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PubMed1995

Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations.

From September 1991 to January 1995 we performed 230 Nissen fundoplications by a laparoscopic technique. Whilst a loose 360 degree fundoplication secured by 3 or 4 sutures was performed in all instances, there was variation between surgeons regarding the performance of hiatal repair and division of short gastric vessels; 207 operations were completed laparoscopically and 23 were converted to an open operation when a satisfactory wrap could not be achieved. Operating time ranged from 30 to 260 min (median 95) and the median postoperative stay was 3 days (1-19). Twenty-three patients (10%) underwent a subsequent operation (14 within 3 months of the original surgery), 2 for recurrent reflux, 10 for para-esophageal herniation, 2 for a misplaced fundoplication resulting in gastric obstruction, 7 for persistent dysphagia (4 due to stenosis of the esophageal hiatus), 1 for bleeding, and 1 for mesenteric thrombosis. (This patient died.) Five other patients were readmitted to hospital subsequent to their discharge--four because of pulmonary emboli and one because of gastric obstruction. Some 226 patients (98%) are free of reflux symptoms with follow-up ranging up to 40 months (median 16). Absence of reflux and the integrity of the fundoplication has been confirmed by postoperative esophageal manometry and pH monitoring in 90 patients, and by barium meal in 126. Postoperative recovery has been quick and wound-related morbidity minimal. Although the rate of surgical revision was significant in this series, the likelihood of complications or further surgery, as well as incidence of conversion to open surgery, decreased in the second half of the experience.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1999

Patterns of success and failure with laparoscopic Toupet fundoplication.

BACKGROUND: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). METHODS: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. RESULTS: At a mean follow-up of 30 months (range, 3-51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. CONCLUSION: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy.

Evaluation Studies as Topic↗
PubMed2001

Successful laparoscopic fundoplication in children with ventriculoperitoneal shunts.

We reported successful laparoscopic fundoplication in 2 pediatric cases with VPS and discuss the safety and feasibility of the procedure. Case 1: A 13-year-old girl with VPS underwent laparoscopic fundoplication. Case 2: a 9-year-old boy with VPS underwent laparoscopic fundoplication. In both cases, laparoscopic Nissen fundoplication was performed with a standard five-port technique with a low pressure of a pneumoperitoneum. The VPS system had no effect on port layout and intraabdominal manipulation and no adverse complications were observed in either case. The effect of a pneumoperitoneum in the VPS system remains controversial, however, the author emphasized that advanced laparoscopic surgery can be performed safely with creating a low pressure of a pneumoperitoneum.

Adolescent↗
PubMed2001

Revisional surgery after failed laparoscopic anterior fundoplication.

BACKGROUND: Partial fundoplication may have functional advantages over a circumferential wrap but the reconstruction is more complex. Revisional surgery for recurrent reflux may be more difficult because of the additional suturing involved in the original operation. We report experience with revisional surgery in a large cohort of patients who had undergone laparoscopic anterior fundoplication and hiatal repair. METHODS: Between August 1993 and September 1999, 11 (3.5%) of 309 patients who had laparoscopic anterior fundoplication for uncomplicated gastroesophageal reflux disease required revisional surgery (1 open and 10 laparoscopic revisions). Data were retrieved from a prospective database supplemented by a postal questionnaire following the second operation. RESULTS: The operative findings were posterior hiatal disruption (n = 9), anterior paraesophageal hernia (n = 1), and inadequate initial esophageal mobilization (n = 1). There were no conversions to open surgery in the laparoscopic group. Ten (91%) of the respondents described the outcome of their repeat procedure as either good or excellent. All patients would recommend the repeat procedure to patients with similar symptoms. CONCLUSIONS: Revisional surgery after laparoscopic anterior fundoplication can be performed safely with a good outcome. Modifications to technique both in the primary procedure and for revision may decrease the incidence of early technical failure.

Fundoplication↗
PubMed2002

Nissen vs Toupet laparoscopic fundoplication.

