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PubMed2000

Chronic dysphagia following laparoscopic fundoplication.

BACKGROUND: Many surgeons practise tailored laparoscopic antireflux surgery in an attempt to prevent postoperative dysphagia. The aim of this study was to determine the effect of 360 degrees fundoplication (Nissen) or 270 degrees fundoplication (Toupet), and the influence of abnormal oesophageal peristalsis, upon postoperative dysphagia. METHODS: This was a cohort study from three tertiary referral centres, using dysphagia before laparoscopic fundoplication and 1 year after operation as the main outcome variable. Preoperative oesophageal manometry was performed on all patients. RESULTS: Some 761 patients underwent Nissen and 85 underwent Toupet fundoplication. Only 2 per cent reported severe postoperative dysphagia. There was a significant selection bias towards the Toupet operation for patients with abnormal oesophageal motility (P < 0.001). For patients whose oesophageal manometric findings were normal there was a significant improvement in dysphagia after Nissen fundoplication (P = 0.02), and no significant change following Toupet fundoplication. There was no significant change in the rate of dysphagia following either method of fundoplication amongst other subgroups in which oesophageal manometry was stratified as non-specific motor disorder, low-amplitude peristalsis, or aperistalsis. CONCLUSION: A tailored approach to the degree of fundoplication is unnecessary as patients with dysmotility suffer no more dysphagia after full laparoscopic Nissen fundoplication than those who have a partial Toupet wrap.

Chronic Disease↗
PubMed2005

Fundoplication in paediatric surgery: a survey in 40 German institutions.

BACKGROUND: There is no generally accepted standard surgical approach to gastrooesophageal reflux disease (GERD) at present. However, laparoscopic fundoplication has been advocated to be the procedure of choice for gastrooesophageal reflux disease in children. We aimed to assess the standards of the diagnostic workup and operative techniques in paediatric surgical institutions in Germany. MATERIAL AND METHODS: A questionnaire including 14 items was sent to all 71 departments of paediatric surgery in Germany. Forty (56 %) took part in the survey. Concepts of routine diagnostic workup, operative techniques, number of procedures, and conversions were assessed. RESULTS: The average annual frequency of fundoplications was less than 20 in 36 units (90 %). Experience with laparoscopic fundoplication was present in 24 institutions (60 %). In 19 out of these (79 %) fewer than 50 laparoscopic fundoplications had been performed altogether up to the time of the survey. Out of 584 fundoplications performed in the year 2002, 184 (32 %) had been done laparoscopically. The ratio of conventional versus laparoscopic fundoplication was 170/130 (57/43 %) in academic, and 226/54 (81/19 %) in non-academic departments. The preferred technique of fundoplication, irrespective of the approach, was the Nissen wrap in 28 (70 %) of the departments. The number of paediatric surgeons performing laparoscopic fundoplication was 1 - 2 in 16 institutions (67 %), 3 or 4 in 6 (25 %), and 5 in 2 (8 %) departments. The conversion rate was reported to be less than 5 % in 15 departments (63 %), and 5 - 10 % in 3 (13 %). CONCLUSION: The laparoscopic approach for surgical repair of GERD in children is not yet generally accepted in Germany. In most departments, training remains problematic due to low numbers of procedures. However, the feasibility of laparoscopic fundoplication in Germany is excellent, with a low rate of conversions.

Child↗
PubMed2003

Improved lung allograft function after fundoplication in patients with gastroesophageal reflux disease undergoing lung transplantation.

