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PubMed1997

A randomized, prospective comparison of the Nissen fundoplication versus the Toupet fundoplication for gastroesophageal reflux disease.

OBJECTIVE: A prospective, randomized trial was performed to determine which of two antireflux procedures, a complete wrap (Nissen) or a 200N wrap (Toupet), was more effective with fewer sequelae. SUMMARY BACKGROUND DATA: Laparoscopic procedures for gastroesophageal reflux disease appear to be as effective as those done by open laparotomy. The Nissen fundoplication is used most frequently, but postoperative bloating, inability to belch, and dysphagia occur. The partial wrap has been said to be as effective with less unfavorable postoperative symptoms. METHODS: Patients with reflux esophagitis were approached laparoscopically using a six-port technique. After division of the short gastric vessels and dissection of the terminal esophagus and fundus of the stomach to allow performance of either procedure, patients randomly were assigned one of the procedures by a card drawn in the operating room. RESULTS: Forty patients underwent operation, but 1 was excluded when an open procedure became necessary. Twenty-three patients received a complete wrap and 16 received a partial wrap. The average operating time was 155 minutes for the Nissen procedures and 162 minutes for the Toupet procedures. The postoperative stay averaged 2.7 days for the Nissen procedures and 2.5 days for the Toupet procedures. There were no deaths. Including the patient converted to an open procedure, three patients had operative complications. At follow-up, Visick scores after the complete wraps were I-13, II-8, III-2 and after the partial wrap were I-12 and II-3. Two patients indicated they would not have the operation again. CONCLUSIONS: A partial or a complete wrap after division of the short gastric vessel offers effective therapy for reflux esophagitis with > 90% patient satisfaction. The authors' study shows no clear advantage of one wrap (partial or complete) over the other.

Female↗
PubMed2002

Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis.

BACKGROUND: Partial fundoplication has traditionally been indicated for patients with gastroesophageal reflux disease (GERD) who have defective peristalsis (DP). Because partial fundoplication had been reported to be a less effective means of controlling acid reflux than total fundoplication, in 1997 we stopped performing partial fundoplication for patients with DP and switched to a floppy total fundoplication. This study analyzes the results of our new strategy and compares it to our former approach. METHODS: We performed a partial fundoplication in 39 patients with DP (distal amplitude >40% of swallows) between 1994 and 1997 and a total fundoplication in 57 patients between 1997 and 2000. Symptoms scores derived from a standard questionnaire with a scale of 0-4 manometry, and 24-h pH monitoring were completed preoperatively in 86 patients and postoperatively in 40 patients. RESULTS: Heartburn scores improved in both groups (preoperative, 2.8; postoperative, 0.65; p<0.05). Dysphagia was 1.1 preoperatively and 0.62 postoperatively (p=NS) in the partial fundoplication group and 1.2 preoperatively and 0.3 postoperatively (p<0.05) in the total fundoplication group. Furthermore, none of the patients in the total fundoplication group developed new dysphagia and none required dilatation. Distal esophageal acid exposure normalized in both groups after operative treatment (median DeMeester score:72.3 vs 11.3, p<0.05, For partial fundoplication; 57.1 vs 6.3, p<0.05, For total fundoplication). Distal esophageal amplitudes averaged 27.8 mmHg preoperatively and 35.6 mmHg (p = NS) in the partial fundoplication group, they averaged 28.2 mmHg preoperatively vs 49.0 mmHg postoperatively (p<0.005) in the total fundoplication group. Two patients with a previous partial fundoplication required a conversion to a total fundoplication. No postoperative dilation was required in either group. CONCLUSIONS: Our study shows that both a partial and a total fundoplication are effective in controlling the symptoms of GERD in patients with defective peristalsis. Dysphagia improves significantly after total fundoplication but not after partial fundoplication. Although both operations brought acid reflux to within normal limits, the effect was more pronounced with total fundoplication. Total, but not partial, fundoplication produced a significant increase in amplitude of esophageal peristalsis, which may explain the subjective improvement during deglutition. Therefore, fundoplication should be the treatment of choice in patients with GERD and defective peristalsis.

Follow-Up Studies↗
PubMed1998

Update: total versus partial laparoscopic fundoplication.

