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PubMed1996

Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication.

BACKGROUND: Helicobacter pylori infection plays an important part in the development of atrophic gastritis and intestinal metaplasia, conditions that predispose patients gastric cancer. Profound suppression of gastric acid is associated with increased severity of gastritis caused by H. pylori, but it is not known whether acid suppression increases the risk of atrophic gastritis. METHODS: We studied patients from two separate cohorts who were being treated for reflux esophagitis: 72 patients treated with fundoplication in Sweden and 105 treated with omeprazole (20 to 40 mg once daily) in the Netherlands. In both cohorts, the patients were followed for an average of five years (range, three to eight). After fundoplication, the patients did not receive acid-suppressive therapy. The presence of H. pylori was assessed at the first visit by histologic evaluation in the fundoplication group and by histologic and serologic evaluation in the omeprazole group. The patients were not treated for H. pylori infection. Before treatment and during follow-up, the patients underwent repeated gastroscopy, with biopsy sampling for histologic evaluation. RESULTS: Among the patients treated with fundoplication, atrophic gastritis did not develop in any of the 31 who were infected with H. pylori at base line or the 41 who were not infected; 1 patient infected with H. pylori had atrophic gastritis before treatment that persisted after treatment. Among the patients treated with omeprazole, none of whom had atrophic gastritis at base line, atrophic gastritis developed in 18 of the 59 infected with H. pylori(P<0.001) and 2 of the 46 who were not infected (P=0.62). CONCLUSIONS: Patients with reflux esophagitis and H. pylori infection who are treated with omeprazole are at increased risk of atrophic gastritis.

Adolescent↗
PubMed2005

Long-term outcome is worse after laparoscopic than after conventional Nissen fundoplication.

OBJECTIVE: No long-term studies of laparoscopic and open fundoplication were available in 1994. The aim of this study was to compare reflux control and side effects after laparoscopic and open fundoplication. MATERIAL AND METHODS: Adult patients with uncomplicated gastro-oesophageal reflux disease were included in this prospective randomized clinical trial between laparoscopic and open 360-degree fundoplication. Patients with uncomplicated gastro-oesophageal reflux disease were included with the exception of those with weak peristalsis or suspected short oesophagus. Two senior surgeons, well trained in laparoscopic antireflux surgery, performed the 45 laparoscopic operations. Forty-eight patients underwent open surgery performed or supervised by two other senior surgeons, also well trained in gastro-oesophageal surgery. One of the latter recruited all the patients. Manometry and 24-h oesophageal pH monitoring were performed before operation and 6 months postoperatively. Manometry also included a short-term reflux test, an acid clearing test and an acid perfusion test. Symptom evaluation was performed before surgery, 6 months after and at long-term follow-up (33-79 months postoperatively) by the same surgeon. Long-term follow-up also included endoscopy. RESULTS: Six months after laparoscopy 4 patients had disabling dysphagia. None of the patient had disabling dysphagia after laparotomy. Four patients had mild heartburn 6 months after laparoscopy and 2 patients after laparotomy. Between 6 months' follow-up and long-term follow-up, 6 patients were reoperated on in the laparoscopy group and 2 patients in the laparotomy group. Three patients operated on with laparotomy had died of intercurrent diseases. After laparoscopy, at long-term follow-up, 62% of patients (28/45) were satisfied compared with 91% (41/45) after laparotomy. The difference was significant (p<0.01). CONCLUSIONS: Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. At long-term follow-up significantly more patients were satisfied after laparotomy than after laparoscopy.

Adult↗
PubMed1999

Bile reflux into the esophagus. Bilitec 2000 measurements in normal subjects and in patients after Nissen fundoplication.