OBJECTIVES: Bronchiolitis obliterans is the greatest limitation to the long-term applicability of lung transplantation. Although alloimmune events are important, nonimmune events, such as gastroesophageal reflux, might contribute to lung injury and the development of bronchiolitis obliterans syndrome. METHODS: We retrospectively studied the 396 patients who underwent lung transplantation at the Duke Lung Transplant Program from April 1992 to April 2002. Reflux was assessed for using an ambulatory 24-hour esophageal pH probe. RESULTS: Reflux assessment with an esophageal pH probe was obtained in 128 patients after lung transplantation. Abnormal pH study results were present in 93 (73%) patients. Forty-three patients underwent a surgical fundoplication. There was no in-hospital or 30-day mortality in the patients undergoing fundoplication. At the time of fundoplication, 26 patients met the criteria for bronchiolitis obliterans syndrome. After fundoplication, 16 patients had improved bronchiolitis obliterans syndrome scores, with 13 of these patients no longer meeting the criteria for bronchiolitis obliterans syndrome. In patients at least 6 months after lung transplantation and 6 months after fundoplication, the forced expiratory volume in 1 second improved by an average of 24% (mean forced expiratory volume in 1 second before fundoplication, 1.87 L; mean forced expiratory volume in 1 second after fundoplication, 2.19 L/sec; P <.0002). Overall actuarial survival was significantly better in patients who had either normal pH studies or who had fundoplication. CONCLUSIONS: Gastroesophageal reflux disease is very common after lung transplantation and appears to contribute to mortality and development of bronchiolitis obliterans syndrome. Fundoplication in lung transplant recipients with gastroesophageal reflux disease is associated with significant improvements in lung function, particularly if performed before the late stages of bronchiolitis obliterans syndrome.

Actuarial Analysis↗
PubMed1998

Fundoplication wrap disruption: an experimental study in rats.

Antireflux surgery usually gives long lasting control of gastroesophageal reflux disease, but late failures can occur from fundoplication wrap disruption. Disruption presumably occurs when physiological mechanical stresses cause the sutures to pull out of the fundoplication wrap. We hypothesized that complete fundoplications (fundus sutured to fundus) would withstand disruptive forces better than partial fundoplications (fundus sutured to esophagus). Forty-eight rats underwent fundoplication (24 partial and 24 complete). Fundoplication wraps were disrupted by distending the stomach (bursting pressure technique) and by distracting the wrap in a tensiometer (breaking strength technique). Bursting pressures were similar in the partial (103.7 +/- 13.5 mmHg) and complete (100.5 +/- 13.1 mmHg) fundoplication wraps (P = 0.93, not significant). In both groups, all disruptions occurred by sutures tearing through the stomach wall. Breaking strength was also equivalent for the two types of wrap. Partial wraps disrupted at 6.69 +/- 1.49 N and complete wraps disrupted at 6.52 +/- 1.28 N (P = 0.77, not significant). Sutures tore out of the stomach side of the partial wrap in five rats and out of the esophagus in the other seven rats with partial wraps. Disruption occurred by sutures tearing through the stomach in all rats with complete fundoplications. This experimental study in the rat did not show any difference in the ability of partial and complete fundoplication wraps to withstand disruptive forces.

Animals↗
PubMed2005

When fundoplication fails: redo?

OBJECTIVE: The largest series in the literature dealing with redo fundoplication was presented and published in 1999 and included 100 patients. Herein we update this initial series of 100, with 207 additional patients who have undergone redo fundoplication (n = 307). SUMMARY BACKGROUND DATA: Increasing numbers of patients are failing esophagogastric fundoplication and requiring redo procedures. Data regarding the nature of these failures have been scant. METHODS: Data on all patients undergoing foregut surgery are collected prospectively. Between 1991 and 2004, 307 patients underwent redo fundoplication for the management of anatomic complications or recurrent GERD. Statistical analysis was performed with multiple chi2 and Mann-Whitney U analyses, as well as ANOVA. RESULTS: Between 1991 and 2004, 1892 patients underwent primary fundoplication for GERD (1734) or paraesophageal hernia (158). Of these, 54 required redo fundoplication (2.8%). The majority of failures (73%) were managed within 2 years of the initial operation (P = 0.0001). The mechanism of failure was transdiaphragmatic wrap herniation in 33 of 54 (61%). In the 231 patients who underwent fundoplication elsewhere, 109 had transdiaphragmatic herniation (47%, P = NS). In this group of 285 patients, 22 (8%) required another redo (P = NS). The majority of the procedures were initiated laparoscopically (240/307, 78%), with 20 converted (8%). Overall mortality was 0.3%. CONCLUSIONS: Failure of fundoplication is unusual in experienced hands. Most are managed within 2 years of the initial operation. Wrap herniation has now become the most common mechanism of failure requiring redo. Redo fundoplication was successful in 93% of patients, and most could be safely handled laparoscopically.