Since the introduction of Nissen fundoplicaton in 1956, there has been concern about the incidence of troublesome mechanical complications, which has necessitated several modifications reducing the overall incidence to around 15%. Increasing knowledge of the pathophysiology of Nissen fundoplication has revealed that these complications are associated with a supracompetent high pressure zone (HPZ) which relaxes incompletely on swallowing and is associated with abolition of gas reflux and physiological acid reflux. Partial fundoplication procedures, which augment various constituents of the valvuloplasty component of competence and utilise a lesser degree of fundoplication, are associated with a very low incidence of mechanical complications, but debate has ensued that reflux control may be suboptimal and less durable than after Nissen fundoplication. However, several good, objective comparative studies and three prospective randomised trials have confirmed that a well conducted partial fundoplication procedure is at least as effective and durable in reflux control as Nissen fundoplication, whilst being associated with a lower incidence of mechanical complications. The debate has intensified since the advent of laparoscopic fundoplication, as several reports have highlighted the increased incidence of mechanical complications following Nissen fundoplication when performed laparoscopically compared with the open approach, with a higher incidence of impaired HPZ relaxation, believed to be associated with altered geometry and other factors inherent in laparoscopic fundoplication. This has resulted in re-operation rates for complications of laparoscopic Nissen fundoplication of 1-7%, and in the laparoscopic era, mechanical complications have overtaken recurrent reflux as the principal reason for revisional fundoplication. Several non-randomised series have shown that laparoscopic partial fundoplication procedures are associated with a similarly low incidence of mechanical complications and a negligible re-operation rate as at open operation, with retention of physiologial HPZ relaxation. These factors have resulted in increasing deployment of partial fundoplication procedures, and increasing support for the 'tailored' approach to anti-reflux surgery. Several prospective randomised studies between laparoscopic partial and total fundoplication procedures are currently in progress, and early results favour partial fundoplication because of the considerably lower incidence of mechanical complications. The continuance of these studies, as well as those underway which compare different partial fundoplication procedures and include economic and quality-of-life assessment, should enable the rational choice of the most appropriate laparoscopic anti-reflux procedure to be placed on a firm scientific footing.

Fundoplication↗
PubMed2006

EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure.

BACKGROUND: In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication. METHODS: EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined. RESULTS: EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern. CONCLUSIONS: EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Animals↗
PubMed2003

Fundoplication improves disordered esophageal motility.

Patients with gastroesophageal reflux disease (GERD) and disordered esophageal motility are at risk for postoperative dysphagia, and are often treated with partial (270-degree) fundoplication as a strategy to minimize postoperative swallowing difficulties. Complete (360-degree) fundoplication, however, may provide more effective and durable reflux protection over time. Recently we reported that postfundoplication dysphagia is uncommon, regardless of preoperative manometric status and type of fundoplication. To determine whether esophageal function improves after fundoplication, we measured postoperative motility in patients in whom disordered esophageal motility had been documented before fundoplication. Forty-eight of 262 patients who underwent laparoscopic fundoplication between 1995 and 2000 satisfied preoperative manometric criteria for disordered esophageal motility (distal esophageal peristaltic amplitude < or =30 mm Hg and/or peristaltic frequency < or =80%). Of these, 19 had preoperative manometric assessment at our facility and consented to repeat study. Fifteen (79%) of these patients had a complete fundoplication and four (21%) had a partial fundoplication. Each patient underwent repeat four-channel esophageal manometry 29.5 +/- 18.4 months (mean +/- SD) after fundoplication. Distal esophageal peristaltic amplitude and peristaltic frequency were compared to preoperative data by paired t test. After fundoplication, mean peristaltic amplitude in the distal esophagus increased by 47% (56.8 +/- 30.9 mm Hg to 83.5 +/- 36.5 mm Hg; P < 0.001) and peristaltic frequency improved by 33% (66.4 +/- 28.7% to 87.6 +/- 16.3%; P < 0.01). Normal esophageal motor function was present in 14 patients (74%) after fundoplication, whereas in five patients the esophageal motor function remained abnormal (2 improved, 1 worsened, and 2 remained unchanged). Three patients with preoperative peristaltic frequencies of 0%, 10%, and 20% improved to 84%, 88%, and 50%, respectively, after fundoplication. In most GERD patients with esophageal dysmotility, fundoplication improves the amplitude and frequency of esophageal peristalsis, suggesting refluxate has an etiologic role in motor dysfunction. These data, along with prior data showing that postoperative dysphagia is not common, imply that surgeons should apply complete fundoplication liberally in patients with disordered preoperative esophageal motility.