BACKGROUND: Bilitec 2000 is a new spectrophotometric system that can detect bilirubin within the esophagus. The aim of this study was to test this new system in vitro and in vivo with special attention to patients operated on laparoscopically for gastroesophageal reflux with Nissen fundoplication. METHODS: In vitro studies of gallbladder bile dilution curves at different pHs were performed with a combined pH and Bilitec probe and by investigation of the drift of the Bilitec system. In vivo studies were performed in 34 normal individuals and 12 patients operated on with a laparoscopic Nissen fundoplication. Intra/intervariations were evaluated in normal individuals. RESULTS: The Bilitec system was able to detect changes in absorbance value within the range 0.14-0.6. Absorbance values were about 30% lower in an acid environment. The percentage of the total time with bile reflux was a median (range) of 3.9 (0-49.6) in normal individuals, with an intravariation within the intervariation, and 8.7 (0-36.6) in patients after a Nissen fundoplication. These values did not differ significantly. Eighty-two per cent of the normal subjects had some degree of bile reflux, if an absorbance value > or = 0.14 was accepted as the threshold value for the presence of bile reflux. CONCLUSIONS: Bile reflux in normal individuals is frequent and not different from that in patients after a Nissen fundoplication. Surprisingly, the latter had bile reflux but no or minimal acid reflux. Factors other than bilirubin may interfere with the measurements.

Adult↗
PubMed2002

Effect of laparoscopic failure on outcome of laparoscopic nissen fundoplication: independent review.

PURPOSE: This study was undertaken to determine whether conversion or early reoperation contributed significantly to the eventual outcome of laparoscopic Nissen fundoplication. PATIENTS AND METHODS: An independent surgeon, blinded to the operative events, administered two general and one system-specific quality of life tools to the first 100 consecutive patients booked for laparoscopic fundoplication in a community hospital, where the open conversion rate was 4 patients/surgeon and the early reoperation rate 1.5 patients/surgeon for the first 20 operations. Patients were also asked about need for medication, dysphagia, satisfaction (analog scale), and whether, if given it to do over, they would opt for surgery again. RESULTS: Of the original 100 patients, 40 were studied an average of 5 years after surgery: 26 completed laparoscopically and 14 with laparoscopic failure (13 conversions and 1 early reoperation). Patient characteristics in the two groups were similar, except that there were more older patients with more fixed intrathoracic hiatus hernias in the failure group. Among the parameters examined, no statistically significant differences could be detected between laparoscopic and converted patients. CONCLUSIONS: General and system-specific quality of life, digestive symptoms, need for medication, patient satisfaction, and willingness to have surgery over again are not altered by conversion or reoperation. Thus, surgeons who have adequate laparoscopic skills, experience with open fundoplication, and training in laparoscopic Nissen fundoplication should feel free to add it to their repertoires provided the likelihood of conversion and reoperation secondary to inexperience is understood by the patient.

Female↗
PubMed2003

Laparoscopic Heller myotomy with bolstering partial posterior fundoplication for achalasia.

BACKGROUND: The ideal antireflux procedure following laparoscopic Heller myotomy for achalasia is controversial. We present a novel laparoscopic technique of partial posterior fundoplication to bolster the myotomy. METHODS: Between August 1998 and March 2002, eight patients (five females and three males; median age, 40 years) underwent a laparoscopic Heller myotomy with bolstering partial posterior fundoplication. Results of barium swallow and manometry studies were consistent with achalasia. Failed medical treatments included balloon dilation, botulinum injection, and calcium channel blockers. RESULTS: The preoperative weight loss was 33 lb (range, 10-50) with a mean duration of symptoms of 29 months (range, 12-72). Seventy-one percent of the patients had reflux. Myotomy was confirmed with endoscopic guidance. Partial posterior fundoplication was performed with the edges of the myotomy on the right and left sides sutured to the stomach, which covered the myotomy. No conversion was required. In one patient, a perforation was recognized, repaired, and bolstered. The mean operative blood loss was 72 mL (range, 30-150). The mean operative time was 4 hours. Patients resumed solids at 2.5 days (range, 2-5). Postoperative complications included subcutaneous emphysema (n = 1), pneumothorax (n = 1), and umbilical port hernia (n = 1). None of the patients had reflux symptoms at 3 to 18 months of follow-up. CONCLUSION: Laparoscopic Heller myotomy with partial posterior fundoplication is technically feasible and effectively prevents reflux symptoms. Bolstering the myotomy may help heal small esophageal perforations.