BACKGROUND: Nissen fundoplication (360 degrees ) is the standard operation for the surgical management of gastroesophageal reflux disease (GERD). To avoid postoperative dysphagia, it has been proposed that antireflux surgery be tailored according to the degree of preexisting esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and the Toupet procedure (270 degrees ) has been recommended for these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques in terms of reflux control and complication rate (dysphagia). Our objective was to determine the impact of preoperative esophageal motility on the clinical and objective outcome, following Toupet vs Nissen fundoplication and to evaluate the success rate of these procedures. METHODS: From May 1999 until May 2000, 200 patients with GERD were included in a prospective randomized study. After preoperative examinations (clinical interview, endoscopy, 24-h pH study and esophageal manometry), 100 patients underwent either a laparoscopic Nissen (50 with and 50 without motility disorders), or a Toupet procedure (50 with and 50 without motility disorders). Postoperative follow-up after 4 months included clinical interview, endoscopy, 24-h pH study and esophageal manometry. RESULTS: Interviews showed that 88% (Nissen) and 90% (Toupet) of the patients, respectively, were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication than after a Toupet (30 vs 11, p <0.001) and did not correlate with preoperative motility. In terms of reflux control, the Toupet proved to be as effective as the Nissen procedure. CONCLUSION: Tailoring antireflux surgery to esophageal motility is not indicated, since motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation because it has a lower rate of dysphagia and is as effective as the Nissen fundoplication in controlling reflux.

Adult↗
PubMed2002

Laparoscopic vs open approach for Nissen fundoplication. A comparative study.

BACKGROUND: Several studies, most of them nonrandomized, have shown similar functional results for both laparoscopic and open Nissen fundoplication, the operation of choice for the treatment of gastroesophageal reflux disease (GERD). METHODS: A total of 106 patients with documented GERD were randomized to receive either a laparoscopic or an open Nissen fundoplication. Preoperative and postoperative investigations included clinical assessment, esophagogram, upper gastrointestinal endoscopy, esophageal manometry, and 24-h ambulatory pHmetry. RESULTS: Both approaches were successful in controlling reflux. There was an overall improvement in esophageal peristalsis and an increase in lower esophageal sphincter (LES) pressure in both groups. Open Nissen fundoplication was associated with a significantly increased rate of wound (p <0.001) and respiratory (p <0.05) complications. Hospitalization was also longer after the open technique (p <0.001). At 3-month follow-up, although the rate of postoperative dysphagia was similar for the two approaches, the open approach was associated with a significantly higher incidence of postprandial epigastric fullness (p <0.05) and bloating syndrome (p <0.01). CONCLUSIONS: The open and laparoscopic approaches for the Nissen fundoplication are equally effective in controlling GERD. The open approach is associated with a significantly higher rate of wound and respiratory complications and, at early stages, an increased rate of postprandial epigastric fullness and abdominal bloating. The dysphagia rate is similar with both methods.

Adult↗
PubMed2003

Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy.

BACKGROUND: Recent reports have suggested that antireflux surgery should not be advised with the expectation of elimination of medical treatment. We reviewed our results with laparoscopic fundoplication as a means of eliminating the symptoms of gastroesophageal reflux disease (GERD), improving quality of life, and freeing patients from chronic medical treatment for GERD. METHODS: A total of 297 patients who underwent laparoscopic fundoplication (Nissen, n = 252; Toupet, n = 45) were followed for an average of 31.4 months. Preoperative evaluation included endoscopy, barium esophagram, esophageal manometry, and 24-h pH analysis. A preoperative and postoperative visual analogue scoring scale (0-10 severity) was used to evaluate symptoms of heartburn, regurgitation, and dysphagia. A GERD score (2-32) as described by Jamieson was also utilized. The need for GERD medications before and after surgery was assessed. RESULTS: At 2-year follow-up, the average symptom scores decreased significantly in comparison to the preoperative values: heartburn from 8.4 to 1.7, regurgitation from 7.2 to 0.7, and dysphagia from 3.7 to 1.0. The Jamieson GERD score also decreased from 25.7 preoperatively to 4.1 postoperatively. Only 10% of patients were on proton pump inhibitors (PPI) at 2 years after surgery for typical GERD symptoms. A similar percentage of patients (8.7%) were on PPI treatment for questionable reasons, such as Barrett's esophagus, "sensitive" stomach, and irritable bowel syndrome. Seventeen patients (5.7%) required repeat fundoplication for heartburn ( n = 9), dysphagia ( n = 5), and gas/bloating ( n = 3). CONCLUSIONS: Laparoscopic fundoplication can successfully eliminate GERD symptoms and improve quality of life. Significant reduction in the need for chronic GERD medical treatment 2 years after antireflux surgery can be anticipated.