Adult↗
PubMed2005

Fundoplication and the risk of esophageal cancer in gastroesophageal reflux disease: a Veterans Affairs cohort study.

BACKGROUND AND AIMS: It has been proposed that fundoplication can reduce the risk of esophageal cancer in patients with gastroesophageal reflux disease (GERD). In this cohort study, we assessed the effect of fundoplication on the incidence of esophageal cancer. METHODS: We identified all Veterans Affairs (VA) patients with GERD who had fundoplication between 1986 and 1990 and matched (1-2) to controls with GERD and no fundoplication and to controls with no GERD. We calculated incidence rates for esophageal cancer through October 2002 and examined the effect of fundoplication on the risk of esophageal cancer using Kaplan-Meier survival analysis and Cox proportional hazard analysis. We calculated and adjusted for the propensity score for receiving fundoplication. RESULTS: We identified 946 patients who had fundoplication, 1,892 patients who had GERD without fundoplication, and 5,676 patients with no GERD. The mean age was 55 yr and 97.5% were men in all three groups. During a follow-up of 11,156 patient-years (PY), there were eight cases of esophageal cancer (72/100,000) in the fundoplication group. During a follow-up of 20,115 PY, there were eight cases of esophageal cancer (40/100,000) in the GERD without fundoplication group. During a follow-up of 59,439 PY, no patients in the group with no GERD developed esophageal cancer. The Kaplan-Meier analysis showed no significant difference in cumulative esophageal cancer rates between the fundoplication group and the GERD no-fundoplication group. The adjusted hazard ratio of esophageal cancer with fundoplication was 1.88 (95% CI: 0.70-5.03). CONCLUSIONS: GERD is a risk factor for esophageal cancer, but there is insufficient evidence that fundoplication reduces that risk.

Adult↗
PubMed2007

Factors predicting failure of redo Nissen fundoplication in children.

Recurrence of gastro-oesophageal reflux (GOR) following redo Nissen fundoplication represents a significant clinical problem. The aim of this study was to identify factors predicting failure of redo Nissen fundoplication. The notes of children who underwent redo Nissen fundoplication for recurrent GOR in a single institution between June 1994 and May 2005 were reviewed. Data are reported as median (range), or as numbers of cases. Multiple logistic regression analysis, using type of first fundoplication, neurological status, presence of gastrostomy, age-weight, retching-gas bloat after first fundoplication, associated anomalies, oesophageal atresia and length of follow-up as factors, was used to generate a model to identify factors predicting recurrent vomiting (failure) after redo. Eighty-one children underwent redo Nissen fundoplication 15.9 months (0.2-176) after the initial Nissen fundoplication. In 29, the first Nissen was laparoscopic. Age at redo Nissen fundoplication was 3.3 years (0.3-15.9) and weight 12.8 kg (5-60). Thirty-four children (42%) presented with recurrent vomiting (failure). Overall, the model successfully predicted vomiting (failure) after redo fundoplication (P = 0.009). Open surgery at first fundoplication (P = 0.011) and neurological impairment (P = 0.046) were both significant predictors of redo failure in the model, whereas presence of gastrostomy (P = 0.035) and older-heavier age-weight (P = 0.028) were associated with significantly better results. Retching-gas bloat, associated anomalies and oesophageal atresia were not significant predictors of failure. Redo Nissen fundoplication has a high failure rate. Risk factors are open fundoplication at first operation and neurological impairment. Redo fundoplication after primary laparoscopic Nissen has a lower risk of failure.

Adolescent↗
PubMed2005

Nissen or partial posterior fundoplication: which antireflux procedure has a lower rate of side effects?