Adult↗
PubMed1997

Laparoscopic redo Nissen fundoplication.

Nine patients underwent redo laparoscopic Nissen fundoplication because of failed primary laparoscopic antireflux procedure. Symptoms prior to reoperation included heartburn (n = 5), dysphagia (n = 2), dysphagia and heartburn (n = 1), and early satiety and epigastric pain (n = 1). Endoscopic and radiologic findings prior to reoperation included esophagitis (n = 6), reflux (n = 6), stenosis (n = 2), and hiatal hernia (n = 1). Findings at reoperation included fundoplication positioned on the stomach (n = 5); a disrupted cruroplasty (n = 1); gastric volvulus (n = 1); and an excessively tight wrap (n = 1) or cruroplasty (n = 1). Reconstruction of the fundoplication was performed according to accepted principles for this procedure. All patients were discharged within 2 days after the redo procedure. Follow-up time is 4-14 months. Preoperative symptoms were relieved in all patients and all antireflux medication have been discontinued. Routine postoperative esophagram and endoscopy demonstrated intact repair and without gastroesophageal reflux or stenosis. Reoperative laparoscopic Nissen fundoplication is feasible and effective.

Adult↗
PubMed2000

Fundoplication: a model for immunologic aspects of laparoscopic and conventional surgery.

BACKGROUND AND PURPOSE: Immunologic investigations of laparoscopic and conventional procedures have recently been performed during cholecystectomy or colon resection, but the results might have been influenced by the amount of dissection or the presence of malignant tumor. Because fundoplication is characterized by moderate dissection and no resection, we supposed it to be an appropriate procedure for comparing immunologic changes during laparoscopic and conventional surgery. PATIENTS AND METHODS: Immunologic analysis (interleukin [IL]-6, IL-10, leukocytes, HLA-DR monocytes) was carried out on the peripheral blood of 34 patients who underwent elective Nissen fundoplication by the laparoscopic (LAP; N = 26) or conventional (OPEN; N = 8) technique for gastroesophageal reflux disease. Blood samples were obtained before and 1 and 4 hours after the beginning of the operation and on days 1, 2, 4, 7 after the procedure. RESULTS: A very fast and significant (P < 0.01) increase of the proinflammatory cytokines (IL-6, IL-10) and leukocytes and a decrease of cell-mediated functions (HLR-DR monocytes) were detected. Most of the analyzed measures had returned to preoperative values by 2 days after the procedure. All of the changes were similar in the two groups with the exception of IL-6. Throughout the post-operative study period, IL-6 concentrations were higher in the OPEN group, being significant 4 hours, 1 day, 2 days, and 4 days after the operation. CONCLUSION: The investigation measures do not give evidence that laparoscopic fundoplication is superior to conventional fundoplication in its immunologic effects.

Adult↗
PubMed1998

The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with "typical" symptoms.

OBJECTIVE: To evaluate prospectively the outcome of laparoscopic fundoplication in a large cohort of patients with typical symptoms of gastroesophageal reflux. SUMMARY BACKGROUND DATA: The development of laparoscopic fundoplication over the past several years has resulted in renewed interest in the surgical treatment of gastroesophageal reflux disease (GERD). METHODS: One hundred patients with typical symptoms of GERD were studied. The study was limited to patients with positive 24-hour pH studies and "typical" symptoms of GERD. Laparoscopic fundoplication was performed when clinical assessment suggested adequate esophageal motility and length. Outcome measures included assessment of the relief of the primary symptom responsible for surgery; the patient's and the physician's evaluation of outcome; quality of life evaluation; repeated upper endoscopy in 30 patients with presurgical esophagitis; and postsurgical physiologic studies in 28 unselected patients, consisting of 24-hour esophageal pH and lower esophageal sphincter manometry. RESULTS: Relief of the primary symptom responsible for surgery was achieved in 96% of patients at a mean follow-up of 21 months. Seventy-one patients were asymptomatic, 24 had minor gastrointestinal symptoms not requiring medical therapy, 3 had gastrointestinal symptoms requiring medical therapy, and 2 were worsened by the procedure. Eighty-three patients considered themselves cured, 11 were improved, and 1 was worse. Occasional difficulty swallowing not present before surgery occurred in 7 patients at 3 months, and decreased to 2 patients by 12 months after surgery. There were no deaths. Clinically significant complications occurred in four patients. Median hospital stay was 3 days, decreasing from 6.3 in the first 10 patients to 2.3 in the last 10 patients. Endoscopic esophagitis healed in 28 of 30 patients who had presurgical esophagitis and returned for follow-up endoscopy. Twenty-four-hour esophageal acid exposure had returned to normal in 26 of 28 patients studied after surgery. Lower esophageal sphincter pressures had also returned to normal in all patients, increasing from a median of 5.1 mmHg to 14.9 mmHg. CONCLUSIONS: Laparoscopic Nissen fundoplication provides an excellent symptomatic and physiologic outcome in patients with proven gastroesophageal reflux and "typical" symptoms. This can be achieved with a hospital stay of 48 hours and a low incidence of postsurgical complications.