Adolescent↗
PubMed2003

Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn.

BACKGROUND: Heartburn and gastroesophageal reflux disease (GERD) affects approximately 25-50% of morbidly obese patients. Although objective physiologic testing has been reported extensively in patients following Nissen fundoplication, there are no previous reports of such testing in morbidly obese patients. A life-saving surgical alternative for the morbidly obese patient is gastric bypass surgery, which usually improves heartburn symptoms in addition to many serious health conditions such as diabetes, hypertension, and sleep apnea. We hypothesized that, in morbidly obese patients, gastric bypass surgery would be as effective as Nissen fundoplication in reducing both heartburn symptoms and esophageal acid exposure, as reflected by the DeMeester score. METHODS: Between 1995 and 2000, all patients undergoing laparoscopic Nissen fundoplication (LN) and laparoscopic gastric bypass (LGB) in our practice underwent preoperative and postoperative esophageal physiologic testing. Patients were included in this study that were morbidly obese and had significant heartburn symptoms or objective evidence of acid reflux, and had repeat esophageal physiologic testing after either LN or LGB. Data were obtained through retrospective review of prospectively collected data. RESULTS: Twelve patients met the inclusion criteria: six patients who had LN and six who had LGB. The mean body mass index (BMI) was 55 kg/m2 in the LGB group and 39.8 in the LN group. After surgery, the mean DeMeester score decreased from 64.3 to 2.8 in the LN group ( p = 0.01) and from 34.7 to 5.7 in the LGB group ( p = 0.1). Both groups' mean postoperative DeMeester scores were normal after surgery, and there was no significant difference between the two groups ( p = 0.3). Both groups experienced a significant improvement in heartburn symptoms postoperatively. The mean preoperative symptom score improved from 3.5 to 0.5 in the LN group ( p = 0.01) and from 2.2 to 0.2 in the LGB group ( p = 0.003). There was no difference in the mean postoperative symptom scores between the groups ( p = 0.35). After surgery, mean LES resting pressures increased from 12.9 to 35.5 ( p = 0.003) in the LN group and from 23.6 to 29.7 ( p = 0.45) in the LGB group. There were no complications in either group. CONCLUSION: Results of this study show that laparoscopic gastric bypass and laparoscopic Nissen fundoplication are both effective in treating heartburn symptoms and objective acid reflux in morbidly obese patients. The health benefits of weight loss after laparoscopic gastric bypass should make this operation the procedure of choice in the morbidly obese patient with heartburn.

Adult↗
PubMed2003

Anesthesiologic aspects of laparoscopic fundoplication for gastroesophageal reflux in children with chronic respiratory and gastroenterological symptoms.