Fundoplication↗
PubMedDate not supplied

[Intraoperative endoscopy in laparoscopic fundoplications].

BACKGROUND: Laparoscopic fundoplications are the standard surgical treatment of patients with gastroesophageal reflux disorder. Adequate technique is the most important outcome factor. There is no standardized method to evaluate the procedure itself. Intraoperative endoscopy is a method to evaluate laparoscopic fundoplications. MATERIAL AND METHODS: This was a retrospective observational study of patients undergoing laparoscopic fundoplications from July 1999 to June 2004, excluding open procedures and reoperations of previous failed laparoscopic fundoplications. Intraoperative endoscopy was performed during the dissection and suturing of the procedure to determine if correction of the technique is necessary. Number of changes were recorded and analyzed with Student's t-test. RESULTS: Three hundred patients were operated on, 23 were excluded (14 reoperations and nine conventional laparotomies). Of the 277 patients included, 178 were males and 99 females. Average age was 43.4 +/- 14 years (range: 12-85). There were 71 Toupet and 206 Nissen fundoplications. Intraoperative endoscopy determined correction of the technique in 77 patients with 1.69 +/- 0.96 changes; 68 rotated and/or angled fundoplications, one rotation with distended stomach, one redundant gastric fundus, and seven change in the type of fundoplication from Nissen to Toupet because of tightness (3.7 +/- 1.1 changes, p = 0.0001) to achieve adequate fundoplication. CONCLUSIONS: Intraoperative endoscopy confirms adequate technique and prevents inadequate laparoscopic fundoplications. Further studies will determine if routine use is justified to prevent postoperative complications and to improve outcome.

Adolescent↗
PubMed2006

Results after laparoscopic fundoplication: does age matter?

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward popu lation of older patients. One hundred eight patients more than 70 years of age (range, 70-90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18-59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores (P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved (P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores (P < 0.01) and lower reflux scores (P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.

Adolescent↗
PubMed1993

Efficacy of the Nissen fundoplication in the management of gastroesophageal reflux following esophageal atresia repair.

From January 1974 to December 1988, 80 patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) were treated at the C.S. Mott Children's Hospital with division of their TEF and esophagoesophagostomy. Thirty-four in this group developed gastroesophageal reflux (GER). After an unsuccessful trial of medical management, 21 underwent Nissen fundoplication, and an additional child with refractory GER died intraoperatively before completion of her fundoplication. Following fundoplication, only eight patients had an uncomplicated course with elimination of reflux and no postoperative dysphagia. Wrap disruption and recurrent reflux occurred in 7 of the 21 (33%), a markedly higher incidence than the 10% figure seen in 220 children without EA who have undergone fundoplication at this institution. Upward tension on the wrap due to the presence of a shortened esophagus probably predisposes to an increased frequency of fundoplication failure in the EA child. In addition, postoperative dysphagia requiring prolonged gastrostomy feedings complicated eight otherwise successful initial or redo-fundoplications. Prolonged dysphagia in this group is likely related to the inability of the dyskinetic esophagus, common in EA, to overcome the increased resistance caused by the Nissen fundoplication. Three deaths (14%) from complications related to antireflux surgery occurred in the series. Although 15 of the 21 children (71%) eventually had excellent long-term results following initial or redo-fundoplication with elimination of reflux and normalization of oral intake, morbidity and mortality were clearly significant. Due to the high incidence of postoperative dysphagia and recurrent reflux, the transabdominal Nissen fundoplication may not be appropriate in EA patients.

Child↗
PubMed1986

Postoperative small bowel obstruction in infants and children: a problem following Nissen fundoplication.