Fundoplication↗
PubMed1998

Functional results of laparoscopic fundoplication in children.

BACKGROUND: There is no evidence that the results of laparoscopic fundoplication in children match those of the open procedure. In the current report, pre- and postoperative function of the antireflux barrier is examined in children having laparoscopic fundoplication for gastroesophageal reflux. METHODS: Twenty-seven patients with gastroesophageal reflux, aged 7.2+/-4.5 years, were operated on for unremitting gastrointestinal symptoms (n = 24), with respiratory tract disease (n = 11), cystic fibrosis (n = 2), or brain damage (n = 11). Gastrostomy was added in 5 cases. Barium contrast study, pH-metering, endoscopic examination, and biopsy were performed before and after a median of 19 months (range, 8 to 46) after operation. RESULTS: At diagnosis, 15 of 21 patients had esophagitis that was moderate or severe in 11 (1 with Barrett's esophagus). Symptoms disappeared after fundoplication in all but 2 patients, in whom they became milder. The reflux index decreased from 20.2+/-20% to 4.9+/-9% and became normal in all except 4 children (2 with brain damage and 1 with cystic fibrosis). Open repair of the failed wrap was considered necessary in only 1 of them. CONCLUSIONS: Laparoscopic fundoplication is as effective as the open procedure (14% overall failure rate). However, the failure rate in neurologic patients (18%) suggests that before reaching conclusions on the benefits of this approach, careful long-term assessment of the functional results is necessary.

Biopsy↗
PubMed2002

Nissen fundoplication surgery for extraesophageal manifestations of gastroesophageal reflux (EER).

OBJECTIVE: To determine the outcome of Nissen fundoplication surgery for the treatment of patients with chronic extraesophageal manifestations of reflux (EER). METHODS: A retrospective medical record analysis was performed. Patient demographics, extraesophageal disease secondary to gastroesophageal reflux (GER), methods of GER diagnosis, acid suppression therapy before antireflux surgery, and response to surgical intervention were evaluated. RESULTS: The charts of 29 patients who underwent Nissen fundoplication surgery for EER were included in the study. Hoarseness was present in 17 patients; laryngopharyngeal reflux (LPR) was the most common diagnosis (n = 20). Barium esophagram was done in all patients and revealed abnormalities indicative of GER in 26 patients. Twenty-four-hour ambulatory pH study was done in 27 patients and pharyngeal reflux was present in 19. Preoperative esophageal endoscopy was performed in 22 patients. This study revealed evidence of gastroesophageal reflux disease (GERD) in 14 patients with 8 having evidence of Barrett's esophagus. Sixteen of the 29 patients had symptoms or findings of GERD. Twenty-eight patients had laparoscopic Nissen fundoplication (LNF) and 1 had an open procedure. Twenty-five of the 29 patients (follow-up ranging from 6-108 mo) had excellent results with near-total freedom from symptoms and are taking no acid-suppressive medications. CONCLUSIONS: GER has an important role in the cause of many otolaryngologic and pulmonary disorders. Nissen fundoplication is an effective modality to treat EER in selected cases.