INTRODUCTION: During the past three decades laparoscopy has significantly improved. As fundoplication extensively benefits by the great advantages of the minimally invasive approach, many surgeons chose laparoscopic fundoplication for the treatment of gastroesophageal reflux in adults and children as well. Pneumothorax, cardiovascular collapse, hypoxia, and hypercarbia are some of the anesthesiologist's principal fears during carbon dioxide insufflation. Thus, monitoring cardiovascular and respiratory status is mandatory to early detect any complication and to maintain a proper balance during pneumoperitoneum. MATERIALS AND METHODS: At Gaslini Children's Hospital we performed a prospective nonrandomized study aimed at describing the main cardiorespiratory changes produced by pneumoperitoneum in 33 pediatric patients operated on by laparoscopic fundoplication between January 2000 and June 2001. Patients were divided into two groups; namely, group A and group B. Group A included 14 patients with chronic respiratory symptoms, and group B included 19 children who preoperatively mainly emphasized gastrointestinal symptoms. We monitored intraoperative cardiorespiratory status, timed length of surgery, and described intraoperative complications. RESULTS: No significant cardiovascular changes occurred during carbon dioxide insufflation. Partial oxygen saturation remained still in all the patients. End tidal CO2, meanly higher in group A children, increased in all the patients after pneumoperitoneum creation, but never exceeded 45 mmHg. Similarly, peak inspiratory pressure increased in all the patients, but was always maintained within acceptable values. Finally, group B patients required a harder and slower surgery, whose length seems to be negatively influenced by age. No intraoperative complication occurred. CONCLUSIONS: Carbon dioxide insufflation does not impair cardiovascular function, if intraabdominal pressure is maintained lower than 10 mmHg nor does it interfere with gas exchanges. Pneumoperitoneum slightly reduces ventilatory function, mainly in respiratory patients with various degrees of underlying bronchopulmonary impairments, but this effect is easily correctable. Thus, laparoscopic fundoplication is feasible and safe in both respiratory and gastroenterological patients, although surgery is easier and faster if periesophagitis is less evident.

Anesthesia↗
PubMed2006

Effects of laparoscopic Nissen fundoplication on esophageal motility: long-term results.

BACKGROUND: This study aimed to evaluate the long-term impact of laparoscopic Nissen fundoplication on esophageal motility in patients with preoperative esophageal dysmotility. METHODS: This study prospectively followed 580 patients who underwent laparoscopic Nissen fundoplication between 1992 and 1999. Esophageal manometry, 24-h pH monitoring, and symptom score assessment were performed before surgery, then 6 months, 2 years, and 5 years after surgery. Preoperatively, 533 of the patients (93.5%) had normal esophageal contractile pressure (group 1), whereas 38 of the patients (6.5%) had reduced contractile pressure (<30 mmHg) (group 2). RESULTS: Esophageal contractile pressures increased significantly in the patients with low preoperative values, whereas it remained unchanged in the patients with normal preoperative contractile pressures. Both groups reported a significant reduction in the dysphagia symptom score after surgery. CONCLUSION: Nissen fundoplication produces a significant long-lasting increase in esophageal contractile pressures in patients with preoperative esophageal dysmotility (i.e., contractile pressure lower than 30 mmHg). Preoperative esophageal dysmotility is therefore not a contraindication to laparoscopic Nissen fundoplication.

Adult↗
PubMed2007

Gastric emptying of glucose solution and associated plasma concentrations of GLP-1, GIP, and PYY before and after fundoplication.

BACKGROUND: This study was designed to assess the relationship between gastric emptying of glucose solution and the ensuing plasma concentrations of glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and glucose-dependent insulinotropic polypeptide (GIP) in patients having undergone fundoplication for gastroesophageal reflux (GERD). SUBJECTS AND METHODS: In 10 male patients the emptying of 50% glucose solution was determined scintigraphically and its relationship with plasma glucose, GLP-1, PYY, and GIP concentrations was studied before and 3 months after fundoplication. RESULTS: In the first 30 min after glucose ingestion, emptying was significantly (p = 0.048) faster after fundoplication than before. Emptying and GLP-1 and GIP correlated: the faster the emptying during the first 30 min the greater the concentrations integrated over that period (p = 0.04; p = 0.01; p = 0.02). Emptying and PYY concentrations were unrelated. In the 120-180 min. period, blood glucose concentrations were lower the faster the emptying in the initial 30 min (p = 0.06) and the entire 50-min recording period (p = 0.03) had been. The GLP-1 concentrations integrated over the first 30 min correlated inversely with the integrated plasma glucose during the third hour after ingestion (p = 0.004). CONCLUSIONS: After fundoplication, gastric emptying may, if accelerated in its initial phases, give rise to greater and earlier increases in plasma glucose, GLP-1, and GIP concentrations and thus to reactive hypoglycemia.

Adult↗
PubMed2006

Midterm follow-up evaluation after a novel approach to anterior fundoplication for achalasia.