INTRODUCTION: In patients with gastroesophageal reflux disease (GERD) it is still controversial as to which type of antireflux procedure-the Nissen or the partial posterior fundoplication-offers the lower rate of side effects in the long term. PATIENTS AND METHODS: In this follow-up study the Nissen fundoplication was performed only in GERD patients with normal oesophageal peristalsis. The partial posterior fundoplication was preserved for patients with weak peristalsis. Only patients with effective postoperative control of GERD were included in the study. The study groups consisted of 77 patients who underwent the Nissen fundoplication and 132 patients who underwent partial posterior fundoplication. Clinical assessment of side effects was performed after a median of 52 months following surgery. Manometric assessment of the lower esophageal sphincter (LES) and of esophageal peristalsis was achieved 6 months after surgery. RESULTS: Side effects such as dysphagia, bloating, inability to belch and vomit, epigastric pain and early satiety were significantly more common after the Nissen fundoplication than after partial posterior fundoplication. Improvement of the antireflux barrier was equal in both groups; however, LES relaxation was incomplete following the Nissen fundoplication but normal after partial posterior fundoplication. Partial posterior fundoplication resulted in improved oesophageal peristalsis, whereas the Nissen fundoplication caused slight impairment of peristalsis. CONCLUSIONS: Partial posterior fundoplication is a more physiological antireflux procedure than the Nissen fundoplication, and, therefore, this operation has now become our preferred technique for all GERD patients.

Deglutition Disorders↗
PubMed2005

Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication.

BACKGROUND: Total fundoplication for gastro-oesophageal reflux disease may be followed by unwanted side-effects. A randomized trial demonstrated that an anterior 180 degrees partial fundoplication achieved effective reflux control and was associated with fewer side-effects in the short term than total fundoplication. This paper reports longer-term (5 year) outcomes from that trial. METHODS: Between December 1995 and June 1997, 107 patients were randomized to undergo either laparoscopic total fundoplication or a laparoscopic anterior 180 degrees fundoplication. After 5 years, 101 of 103 eligible patients (51 total, 50 anterior) were available for follow-up. Each patient was interviewed by a single blinded investigator and a standardized questionnaire was completed. The questionnaire focused on symptoms and overall satisfaction with the results of fundoplication. RESULTS: There were no significant differences between the two groups with regard to control of heartburn or patient satisfaction with the overall outcome. Dysphagia, measured by a visual analogue score for solid food and a composite dysphagia score, was worse at 5 years after total fundoplication. Symptoms of bloating, inability to belch and flatulence were also more common after total fundoplication. Reoperation was required for dysphagia in three patients after total fundoplication and for recurrent reflux in three patients after anterior fundoplication. CONCLUSION: Anterior 180 degrees partial fundoplication was as effective as total fundoplication for managing the symptoms of gastro-oesophageal reflux in the longer term. It was associated with a lower incidence of side-effects, although this was offset by a slightly higher risk of recurrent reflux symptoms.

Deglutition Disorders↗
PubMed2006

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial.

BACKGROUND: The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication. METHODS: Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. RESULTS: One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. CONCLUSIONS: Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.

Australia↗
PubMed2006

Single center prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees fundoplication.

Although Nissen fundoplication is a very effective treatment for gastroesophageal reflux, it is associated with a small incidence of troublesome postoperative side effects. To prevent this, progressive modification of surgical techniques has led to the development of an anterior 90 degrees fundoplication. We undertook a prospective randomized trial to compare this procedure with Nissen fundoplication to determine whether it would achieve a better clinical outcome. Patients presenting to a single center for primary laparoscopic antireflux surgery were randomized to undergo either an anterior 90 degrees fundoplication (n = 40) or a Nissen fundoplication without division of the short gastric vessels (n = 39). Clinical questionnaires were used to assess outcome at 1 month, 3-6 months, and 12 months. Both patients and the clinical interviewer were masked as to which procedure was performed. Follow-up with endoscopy, esophageal manometry, and pH monitoring was also undertaken. Operating time was similar for the two procedures (60 minutes for anterior vs. 55 minutes for Nissen fundoplication). Early postoperative complications were more common after Nissen fundoplication (18% vs. 5%). Two patients underwent laparoscopic reoperation for recurrent reflux after anterior 90 degrees fundoplication, and four underwent laparoscopic reoperation after Nissen fundoplication (dysphagia, 3 patients; acute hiatus hernia, 1 patient). One year after surgery, dysphagia and other wind-related side effects were less common after anterior 90 degrees fundoplication. Control of reflux symptoms and satisfaction with the overall outcome was similar for the two procedures. Anterior 90 degrees fundoplication is followed by fewer side effects than Nissen fundoplication. This advantage is offset by a greater likelihood of reflux recurrence. However, this does not diminish patient satisfaction.