Antacids↗
PubMed1996

Laparoscopic fundoplication in the treatment of severe gastroesophageal reflux disease: preliminary results of a prospective trial.

To determine the technical feasibility and success of laparoscopic fundoplication in the treatment of severe gastroesophageal reflux disease (GERD), 18 consecutive adult patients were enrolled in a prospective study. All patients had received unsuccessful conservative treatment, were refractory to medical management, or had recurrence of symptoms of esophagitis after omeprazole therapy. All patients had severe acid reflux on 24-hour esophageal pH monitoring, endoscopic evidence of previous or ongoing esophagitis, and a defective lower esophageal sphincter on manometry. Complete (Nissen) fundoplication was done in 11 and partial (Toupet) fundoplication in 7 patients; the mean operative time was 183 minutes (range, 120 to 357 minutes). Feedings were initiated on the first postoperative day, and the average length of stay was 2.6 days (range, 1 to 6). There were no deaths or conversions to laparotomy. Postoperative morbidity consisted of transient bloating in three patients and dysphagia requiring dilatation in four patients. Return to work or normal activity averaged 19 days (range, 3 to 28), and 17 patients (94%) reported good to excellent results, with a median follow-up of 7 months. Laparoscopic fundoplication is technically feasible and offers a sound surgical alternative to patients with refractory GERD, but longitudinal follow-up is required to confirm long-term results.

Adult↗
PubMed2000

Laparoscopic fundoplication for gastroesophageal reflux: effects on esophageal motility.

Laparoscopic Nissen-Rossetti fundoplication is now recognized as a valid therapy for the treatment of gastroesophageal reflux disease. This retrospective study evaluates the effects of laparoscopic fundoplication on esophageal motility and correlates these effects to postsurgical symptoms. A total of 123 patients underwent laparoscopic fundoplication at our institution. Pre- and postoperative esophageal manometric data were analyzed with regard to the effect of surgery and postsurgical outcome. Postoperative lower esophageal sphincter pressure was significantly increased compared wtih preoperative values (1.7 +/- 0.8 kPa vs 0.9 +/- 0.7 kPa). Duration and amplitude of esophageal body contractions were not modified. The percentage of deglutition-induced complete peristaltic waves and the velocity of propagation were significantly decreased after surgery (P < 0.05). Postoperative symptoms were significantly correlated with postoperative lower esophageal sphincter pressure only. Laparoscopic fundoplication significantly increases lower esophageal sphincter pressure. It significantly decreases esophageal body peristaltic efficiency, a decrease that is most likely of minor clinical significance.

Adolescent↗
PubMed2001

Quality of life 2 years after laparoscopic total fundoplication: a prospective study.

This study was a prospective evaluation of the quality of life of 50 patients after laparoscopic total fundoplication surgery for gastroesophageal reflux disease. The quality of life of 50 consecutive patients who underwent laparoscopic total fundoplication was evaluated using the Gastrointestinal Quality of Life Index questionnaire, which included 36 items in five different areas: symptoms, physical well-being, psychologic well-being, social relationships, and effects of medical treatment. Twenty-seven men and 23 women with a mean age of 52.6 +/- 16 years (range, 31-68 years) with gastroesophageal reflux disease were treated by laparoscopic total fundoplication (Nissen-Rosetti) and were included in the study. The follow-up was at least 2 years after surgery. The quality of life was evaluated before the surgery and 1 month, 3 months, 6 months, 1 year, and 2 years after surgery with follow-up in 100% of the cases. A control group of 50 healthy volunteers representing an identical population to that of the patients operated on (with respect to age, sex, body mass index, profession, and smoking) anonymously completed the same questionnaire. The preoperative and postoperative Gastrointestinal Quality of Life Index questionnaire scores of patients who had laparoscopic total fundoplication were compared with the Gastrointestinal Quality of Life Index questionnaire scores of the control group. Before surgery, the Gastrointestinal Quality of Life Index questionnaire score (86.7 +/- 8.5) was much inferior to that of the control group (123.8 +/- 13.6) (P < 0.001). This score significantly improved 3 months after surgery and was comparable (not significant) to that of the healthy control population 3 months, 6 months, 1 year, and 2 years after surgery (119.3 +/- 7.8). Improvements were reported mainly with respect to gastrointestinal symptoms and physical well-being. Social relationships were not modified. The quality of life of patients after laparoscopic surgery for gastroesophageal reflux disease improved and was close to the level expected in a healthy individual.