BACKGROUND: This study aimed to compare the outcomes for Heller myotomy alone and combined with different partial fundoplications. METHODS: The authors retrospectively reviewed their experience with 69 laparoscopic myotomies and 14 Heller myotomies, 80% of which were performed with partial fundoplication including 20 Toupet, 18 Dor, and 17 modified Dor procedures, in which the fundoplication is sutured to both sides of the crura and not the myotomy. RESULTS: The mean age of the study patients was 69 years (range, 15-80 years). Four mucosal perforations were repaired intraoperatively. There was one small bowel fistula in an area of open hernia repair distant from the myotomy. One patient with severe chronic obstructive pulmonary disease died of pneumonia. Phone follow-up evaluation was achieved in 68% of the cases at a mean of 37 months (range, 2-97 months). The results for no dysphagia and for heartburn requiring proton pump inhibitors, respectively, were as follows: Heller myotomy (85.7%, 28.5%), Toupet (66.6%, 33.3%), Dor (83.3%, 20%), and modified Dor (84.6%, 15.3%). Two patients with reflux strictures required annual dilation (Toupet, Dor). Two patients required revisions: one redo Heller myotomy (Dor) and one esophageal replacement (Toupet). CONCLUSION: Heller myotomy provides excellent dysphagia relief with or without fundoplication. Heartburn is a significant problem for a minority of patients. In the authors' hands, Toupet had the worst results and modified Dor was most protective for heartburn.

Adolescent↗
PubMed2000

The Tübingen balloon. A new method for adjusting the tension of the fundic wrap during laparoscopic Nissen fundoplication.

An adequate fundic wrap is fundamental to the success of conventional and laparoscopic Nissen fundoplications. Nevertheless, up to now there has been no standardized method for the surgeon to determine intraoperatively the width and tension of the fundic wrap according to objective criteria. With the support of Rüsch (Kernen, Germany), we developed a measurement balloon for use in laparoscopic Nissen fundoplication. The balloon allows the surgeon to define the width of the wrap and predetermine its length, as well as to measure its tension. Depending on the measured balloon pressure, the surgeon can perform fundic sutures more or less tightly. On the basis of 41 fundoplication model tests, we found that a fundic wrap typically described as "loose and floppy" produced a balloon pressure of 50-60 mmHg. In 10 laparoscopic Nissen fundoplications on domestic pigs, we were able to adjust the fundic wrap intraoperatively to a balloon pressure in this range (mean; 53.5; SD; 2.25). After the optimal intraoperative balloon pressure in humans has been investigated in a prospective study that is in progress, the Tübingen balloon is expected to serve as an instrument for quality assurance in reflux surgery.

Animals↗
PubMed2000

360 degrees laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease.

BACKGROUND: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However, a relatively high incidence (7-11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication has recently been reported. METHODS: Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic 360 degrees fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months. Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform an effective tension-free closure of the hiatus. A polypropylene mesh (3 x 4 cm) was placed on the hiatus behind the esophagus and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses). RESULTS: Between August 1995 and February 1998, the technique, complete with 360 degrees fundoplication, was used for 67 patients with GERD. At mean follow-up of 22.5 months (range, 1-30), there was no evidence of postoperative paraesophageal hernia or complications related to the use of the mesh. CONCLUSIONS: This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed.

Adolescent↗
PubMed1997

Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study.

BACKGROUND: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. METHODS: Some 110 consecutive patients with prolonged symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. RESULTS: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. CONCLUSIONS: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery.

Adult↗
PubMed1997

Partial fundoplication for gastroesophageal reflux.

