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PubMedDate not supplied

Outcome of laparoscopic anterior 180-degree partial fundoplication for gastroesophageal reflux disease.

Although Nissen fundoplication controls gastroesophageal reflux disease effectively, it is associated with an incidence of side effects. For this reason we have investigated the use of a laparoscopic 180-degree anterior fundoplication as a technique that has the potential to control reflux, but with less associated postoperative dysphagia and fewer gas-related side effects. Good short-term (6-month) outcomes have been previously reported within the content of a randomized trial. This report details the technique we used and describes the outcome of this procedure with longer follow-up in a much larger group of patients. The outcome for patients with gastroesophageal reflux disease who underwent a laparoscopic anterior 180-hemifundoplication was determined. Clinical follow-up was carried out prospectively by an independent scientist who applied a standardized questionnaire yearly following surgery. This questionnaire evaluated symptoms of reflux, postoperative problems including dysphagia, gas bloat, ability to belch, and overall satisfaction with clinical outcome. From July 1995 to May 1999, a total ofc107 patients underwent a laparoscopic anterior hemifundoplication. Four patients underwent further surgery for recurrent heartburn, and persistent troublesome dysphagia occurred in one. At 1 year 89% of patients remained free of reflux symptoms, and at 3 years 84% remained symptom free. Of those with symptoms of reflux, approximately half of them had only mild symptoms. The overall incidence and severity of dysphagia for liquids and solids was not altered by partial fundoplication. Epigastric bloating that could not be relieved by belching was uncommon, and only 11% of the patients at 1 year and 10% at 3 years following surgery were unable to belch normally. Overall satisfaction with the outcome of surgery remained high at 3 years' follow-up. Laparoscopic anterior partial fundoplication is an effective operation for gastroesophageal reflux, with a low incidence of side effects and a good overall outcome.

Adolescent↗
PubMedDate not supplied

Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication.

Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery.

Adult↗
PubMedDate not supplied

Physiologic mechanism and preoperative prediction of new-onset dysphagia after laparoscopic Nissen fundoplication.

The aim of this study was to determine whether preoperative physiologic factors can account for and be used to predict the development of postoperative dysphagia after laparoscopic Nissen fundoplication. One hundred sixty-three patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication with a median follow-up of 14 months (range 6 to 81 months). Preoperative dysphagia was present in 37% (60 of 163) and was relieved in all but five patients (92%). Female sex (P = 0.01) and the presence of a stricture (P = 0.02) were the only preoperative variables associated with the presence of preoperative dysphagia. Eight percent (8 of 103) of patients without preoperative dysphagia developed new-onset dysphagia, and of these 63% (5 of 8) had a normal lower esophageal sphincter (LES) (pressure >6 mm Hg; length >2 cm; abdominal length >1 cm). New-onset dysphagia was significantly more common in patients with a normal LES (22% [5 of 23] vs. 4% [3 of 80], P = 001). Patients with a normal LES had almost a sixfold increase in the risk of developing dysphagia as those with an abnormal LES (relative risk = 5.8). Only a preoperative normal LES (P = 0.02) or mean LES pressures (P = 0.04) were positively associated with the development of postoperative dysphagia. The severity of this dysphagia also showed a strong positive trend of increasing with mean preoperative LES pressures (P = 0.07). Finally, preoperative LES pressure significantly correlated with postoperative LES pressure (r = 0.48, P = 0.01) and with mean residual LES (nadir) pressure (r = 0.33, P = 0.05) offering insight into the mechanism of this dysphagia. In conclusion, preoperative LES parameters play a role in the development of dysphagia after laparoscopic Nissen fundoplication. Patients with a normal LES or high mean LES pressures are at increased risk for developing this complication and should be informed of this before laparoscopic Nissen fundoplication.

Adolescent↗
PubMedDate not supplied

Functional outcome after Heller myotomy and fundoplication for achalasia.