Adult↗
PubMed2002

Long-term gastrointestinal symptoms after laparoscopic nissen fundoplication.

Patients who have undergone fundoplication may be at risk for recurrent gastroesophageal reflux and may experience postoperative gastrointestinal symptoms. We investigated the long-term symptomatic outcome after laparoscopic Nissen fundoplication. Between 1993 and 1998 we treated 60 patients with laparoscopic fundoplication for gastroesophageal reflux disease. Signs of recurrence and gastrointestinal symptoms were assessed in 55 (92%) patients after a minimum follow-up of 1 year (median: 3.6 years). At follow-up, 52 patients (95%) were completely free of reflux symptoms. Mild gastrointestinal symptoms (flatulence, 60%; early satiety, 51%; meteorism, 42%; inability to vomit, 27%; dysphagia, 25%; diarrhea, 25%; epigastric pain, 24%; inability to belch, 22%) were found in a total of 51 patients (93%). Disturbing symptoms occurred in only 9 patients (16%). Laparoscopic Nissen fundoplication results in excellent control of gastroesophageal reflux disease at long-term follow-up. Despite a high rate of gastrointestinal symptoms, patient satisfaction showed the operation to be effective and well tolerated.

Adult↗
PubMed2006

Effect of laparoscopic Nissen fundoplication on symptoms and gastric myoelectric activity in gastroesophageal reflux disease.

BACKGROUND: Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD). The aim of this study was to determine whether laparoscopic fundoplication alters gastric myoelectric activity. Change of digestive symptoms was also assessed. METHODS: Sixteen patients with GERD (2 males, 14 females, mean age: 53 years) undergoing a laparoscopic fundoplication participated. Electrogastrography (EGG) was assessed before and after the subject ingested water until full (water load). Symptoms of upper abdominal discomfort, early satiety, postprandial abdominal distension, nausea, vomiting, and anorexia were recorded. At a 2-month postoperative follow-up, preoperative tests were repeated. RESULTS: The EGG was abnormal in 11 of 16 patients (69%) preoperatively and 6 of 16 patients (38%) postoperatively. The EGG changed from abnormal to normal in 5 of 16 patients (31%). The percentage of power at 3 cpm increased significantly during the fasting state postoperatively (29.9% vs. 21.2%, P < 0.05). There was a significant improvement in epigastric pain (P < 0.001), early satiety (P < 0.01), and postprandial fullness (P < 0.001). CONCLUSIONS: Increased presence of normal 3 cpm activity is the predominant effect of fundoplication on gastric myoelectric activity. Dyspeptic symptoms are also significantly improved postoperatively.

Adult↗
PubMed2004

Review article: approaches to the long-term management of adults with GERD-proton pump inhibitor therapy, laparoscopic fundoplication or endoscopic therapy?

The goals of gastro-oesophageal reflux disease (GERD) treatment are to control symptoms, heal the injured oesophageal mucosa, and prevent complications. Pharmacological therapy is effective in producing acute symptom relief and mucosal healing, as well as the long-term maintenance of remission. Proton pump inhibitors are the mainstay of GERD therapy. However, the need for daily administration, failure to provide complete symptom relief and costs of these agents may limit their use in some patients, prompting a consideration of alternative treatment strategies. Laparoscopic fundoplication may achieve symptom relief and healing of the oesophagitis in these individuals, but its invasiveness, cost and inherent surgical risks have created an interest in endoscopic therapies for GERD, with several emerging during the past few years. These interventions may either be viewed as an alternative therapy or as 'bridge' therapy, with patients still choosing to be treated with acid anti-secretory drugs or fundoplication if the endoscopic procedure fails to provide adequate symptom relief or if symptoms recur. Patient selection is critical for the success of fundoplication as well as endoscopic procedures, with ideal candidates being those with well-established endoscopically documented GERD, abnormal pH monitoring, normal oesophageal motility studies, and who have experienced at least partial symptom relief with proton pump inhibitor therapy. Hiatal hernia is not a contra-indication to fundoplication, while endoscopic intervention is best suited for those with a hiatal hernia of less than 3 cm in length. The long-term efficacy, cost-effectiveness, and impact of endoscopic procedures on extra-oesophageal manifestations of GERD and risk for GERD-related complications has not been determined.