A serious consequence of antireflux surgery is postoperative small bowel obstruction in an infant who cannot speak and has been rendered unable to vomit. We reviewed the operative rate for small bowel obstruction following all antireflux operations (210 Nissen fundoplications, 16 Hill fundoplications, 12 modified Thal fundoplications, and 3 Boerema anterior gastropexies) performed on children at our institution between January 1977 and July 1984. Eighteen patients (17 Nissen fundoplications, one Hill fundoplication) were operated upon for small bowel obstruction within two years after the primary operation. The most consistent clinical findings in these children were abdominal distention and a decreased frequency of bowel movements. For operations performed between January 1982 and July 1984, reoperation for small bowel obstruction was needed in 6.1% (6/99) of children following Nissen fundoplication as compared to 0.9% (6/649), P less than 0.001) of children following other major laparotomies. A combination of our experience with that reported by others suggests an estimated incidence of postoperative adhesive small bowel obstruction of 5.5% (24/436) for Nissen fundoplication, 0.9% (3/347) for modified Thal fundoplication, and 0.8% (1/126) for Boerema anterior gastropexy. The performance of a Nissen fundoplication has led to a significant rate of reoperation for small bowel obstruction compared with other major laparotomies and antireflux operations performed in children.

Adolescent↗
PubMed1999

Transition from open to laparoscopic fundoplication: the learning curve.

BACKGROUND: Two of us (B.C.S. and C.W.D.) began performing laparoscopic fundoplication in 1992. We have always designated the resident as the operating surgeon. OBJECTIVE: To determine the time necessary for both experienced surgeons and residents to become proficient in laparoscopic fundoplication. DESIGN: The medical records of 241 consecutive patients undergoing laparoscopic fundoplication were reviewed. This period started with the implementation of the procedure in January 1992 and ended in March 1998. For 3 consecutive years, residents were given a questionnaire regarding their confidence in performing laparoscopic fundoplication. RESULTS: Laparoscopic fundoplication was attempted in 241 patients and completed in 203 patients (84%). Comparing the first 25 attempted laparoscopic fundoplications with the second 25, there were 14 conversions (56%) vs 4 conversions (16%) (P<.01). Average operative times decreased from 236 to 199 minutes (P<.05), and the intraoperative complication rates were 5 (20%) and 1 (4%), respectively. Subsequently, the conversion rate stabilized at 2%. The operative time continued to decline to an average of 99 minutes for the last 25 laparoscopies. Senior residents and recent graduates returning the questionnaire performed an average of 112 laparoscopic procedures, including 15.7 laparoscopic fundoplications. They felt comfortable with the procedure after performing an average of 10.6 operations. CONCLUSIONS: The learning curve is very steep for the first 25 laparoscopic fundoplications for experienced surgeons. However, improvements, as judged by decreases in operative time, conversion rate, and intraoperative complications, continue to occur after 100 cases. Under supervision, residents can become comfortable with this procedure after about 10 to 15 procedures.

Clinical Competence↗
PubMed2006

Medium- and long-term outcome of laparoscopic redo fundoplication.

BACKGROUND: For a small subset of patients, laparoscopic fundoplication fails, typically resulting in recurrent reflux or severe dysphagia. Although redo fundoplications can be performed laparoscopically, few studies have examined their long-term efficacy. METHODS: Using a prospectively maintained database, the authors identified and contacted 41 patients who had undergone redo laparoscopic fundoplications at the University of Washington between 1996 and 2001. The median follow-up period was 50 months (range, 20-95 months). Current symptoms were compared with those acquired and entered into the authors' database preoperatively. Patients also were asked to return for esophageal manometry and pH testing. RESULTS: All redo fundoplications were performed laparoscopically. There were no conversions. The most common indication for redo fundoplication was recurrent reflux. The most common anatomic abnormality was a herniated wrap. Heartburn improved in 61%, regurgitation in 69%, and dysphagia in 74% of the patients. Complete resolution of these symptoms was achieved, respectively, in 45%, 41% and 38% of these same patients. Overall, 68% of the patients rated the success of the procedure as either "excellent" or "good," and 78% said they were happy they chose to have it. For those who underwent reoperation for gastroesophageal reflux disease, distal esophageal acid exposure according to 24-h pH monitoring decreased after redo fundoplication from 15.7% +/- 18.1% to 3.4% +/- 3.6% (p = 0.041). CONCLUSION: Although not as successful as primary fundoplication, a majority of patients can expect durable improvement in their symptoms with a laparoscopic redo fundoplication.