This study aims to provide longitudinal prospective data on symptomatic outcome following Heller myotomy with fundoplication and to examine variables that might predict a poor outcome. Patients were prospectively followed by means of a biannual mailed questionnaire that assessed symptoms, satisfaction with the procedure, medication, and need for further intervention. Patients were classified as achieving a good or poor outcome based on predetermined criteria. Duration of clinical remission was determined using Kaplan-Meier curves. Between 1992 and 1999, 62 patients with at least 12 months' follow-up were categorized as having either a good outcome (41 patients) or a poor outcome (21 patients). The cumulative probability of a good outcome at 7 years was 37%. Dysphagia significantly increased over the follow-up period despite initial resolution. Patient variables (age, sex, symptom duration, esophageal dilatation, manometric findings) and operative factors (myotomy length, wrap type, case number mucosal perforation, primary therapy) were not demonstrated to influence outcome at 3 years. A comparison of Nissen fundoplication with partial fundoplication suggested increased dysphagia and chest pain in the Nissen group. Despite initial symptomatic relief, patients with achalasia suffer a progressive decline with recurrent dysphagia and regurgitation. The type of fundoplication used may contribute to these poor results.

Deglutition Disorders↗
PubMedDate not supplied

Static and dynamic function of the lower esophageal sphincter before and after laparoscopic Nissen fundoplication.

The means by which fundoplication protects against reflux is disputed. We studied the resting and dynamic features of the lower esophageal sphincter (LES) and 24-hour pH monitoring in 26 patients before and after laparoscopic Nissen fundoplication. Resting features were LES pressure, abdominal length, and total length. Dynamic function was assessed by the residual pressure in the LES during a swallow measured as the bolus flowed though the LES. All patients experienced near-total relief of heartburn and all but one had normal postoperative acid scores. Resting LES characteristics were restored to normal. Mean residual pressure on swallowing was 7.1+/-3.2 mm Hg in the patients postoperatively compared with 1.2+/-1 mm Hg preoperatively and 4.0+/-2.4 mm Hg in normal subjects. Eighteen of 26 patients had residual LES pressure within the normal range (<8.2 mm Hg). There was a tendency for residual pressures to be lower as experience with the procedure was gained. Incomplete LES relaxation is not necessary for effective functioning of a Nissen fundoplication. In construction of a Nissen fundoplication, creating a large retroesophageal window and deliberate dissection of the back of the posterior fundus from the left crus allows the creation of an effective antireflux procedure with restoration of static LES parameters to normal and minimal limitation of LES relaxation.

Adult↗
PubMedDate not supplied

Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication.

Laparoscopic Nissen fundoplication has been applied with increasing frequency in the treatment of gastroesophageal reflux disease. The aim of this study was to determine the variables that predict outcome of laparoscopic Nissen fundoplication. A multivariate analysis was performed on data from 199 consecutive patients undergoing laparoscopic Nissen fundoplication. Variables included age, sex, body mass index, primary symptoms, clinical response to acid suppression therapy, erosive esophagitis, 24-hour esophageal pH score, and the percentage of time the esophageal pH was less than 4 on 24-hour pH monitoring, lower esophageal sphincter competence, status of the esophageal body motility, hiatal hernia, carditis, intestinal metaplasia of cardiac epithelium limited to the gastroesophageal junction, and Barrett's esophagus of any length. Clinical outcome was obtained from all patients at a median follow-up of 15 months (range 6 to 74 months) after surgery. One hundred seventy-three patients had an excellent or good outcome (87%) and 26 had a fair or poor outcome. Three factors were significantly predictive of a successful outcome: an abnormal 24-hour pH score (odds ratio = 5.4; 95% confidence interval [CI] = 1. 9-15.3), a typical primary symptom (odds ratio = 5.1; 95% CI = 1. 9-13.6), and a clinical response to acid suppression therapy (odds ratio = 3.3; 95% CI = 1.3-8.7). We conclude that 24-hour pH monitoring provides the strongest outcome predictor of laparoscopic Nissen fundoplication and that outcome is based more on the correct identification of the disease than on its severity.

Adolescent↗
PubMedDate not supplied

Epidural analgesia improves outcome following pediatric fundoplication. A retrospective analysis.

BACKGROUND AND OBJECTIVES: Nissen fundoplication is a common procedure in high-risk pediatric patients. This cohort study evaluated the influence of epidural versus intravenous opioid analgesia on the postoperative course of infants and children undergoing fundoplication. METHODS: A retrospective review was made of the perioperative courses of 155 consecutive patients, aged 1 month to 19 years, who underwent elective open fundoplication from January 1993 to October 1994. Of these 155 patients, 72 received perioperative analgesia with epidural opioids, while 83 received parenteral opioids. Outcome variables included major morbidity factors, recovery of bowel and bladder function, and economic impact. RESULTS: Patients in the epidural and parenteral groups did not differ with respect to age, weight, or associated preoperative medical diagnoses. The postoperative complication rate was significantly decreased in the epidural group (5.5% versus 20%) (P < .001). In the epidural group 4 patients required mechanical ventilation for longer than 24 hours, compared with 15 in the parenteral group. Patients in the epidural group were discharged earlier from the hospital and incurred approximately 20% less in hospital charges on average than their cohorts in the intravenous group. CONCLUSIONS: These findings suggest that perioperative epidural analgesia, administered by a dedicated pain service, amy improve outcome in high-risk pediatric patients undergoing fundoplication.