Adult↗
PubMed1999

Motor and sensory function of the proximal stomach in reflux disease and after laparoscopic Nissen fundoplication.

OBJECTIVE: After Nissen fundoplication, dyspeptic symptoms such as fullness and early satiety develop in >30% of patients. These symptoms may result from alterations in proximal gastric motor and sensory function. METHODS: We have evaluated proximal gastric motor and sensory function using an electronic barostat in 12 patients after successful laparoscopic Nissen fundoplications (median follow-up; 12 months). Twelve age- and gender-matched patients with severe gastroesophageal reflux disease (GERD) and 12 healthy volunteers served as controls. Studies were performed in the fasting state and after meal ingestion. Gastric emptying tests were performed in all patients. Vagus nerve integrity was measured by the response of pancreatic polypeptide (PP) to insulin hypoglycemia. RESULTS: Minimal distending pressure and proximal gastric compliance were not significantly different between post-Nissen patients, GERD patients, and healthy controls. Postprandial relaxation of the stomach, however, was significantly (p < 0.05) reduced post-Nissen (267 +/- 34 ml), compared with controls (400 +/- 30 ml) and GERD (448 +/- 30 ml). Postprandial relaxation was significantly (p < 0.01) prolonged in GERD patients. Postprandial relaxation of the stomach correlated with gastric emptying of solids (r = 0.62; p = 0.01). Gastric emptying of solids became significantly (p < 0.05) faster after fundoplication. Postprandial fullness was significantly (p < 0.05) increased in the operated patients. CONCLUSIONS: Post-Nissen patients have a significantly reduced postprandial gastric relaxation and significantly accelerated gastric emptying, which may explain postoperative dyspeptic symptoms. The abnormalities result from fundoplication and not from vagus nerve injury or reflux per se, because in reflux patients gastric relaxation and gastric emptying are prolonged.

Adult↗
PubMed2007

Recurrent gastroesophageal reflux in neurologically impaired patients after fundoplication.

AIM: To evaluate the outcome and analyse the main causes of complications and failures of antireflux surgery for gastroesophageal reflux disease (GERD) in neurologically impaired patients (NIP). METHODS: From 1985 to 1999 44 NIP (mean age 12 years) underwent surgery for GERD. Type of surgery, complications and recurrent reflux were analysed. RESULTS: Twenty-seven patients (61%) showed preoperatively severe failure to thrive. All patients showed pathologic results in 24-h pH monitoring. Surgical treatment consisted of ventral (n = 25, Thal) or dorsal (n = 4, Toupet) semifundoplication or a Nissen fundoplication (n = 15). Postoperatively, all patients showed an impressive growth, regress of symptoms and improvement of results of diagnostic investigations. Late complications and recurrence of reflux were significantly related to preoperative extreme dystrophy (p < 0.0025). In six patients (15%) severity of symptoms related to recurrent reflux required a reoperation 17.8 month postoperatively (range 8-35 month). Recurrent reflux was found in 40% after ventral semifundoplication and in 46% after Nissen fundoplication (8 and 47 months postoperatively, respectively). CONCLUSION: Symptoms improved impressively after fundoplication in mentally retarded children. The incidence of recurrent reflux is not related to the type of surgery, however, it occurs significantly earlier with ventral semifundoplication when compared with Nissen fundoplication. Both late complications as well as recurrent reflux are related significantly to preoperative dystrophy.

Adolescent↗