Adult↗
PubMed1997

Efficacy of partial wrap fundoplication for gastroesophageal reflux after repair of esophageal atresia.

Gastroesophageal reflux (GER) often develops in children who have undergone prior repair of esophageal atresia/tracheoesophageal fistula (EA/TEF). Fundoplication is necessary in many of these children. The complete wrap (Nissen) fundoplication is often used in this setting. However, poor results have been noted, with a mean failure rate of 30% reported in four recent studies. A partial wrap fundoplication for GER associated with EA/TEF is theoretically attractive, because the poor esophageal motility and diminished acid clearance (already physiologically present) is exacerbated by a complete wrap fundoplication. The authors reviewed their extensive experience with partial wrap (Thal) fundoplication in EA/TEF to determine if the failure rate was better than that reported for the Nissen fundoplication. In the past 18 years, the authors performed 1,467 fundoplication procedures. During the same period, 143 children underwent repair of EA/TEF. Fifty-nine children underwent fundoplication after a previous EA/TEF repair. Most of the fundoplications (58 of 59, 98%) were Thal procedures. Defining failure strictly as a need for reoperation, the failure rate in our series was 15% (9 of 59 children). Compared with the failure rate in the 1,408 non-EA/TEF patients (61 of 1408, 4.3%), results were significantly worse for the EA/TEF group (P > .001). The failure rate of Thal fundoplication performed for GER in the EA/TEF population is substantially higher than the non-EA/TEF patients. The same factors responsible for the development of reflux in these children (poor acid clearance, altered motility, esophageal shortening) may contribute to the higher failure rate. Although partial wrap fundoplication frequently failed (15%), the results were still substantially better than those reported for Nissen fundoplication in these children (30% failure rate).

Adolescent↗
PubMedDate not supplied

Comparison of laparoscopic total and partial fundoplication for gastroesophageal reflux.

Approximately 25% of patients with gastroesophageal reflux severe enough to be considered for surgical treatment have dysfunction of esophageal peristalsis in addition to dysfunction of the lower esophageal sphincter. A standard total (i.e., Nissen) fundoplication in these patients may be followed by dysphagia, so many experts recommend a partial fundoplication as an alternative. The goal of this study was to compare the clinical results and changes in esophageal function following laparoscopic total and partial fundoplication. Ninety-three patients with gastroesophageal reflux disease had laparoscopic antireflux operations. Total fundoplication was performed in 50 patients with normal esophageal peristalsis. Partial fundoplication was chosen for 43 patients with severe abnormalities of esophageal peristalsis. The same percentage of patients has resolution of heartburn (93%) and regurgitation (97%) after partial as compared to total fundoplication. Dysphagia developed in four patients (8%) after total fundoplication (one patient required dilatation) and in no patients after partial fundoplication. Both operations produced similar changes in lower esophageal sphincter function, but only partial fundoplication was associated with improvement in esophageal dysfunction. Esophageal acid exposure became normal in 92% of patients after total and in 91% of patients after partial fundoplication. Partial fundoplication improves lower esophageal sphincter pressure and esophageal body function and, in patients with abnormal esophageal peristalsis, it corrects reflux without producing dysphagia. Partial and total fundoplication are both indicated in patients with gastroesophageal reflux disease, and the choice of which procedure to use should be based on each patient"s specific esophageal motor function abnormalities.

Deglutition Disorders↗
PubMed2000

The effect of fundoplication on the motility of the canine lower oesophageal sphincter.