Adolescent↗
PubMed2000

Children with neurological disorders do not always need fundoplication concomitant with percutaneous endoscopic gastrostomy.

Whether antireflux surgery should be routinely performed at the time of gastrostomy in children with neurological disorders is debatable because of the risk of gastroesophageal reflux. Some argue that these children should be screened for occult gastroesophageal reflux as this will determine the need for fundoplication. This study retrospectively examines outcome in 29 children with neurological disorders who underwent percutaneous endoscopic gastrostomy (PEG) without concomitant fundoplication. Children were included if they had no clinical evidence of severe gastroesophageal reflux before PEG insertion. The median age of children at PEG insertion was 5.6 years (range 1.1 to 18.0). The children were followed for a median of 2.6 years (range 0.4 to 4.9). Insertion of PEG was technically impossible in two children; and an asymptomatic gastrocolic fistula in another child led to subsequent tube removal. Fourteen of the 26 remaining children developed symptomatic gastroesophageal reflux after PEG; five of these showed no reflux on pH monitoring prePEG. Control of symptoms was achieved by medical intervention in 12, but two required fundoplication. Our findings indicate that in the child with neurological disabilities without symptoms indicating severe gastroesophageal reflux, fundoplication is unlikely to be necessary as a consequence of PEG insertion. We conclude that routine investigation for gastroesophageal reflux in the child without severe vomiting can be avoided and the number of antireflux procedures reduced.

Child, Preschool↗
PubMed1998

Cisapride enhances the effect of partial posterior fundoplication on esophageal peristalsis in GERD patients with poor esophageal contractility.

Partial posterior fundoplication improves esophageal peristalsis in patients with gastroesophageal reflux disease (GERD) associated with poor esophageal body function. The aim of this study was to investigate whether postoperative administration of cisapride enhances the effect of surgery on esophageal peristalsis. Laparoscopic partial posterior fundoplication was performed on 34 consecutive GERD patients with poor esophageal body motility. These patients were randomized in groups without and with postoperative treatment with cisapride 20 mg twice daily for six months. Esophageal manometry was performed preoperatively and six months following surgery. Esophageal body function improved significantly following partial posterior fundoplication without or with postoperative treatment with cisapride. However, this effect was more pronounced in the group of patients receiving cisapride. Partial posterior fundoplication combined with postoperative treatment with cisapride should be the therapy of choice in GERD patients with poor esophageal body motility.

Adult↗
PubMed2002

Results of laparoscopic Nissen fundoplication at 2-8 years after surgery.

BACKGROUND: Although the long-term results of open fundoplication for gastro-oesophageal reflux disease are well documented, there have been few reports of the long-term results of laparoscopic fundoplication. METHODS: Between January 1993 and July 1999, 179 consecutive patients underwent laparoscopic floppy Nissen fundoplication. Of these, 175 were available for long-term follow-up. Structured symptom questionnaires were completed by 140 patients (80 per cent) at 2-5 years (n = 92) or 5-8 years (n = 48) after operation. RESULTS: Patient satisfaction with surgery was 91 per cent at a median follow-up of 48 (range 24-99) months. Visick scores of I or II were recorded by 84 per cent. Ninety per cent of patients remained free from significant reflux symptoms. Side-effects were common (22 per cent) but rarely affected patient satisfaction. Of the 19 patients (14 per cent) taking regular antireflux medication, eight used it for non-reflux symptoms and 12 had normal postoperative pH tests. CONCLUSION: Laparoscopic floppy Nissen fundoplication is an effective and durable treatment for gastro-oesophageal reflux disease. Longer-term follow-up of patients operated on beyond the learning curve can be expected to show further improvements in surgical outcome.

Adolescent↗
PubMed1998

Oesophageal dysmotility is not associated with poor outcome after laparoscopic Nissen fundoplication.