BACKGROUND: About 20% of patients with gastroesophageal reflux disease (GERD) have severely impaired esophageal peristalsis in addition to an incompetent lower esophageal sphincter. In these patients a total fundoplication corrects the abnormal reflux, but it is often associated with postoperative dysphagia and gas bloat syndrome. We studied the efficacy of partial fundoplication in such patients. METHODS: A partial fundoplication (240 degrees -270 degrees ) was performed laparoscopically in 26 patients (11 men, 15 women; mean age 50.5 years) with GERD (mean DeMeester score: 92 +/- 16) in whom manometry demonstrated severely abnormal esophageal peristalsis. RESULTS: All operations were completed laparoscopically and the patients were dicharged an average of 39 h after surgery. The preoperative symptoms resolved or improved in all patients, and no patient developed dysphagia or gas bloat syndrome. Postoperative pH monitoring showed complete or nearly complete resolution of the abnormal reflux in every patient. CONCLUSIONS: Partial fundoplication is an excellent treatment for patients with GERD and weak peristalsis, for it corrects the abnormal reflux and avoids postoperative dysphagia.

Endoscopy, Digestive System↗
PubMed1998

Resolving gastroesophageal reflux with laparoscopic fundoplication. Findings in 138 cases.

BACKGROUND: The purpose of this study was to evaluate the results of 138 cases of gastroesophageal reflux disease resolved laparoscopically with the Rossetti modification of the Nissen fundoplication and to compare them with findings from other studies in an effort to evaluate the procedure's ability to transfer from an academic setting to a community hospital setting. METHODS: We performed laparoscopic Nissen fundoplication on 138 patients and followed them for up to 45 months. Measures included postoperative reflux persistence, complications, operating time, length of hospital stay, and others. These findings were compared, using the Fisher's exact test, chi-square test, and the two-sample t-test, with results from other studies using open and laparoscopic procedures. RESULTS: No patient undergoing laparoscopic fundoplication experienced gastroesophageal reflux after surgery. Complications, not statistically significantly different from those in other studies, occurred in 15 (10.9%), and conversion to an open procedure was required in two (1.5%). The most common postoperative complaint has been dysphagia (21.7%). Operative time averaged 70.6 min, decreasing from an average of 236 min for the first 10 cases to 40.8 min for the last 10. This measure was statistically significantly lower than all other operative times to which it was compared, except one to which it was almost identical (69.9 min). Length of stay (LOS) averaged 2.3 days, ranging from a low of 7 h to a high of 9 days, which made it fall well within limits set by other studies. Overall, LOS fell from a 3.0-day average for the first 20 cases to a 1.9-day average for the last 20 cases. CONCLUSIONS: Laparoscopic Nissen fundoplication resolved gastroesophageal reflux in all 138 patients, and measures for complications, operating time, and LOS were well within values reported by other studies, indicating the ability of this procedure to be successfully transferred from academic medical centers to the community hospital setting.

Adolescent↗
PubMed1998

Laparoscopic or open fundoplication? A complete cost analysis.

BACKGROUND: As part of a prospective observational trial, we set out to determine the direct and indirect costs of an open versus a laparoscopic fundoplication for chronic gastroesophageal reflux disease (GERD). METHODS: Two groups of patients, each comprising 28 subjects, were studied. RESULTS: All patients received a functioning fundoplication that did not require any additional therapy. Because 19 and 12 patients in the open and laparoscopy groups, respectively, were employed in the work force, we were able to assess the costs due to loss of production. The mean operating time was similar for both groups, but postoperative stay differed significantly; though it amounted to 8 days for the open group, it was only 2 days for the laparoscopy group. Postoperative sick leave was 29.9 days in the open and 9.9 in the laparoscopy group (p < 0.05). The costs of the operations were 18,363 SEK for laparoscopy and 12,856 SEK for conventional fundoplication. On the other hand, the cost for hospital stay amounted to 35,488 SEK in the open group but was only 25,571 SEK for those undergoing laparoscopy. When we add outpatient visits, endoscopies, and other medical expenses, the total direct costs in the laparoscopy group come to 27,693 SEK, as compared to 37,482 SEK for the open fundoplication. The indirect medical costs, which were dominated by loss of production (36,732 versus 12,126 SEK), came to 37,126 and 12,595 SEK in the open and laparoscopy groups, respectively. CONCLUSIONS: The total community-based costs for the open and laparoscopic operations for chronic GERD amounted to 74,608 and 40,289 SEK, respectively. Thus, we would recommend the laparoscopic procedure in most cases.

Adult↗