BACKGROUND: A canine model was used to define whether Nissen fundoplication inhibits gastro-oesophageal reflux by inhibiting transient lower oesophageal sphincter relaxations (TLOSR) or by creating a pressure barrier at the gastro-oesophageal junction. METHODS: Four surgical models were studied pre-operatively and postoperatively. These were: (i) the surgical mobilization required for fundoplication (sham fundoplication, n = 5); (ii) a standard fundoplication (n = 4); (iii) anterior and posterior myotomy of the lower oesophageal sphincter (LOS; cardiomyotomy, n = 4); and (iv) combined cardiomyotomy and fundoplication (n = 4). Each operative procedure was assessed for its effect on the incidence of TLOSR and gas reflux events, the mean LOS pressure and the LOS pressure profile during swallow events. RESULTS: Sham fundoplication reduced the rate of evoked TLOSR in response to gaseous gastric insufflation from 9.8+/-1.6/h (mean +/- SEM) to 5.4 +/-1.5/h. The mean LOS pressure was reduced from 25.1+/-2.6 to 18.5+/-2.1 mm Hg but nadir LOS pressure during swallowing was not altered. Nissen fundoplication virtually abolished evoked TLOSR from 10.4+/-1.2/h to 0.4+/-0.4/h, increased mean basal LOS pressure from 19.8+/-2.1 to 27.0+/-1.1 mm Hg and increased the nadir pressure on swallowing from 3.4+/-1.0 mm Hg to 14.4+/-1.0 mm Hg. Cardiomyotomy was associated with a near continuous leakage of gas across a chronically hypotensive LOS. Cardiomyotomy reduced the resting LOS pressure from 14.7+/-1.2 mm Hg to 2.3+/-1.0 mm Hg. Cardiomyotomy with fundoplication was associated with no loss of LOS competence. No gas venting episodes occurred either by passive leakage or by TLOSR. Cardiomyotomy with fundoplication was associated with a fall in mean LOS pressure from 14.3+/-1.5 mm Hg to 7.1+/-1.8 mm Hg but no LOS relaxation occurred during swallowing. CONCLUSION: Nissen fundoplication is highly effective in preventing reflux across a normal or chronically hypotensive LOS. Fundoplication results in a constant, measurable pressure barrier at the lower end of the oesophagus that is not due to a change in intrinsic LOS tone. Following fundoplication TLOSR are prevented by the constant low-pressure barrier.

Animals↗
PubMed2006

Long-term evaluation of patient satisfaction and reflux symptoms after laparoscopic fundoplication with Collis gastroplasty.

BACKGROUND: Esophageal shortening is a complication of advanced gastroesophageal reflux disease (GERD). For patients with short esophagus, Collis gastroplasty combined with fundoplication provides excellent symptomatic relief from GERD disease. The literature lacks studies comparing satisfaction and reflux symptoms between patients who underwent Nissen fundoplication with Collis gastroplasty and those who had primary fundoplication alone. This study aimed to assess long-term satisfaction and GERD-related quality of life after laparoscopic Collis-Nissen fundoplication, and to compare them with those for Nissen fundoplication alone. METHODS: A nested case-control study was conducted. In this study, 14 cases of laparoscopic Collis-Nissen fundoplications were matched for age, gender, and length of the follow-up period to a cohort of 120 control subjects who underwent laparoscopic Nissen fundoplication. All the patients were mailed a follow-up survey which included a Short Form-12 (SF-12) health status (quality-of-life) questionnaire (a validated quality-of-life instrument), a Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire (a GERD-specific quality-of-life instrument), and queries regarding long-term satisfaction and medication use. RESULTS: Both groups showed a significant postoperative increase in QOLRAD mean scores (p = 0.01). However, the difference in the delta (postoperative-preoperative) score between the two groups was not significant (Fig. 1). There were no differences in mental (MCS) or physical (PCS) SF-12 scores between the two groups. The rate of satisfaction with the surgery was similar in the Nissen-Collis fundoplication (87.5%) and Nissen fundoplication (87%) groups. CONCLUSIONS: Collis gastroplasty combined with Nissen fundoplication is an effective procedure for patients with a shortened esophagus diagnosed intraoperatively during antireflux surgery. Patient satisfaction, postoperative quality of life, and QOLRAD score improvement after this procedure are comparable with those observed in patients treated with Nissen fundoplication alone.

Adult↗