BACKGROUND: Nissen fundoplication has become the standard operation in the surgical management of gastro-oesophageal reflux disease. Postoperative dysphagia is thought to occur more commonly in patients with oesophageal dysmotility and it has been recommended that fundoplication be modified or avoided in these patients. The aim of this study was to determine the outcome of patients with normal motility and dysmotility undergoing laparoscopic Nissen fundoplication. METHODS: This was a single-centre prospective cohort study with 1-year follow-up, using dysphagia as the main outcome variable. Of 81 patients who underwent laparoscopic surgery, 48 had normal motility and 33 had oesophageal dysmotility (defined as percentage peristalsis, using ten wet swallows, of 50 per cent or less and/or a mean distal pressure of less than 40 mmHg). RESULTS: Dysphagia was present before operation in 14 of 48 patients with normal motility and 15 of 33 in the dysmotility group (P=0.2). At 3-month follow-up, new or worse dysphagia was present in 13 of 48 patients in the normal group and four of 33 in the dysmotility group (P=0.17). At 1 year the incidence of dysphagia was six of 48 in the normal group and five of 33 in the dysmotility group (P=0.9). CONCLUSION: Preoperative manometric assessment of oesophageal motility does not correlate with postoperative outcome, and oesophageal dysmotility should not be regarded as a contraindication to laparoscopic Nissen fundoplication.

Adolescent↗
PubMed2001

Analysis and surgical treatment of persistent dysphagia after Nissen fundoplication.

BACKGROUND: After Nissen fundoplication, troublesome dysphagia develops in 5-10 per cent of patients. The mechanism of dysphagia has not been fully resolved, in spite of a number of studies focusing on oesophageal motility and lower oesophageal sphincter (LOS) dynamics. Tightness and length of the wrap have had considerable attention, without giving a fully satisfactory explanation of the pathophysiological mechanism. METHODS: Eighteen patients with persistent dysphagia after Nissen fundoplication needing reoperation were studied. Eighteen patients, matched for age and sex, without dysphagia after Nissen fundoplication were used as controls. Reoperation consisted of conversion of a 360 degrees into a 270 degrees wrap. Barium swallow, endoscopy, oesophageal manometry and 24-h pH monitoring were performed before and after (re)operation. RESULTS: Peristaltic amplitude, velocity and duration of contraction were not significantly influenced by operation. In 16 of 18 patients with dysphagia, LOS relaxation was incomplete and the residual relaxation pressure was significantly higher than that in the group without dysphagia (P < 0.01). No correlation was found between LOS pressure and peristaltic amplitude, nor between LOS pressure and ramp pressure in the distal oesophagus. After reoperation, basal LOS pressure decreased significantly (P < 0.01) and LOS relaxation was complete in all but three patients; residual relaxation pressure decreased (P < 0.01) and was significantly lower than that after uncomplicated Nissen fundoplication. In the latter group, LOS pressure, residual relaxation pressure and ramp pressure increased significantly after operation (P < 0.01). CONCLUSION: A return to complete LOS relaxation and a decrease in residual relaxation pressure play an important role in resolving dysphagia.

Adult↗
PubMed2000

Open Nissen fundoplication and highly selective vagotomy as a treatment for gastro-oesophageal reflux disease.

BACKGROUND: Open Nissen fundoplication has been the most common surgical treatment of gastro-oesophageal reflux disease (GORD). The present paper describes the symptomatic result, and quantifies the acid reduction achieved by open Nissen fundoplication combined with highly selective vagotomy (HSV) in a consecutive case series. METHODS: A study of 106 patients undergoing open Nissen fundoplication and HSV for GORD was performed between 1988 and 1996. A history consistent with reflux was obtained and the diagnosis confirmed with ambulatory oesophageal pH studies and endoscopy. Postoperative pH studies were performed, and peri-operative and late complications were recorded. A standard questionnaire was sent out to patients postoperatively to assess the efficacy of surgery. RESULTS: Pre-operative pH studies were performed on 104 (98%) patients, and on 97 (91.5%) following surgery. There was a highly significant improvement in all parameters of the pH study postoperatively. All symptoms, including bloating and dysphagia, improved significantly postoperatively, except flatulence, which was exacerbated. The majority of patients were very satisfied with their outcome, 82% rating the operation from 80 to 100% successful. Complications were rare and there was no mortality. CONCLUSIONS: Open Nissen fundoplication and HSV is an effective method of treating GORD, producing an improvement in symptoms and in ambulatory pH studies.

