stay were similar in both groups. Persistent dysphagia was reported in five of the patients with an Angelchik prosthesis compared with none in the Nissen fundoplication group. Three prostheses were removed because of severe dysphagia while no Nissen fundoplication required revision. No patient with preoperative dysphagia because of stricture reported swallowing difficulties after operation. At clinical assessment at 3, 6, 12 and 24 months after operation, 85-88 per cent of the patients having a Nissen fundoplication were graded Visick 1 or 2 compared with 60-72 per cent of patients in the Angelchik group.

Adult↗
PubMedDate not supplied

Reoperation following failed fundoplication.

Fifty patients reoperated for failed Nissen fundoplication are presented; 29 patients (group 2) were operated between 1983 and 1988 while 21 patients (group 1) were operated before 1983. In group 1, the "slipped Nissen" had been the most frequent cause of reoperation (48%). In group 2, the most frequent causes for the unsuccessful operation were: (1) partial or total disruption of the fundic wrap (62%), (2) slipping of the fundoplication, giving rise to the telescope phenomenon (21%), and (3) creation of a fundoplication which was too low (10%). Refundoplication was performed in cases where the dissection of the previously formed fundic wrap was possible (42/50 = 84%). In group 1, three patients were treated by resection of the cardia, one by an Angelchik prosthesis and one by a distal gastric resection with Roux-en-Y diversion. In group 2, fundectomy was performed in one patient; in another, an Angelchik device was inserted, and in a third patient, fundoplication and proximal gastric vagotomy were performed. The results were excellent or good in 66% of patients in group 1 and in 76% of group 2. Operative mortality was 2% and morbidity, 4%. In conclusion, repeat fundoplication is recommended when reestablishment of the fundic region anatomy is possible during dissection. The operation can usually be performed through an abdominal route. Meticulous preoperative evaluation of the patients including 24-hour pH measurement and manometry is necessary. Good results of refundoplication should be expected in 66%-76% of patients with recurrent disease.

Adolescent↗
PubMedDate not supplied

Lower esophageal sphincter characteristics and esophageal acid exposure following partial or 360 degrees fundoplication: results of a prospective, randomized, clinical study.

In a prospective, randomized, clinical trial, we compared a partial (180-200 degrees, Toupet) with a total fundoplication (360 degrees, Rossetti) in the surgical treatment of gastroesophageal reflux disease. Seventy-one patients entered the trial; 33 were allocated to a partial fundoplication and 38 to a 360 degrees fundic wrap. Each patient was investigated prior to as well as 3 and/or 6 months after the operation, including an endoscopic and clinical assessment. Manometry was carried out via a triple lumen catheter and the pressure in the high pressure zone (HPZ) in the distal esophagus was measured as well as the length of the intraabdominal segment by a "station pull-through" technique. Acid exposure of the esophageal mucosa was evaluated by ambulatory 24-hour pH measurements. Acid exposure of the esophageal mucosa was "normalized" by the 2 operations. In addition, the length of the HPZ was increased to a "normal" level by both operations. The pressure of the HPZ was, however, "normalized" only in patients allocated to a Rossetti fundoplication, whereas patients operated on with a partial fundoplication had a significantly lower HPZ pressure (p less than 0.01). The clinical assessment revealed excellent results in both groups with no significant differences between the 2 operations except for a higher incidence of dysphagia at 3 months after a Rossetti fundoplication (p less than 0.01), which disappeared during the subsequent 3 months.

Adult↗