Adult↗
PubMed2006

Effect of partial and total laparoscopic fundoplication on esophageal body motility.

BACKGROUND: Abnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis. METHODS: The pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14). RESULTS: The LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B. CONCLUSIONS: Laparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients.

Adult↗
PubMed2006

Incorporation of Nissen fundoplication in a rat model of duodenoesophageal reflux.

BACKGROUND: Few in vivo models of esophageal reflux and fundoplication suitable for the study of the pathogenesis of Barrett's esophagus and esophageal cancer exist. We describe a modification of a rat model of duodenoesophageal reflux that incorporates Nissen fundoplication and uses it to study the role of fundoplication in ameliorating esophageal reflux. METHODS: A previously described rat model of duodenoesophageal reflux was modified to include Nissen fundoplication. Reflux threshold (RT), defined as the gastric pressure required to cause gastroesophageal reflux during transgastric instillation of saline, was measured in 12 Sprague-Dawley rats at baseline, after cardiomyotomy with esophagogastroduodenal anastomosis (EGDA), after subsequent Nissen fundoplication, and, finally, after takedown of Nissen fundoplication (NF). RESULTS: Cardiomyotomy with EGDA induced no significant change in RT compared with baseline (mean RT +/- SD: 4.0 +/- 1.9 mmHg and 6.0 +/- 2.5 mmHg, respectively, p = 0.741). Nissen fundoplication led to a 14-fold increase in RT (56.4 +/- 18.2 mmHg) compared with cardiomyotomy. RT pressure reverted to baseline levels after NF takedown (4.7 +/- 2.9 mmHg, p < 0.001). Antegrade esophageal flow was demonstrated without an increase in distal esophageal pressure after NF. CONCLUSIONS: Nissen fundoplication creates a one-way antireflux mechanism that eliminates gastroesophageal reflux in this rat model. This modification of an in vivo model of duodenoesophageal reflux represents a unique opportunity to investigate the effect of NF on cardiomyotomy-induced reflux and distal esophageal exposure to duodenogastric refluxate, and could be useful in the study of the role of NF in preventing progression to BE and ECA.

Animals↗
PubMed2004

J. Maxwell Chamberlain Memorial Paper. Early fundoplication prevents chronic allograft dysfunction in patients with gastroesophageal reflux disease.

BACKGROUND: Chronic allograft dysfunction limits the long-term success of lung transplantation. Increasing evidence suggests nonimmune mediated injury such as due to reflux contributes to the development of bronchiolitis obliterans syndrome. We have previously demonstrated that fundoplication can reverse bronchiolitis obliterans syndrome in some lung transplant recipients with reflux. We hypothesized that treatment of reflux with early fundoplication would prevent bronchiolitis obliterans syndrome and improve survival. METHODS: A retrospective analysis of 457 patients who underwent lung transplantation from April 1992 through July 2003 was conducted. Patients were stratified into four groups: no history of reflux, history of reflux, history of reflux and early (< 90 days) fundoplication and history of reflux and late fundoplication. RESULTS: Incidence of postoperative reflux was 76% (127 of 167 patients) in pH confirmed subgroups. In 14 patients with early fundoplication, actuarial survival was 100% at 1 and 3 years when compared with those with reflux and no intervention (92% +/- 3.3, 76% +/- 5.8; p < 0.02). Further, those who underwent early fundoplication had improved freedom from bronchiolitis obliterans syndrome at 1 and 3 years (100%, 100%) when compared with no fundoplication in patients with reflux (96% +/- 2.5, 60% +/- 7.5; p < 0.01). CONCLUSIONS: Reflux is a frequent medical complication after lung transplantation. Although the number of patients undergoing early fundoplication is small, our results suggest early aggressive surgical treatment of reflux results in improved rates of bronchiolitis obliterans syndrome and survival. Further research into the mechanisms and treatment of nonalloimmune mediated lung allograft injury is needed to reduce rates of chronic lung failure.