Adolescent↗
PubMed2000

Esophagogastric fistula secondary to teflon pledget: a rare complication following laparoscopic fundoplication.

Laparoscopic fundoplication has become the standard operation for gastroesophageal reflux disease. In our service, a laparoscopic fundoplication is performed as a 2-cm floppy 360 degrees wrap with division of the short gastric vessels and the fundoplication is sutured using a prolene 2/0 mattress suture (Ethicon, USA) and buttressed laterally with two teflon pledgets (PTFE 1.85 mm; low porosity, Bard, USA). We report a patient with post-operative dysphagia due to an esophagogastric fistula caused by erosion of a teflon pledget. This is the first such case in 734 laparoscopic fundoplications performed between January 1991 and December 1998. Reoperation was required, resulting in a prolonged convalescence. A review of current literature has not revealed any similar cases. Causes for this rare complication are postulated.

Esophageal Fistula↗
PubMed2002

Long-term effects of myotomy and partial fundoplication for esophageal achalasia.

Controversy persists in the surgical approach to treat esophageal achalasia. This investigation reports the long-term effects of esophageal myotomy and partial fundoplication in treating this disorder. From 1984 to 1998, 32 patients with achalasia underwent myotomy and partial fundoplication (Belsey Mark IV) using a left thoracotomy. The median follow up is 7.2 years. Assessments include clinical evaluation, esophagogram, radionuclide transit, manometry, 24-h pH, and endoscopy. There is no complication and no mortality. Preoperative assessment was compared with that in 0-3, 3-7, and 7-16 postoperative years. Clinically, the prevalence of dysphagia was decreased from 100% to 6%, 12%, and 13%, respectively (P < 0.001). Heartburn remains unchanged (P > 0.25). On radiology, the prevalence of barium stasis was decreased from 97% to 44%, 48%, and 47%, respectively (P=0.001), whereas a pseudo-diverticulum was observed in two-thirds of patients after operation (P=0.001). Percent radionuclide stasis at 2 min was measured as 70%, 17%, 20%, and 20%, respectively (P=0.001). Manometrically, lower esophageal sphincter (LES) gradient was decreased from 29 to 10, 9, and 9 mmHg, respectively (P=0.001). LES relaxation was improved from 41% preoperatively to 100% postoperatively at each postoperative period (P < 0.001). An abnormal acid exposure was observed in four patients after the operation. Endoscopy documented mucosal damage in three patients (P > 0.25). In conclusion, on long-term follow up, myotomy and partial fundoplication for achalasia relieve obstructive symptoms and improve esophageal emptying, and reduce LES gradient and improve LES relaxation. Acid reflux is recorded in 13% of patients and esophageal mucosal damage is identified in 11% of the patient population. A longer myotomy not covered by the fundoplication results in pseudodiverticulum formation and increased esophageal retention.

Adult↗
PubMed2003

Gastroenterologists' views of symptoms following laparoscopic fundoplication: anecdotally based medicine?

BACKGROUND: Currently gastro-oesophageal reflux disease (GORD) can be managed either medically or surgically. The management decision is often based on the referring doctor's perception of the pros and cons of surgical management versus the medical alternative. A large group of gastroenterologists was surveyed to determine their understanding of the common outcomes of surgical management of GORD. METHODS: A 15-question survey was sent to all gastroenterologists in Australia who were members of the Gastroenterology Society of Australia. Questions centred on management decisions and postoperative symptoms in fundoplication patients. The findings were compared to current published outcome data. RESULTS: One hundred and thirty-four gastroenterologists responded anonymously to the survey. More than 75% described fundoplication as a safe and established procedure, and 80% had referred patients who were well controlled on medication for surgical management. The gastroenterologists' perceptions of the problems of postoperative dysphagia and bloating differed from published outcomes. CONCLUSIONS: Gastroenterologists are often the gatekeepers for the management of patients with GORD. The understanding that this group has about surgical outcomes is important so that patients can make well-informed management decisions. The present study found that gastroenterologists are likely to convey to their patients higher degrees of postoperative dysphagia and bloating following fundoplication than is actually reported. This may deter some patients who would benefit from fundoplication from consulting a surgeon.

Adult↗
PubMed2001

Esophageal motility in reflux disease before and after fundoplication: a prospective, randomized, clinical, and manometric study.

BACKGROUND AND AIMS: The purpose of this study was to determine whether esophageal dysmotility affects symptoms of gastroesophageal reflux disease or clinical outcome after laparoscopic fundoplication and whether esophagus motor function changes postoperatively. METHODS: Two hundred patients with a history of long-standing gastroesophageal reflux disease were investigated by clinical assessment, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring between May 1999 and May 2000. Patients were stratified according to presence or absence of esophageal dysmotility (each n = 100) and randomized to either 360 degrees (Nissen) or 270 degrees (Toupet) fundoplication. At a 4-month postoperative follow-up, preoperative tests were repeated. RESULTS: Preoperative esophageal dysmotility was associated with more severe reflux symptoms, more frequent resistance to medical treatment (64% vs. 49%; P < 0.05), and greater decrease in lower esophageal sphincter pressure (9.5 +/- 5.3 vs. 12.4 +/- 6.7 mm Hg; P < 0.0005) compared with normal motility. Postoperatively, clinical outcome and reflux recurrence (21% vs. 14%) were similar. Esophageal motility remained unchanged in 85% of patients and changed from pathologic to normal in 20 (10 Nissen/10 Toupet) and vice versa in 9 (8 Nissen/1 Toupet) patients. CONCLUSIONS: Esophageal dysmotility (1) reflects more severe disease; (2) does not affect postoperative clinical outcome; (3) is not corrected by fundoplication, independent of the surgical procedure performed; (4) may occur as a result of fundoplication; and (5) requires no tailoring of surgical management.

Adult↗
PubMed2002

[Venous stasis and deep vein thrombosis prophylaxis during laparoscopic fundoplication].

AIMS OF THE STUDY: first, to study the effect of a pneumoperitoneum (12 mm Hg) on femoral venous outflow, second, to evaluate the efficacy of mechanical antistasis devices: intermittent pneumatic compression (IPC), intermittent electric calf muscle stimulation (IECS) and graded compression leg bandages (LB) in reducing venous stasis, third, to determinate the incidence of deep venous thrombosis (DVT) after laparoscopic fundoplications using venous occlusion plethysmography method. PATIENTS AND METHODS: 54 patients undergoing elective laparoscopic fundoplications were studied. They were randomized into three groups - 18 patients in each group. The first group received LB, the second group received IECS and the third group IPC during operations. Lower extremity venous blood velocity was evaluated using Doppler ultrasonography during operation. In all 54 patients leg venous outflow was measured 1 day before and 1 day after operation using venous occlusion plethysmography method, in order to detect possible DVT after operation. The blood velocity in the femoral vein without pneumoperitoneum was 20.1 +/- 2.4 cm/s in the IPC group, 20.3 +/- 1.4 cm/s in the IECS group, and 23.9 +/- 1.2 cm/s in the LB group. With the introduction of a pneumoperitoneum (12 mm Hg) and the reverse Trendelenburg position the femoral venous blood velocity was significantly reduced in all groups: 9.3 +/- 0.9 cm/s in IPC group, 9.4 +/- 0.9 cm/s in IECS group, and 9.2 +/- 1.1 cm/s in LB group (p < 0.05). The maximum blood velocity generated by the IPC when a pneumoperitoneum (12 mm Hg) was present was 17.4 +/- 1.9 cm/s, and in the IECS group 14.0 +/- 1.1 cm/s, whereas in the LB group the blood velocity remained the same (9.2 +/- 1.1 cm/s). Calf DVT and pulmonary artery microembolization developed in one patient of the LB group, detected by venous occlusion plethysmography and lung perfusion scintigraphy methods one day after operation. CONCLUSIONS: The femoral vein stasis which appears in laparoscopic fundoplications can be minimized by reducing the intraabdominal pressure during operation, and avoiding reverse Trendelenburg position as much as possible. IPC is more effective than IECS in reducing venous stasis induced by the pneumoperitoneum and the reverse Trendelenburg position. Graded compression by leg bandages is ineffective in patients undergoing laparoscopic gastrofundoplication. With a pneumoperitoneum in place, neither device was able to return the depressed blood flow velocity to the values recorded without a pneumoperitoneum. The incidence of DVT and pulmonary embolism after laparoscopic fundoplications was 1.8 % in our study.

Adult↗