Adult↗
PubMed2005

A physiologic clinical study of achalasia: should Dor fundoplication be added to Heller myotomy?

OBJECTIVE: Myotomy for achalasia disrupts the lower esophageal sphincter, improving emptying at the expense of reflux. We hypothesized that surgical palliation of achalasia requires balancing desirable improvement in esophageal emptying with undesirable production of gastroesophageal reflux. Therefore, we objectively studied the physiologic effects of adding Dor fundoplication to Heller myotomy. METHODS: From December 1996 to June 2004, 149 patients underwent Heller myotomy; 88 (59%) had additional Dor fundoplication. The adequacy of myotomy was assessed by premyotomy to postmyotomy change in lower esophageal sphincter pressures, esophageal emptying by change in timed barium esophagram, and gastroesophageal reflux by postoperative 24-hour pH monitoring. RESULTS: For adequacy of myotomy, postmyotomy resting lower esophageal sphincter pressure was higher with (median, 18 mm Hg) than without (median, 13 mm Hg) Dor fundoplication (P = .002), as was residual lower esophageal sphincter pressure (median, 4.6 vs 1.8 mm Hg; P = .01). For esophageal emptying, postmyotomy barium height and width were similar with or without Dor fundoplication (P > .1). For gastroesophageal reflux, percentage of upright time with a pH of less than 4 was lower with (median, 0.4%) than without (median, 2.9%) Dor fundoplication (P = .005), and percentage of supine time with a pH of less than 4 was lower with (median, 0%) than without (median, 5.8%) Dor fundoplication (P = .007). CONCLUSIONS: The addition of Dor fundoplication reduces the adequacy of myotomy without impairing emptying and reduces reflux. Heller myotomy and Dor fundoplication balance emptying and reflux and therefore should be the surgical treatment of choice for achalasia.

Digestive System Surgical Procedures↗
PubMed1999

Fundoplications resist reflux independent of in vivo anatomic relationships.

BACKGROUND: Antireflux operations restore lower esophageal sphincter (LES) function and hiatal anatomy; however, the relative contributions are unclear. METHODS: We measured the competency of fundoplications, exclusive of in vivo variables, in gastroesophageal explants from 8 cadavers. Using a multichannel manometer, esophageal, LES, and intragastric pressures were recorded during transpyloric distension. Data were compared at baseline, and after Nissen (360 degrees) and Toupet (270 degrees) fundoplications. RESULTS: Before fundoplication, stomachs refluxed immediately upon distension. Nissen fundoplications never refluxed before gastric rupture (46.8 +/- 15.0 mm Hg). LES pressure averaged 2.0 +/- 0.5 times intragastric pressure during distension. Toupet fundoplications refluxed at intragastric pressure <2 mm Hg, then became competent until gastric rupture (49.9 +/- 15.0 mm Hg). LES pressure averaged 2.4 +/- 1.0 times intragastric pressure during distension. CONCLUSIONS: Nissen and Toupet fundoplications increase LES pressure linearly at 2 to 2.5 times intragastric pressure, independent of in vivo variables. Toupet fundoplication lacks the competency of Nissen fundoplication at low intragastric pressures.

Aged↗
PubMed2002

"Floppy" Nissen vs. Toupet laparoscopic fundoplication: quality of life assessment in a 5-year follow-up (part 2).

BACKGROUND AND STUDY AIMS: Quality of life as an outcome variable has become an important measure in clinical research. This study is the second part of a prospective assessment of the quality of life outcome, in a 5-year follow-up of patients who underwent laparoscopic Nissen fundoplication or Toupet fundoplication. Data from a 1-year follow-up have been previously published (part I). PATIENTS AND METHODS: Using the Gastrointestinal Quality of Life Index (GIQLI), the quality of life data of 169 consecutive patients who had undergone a laparoscopic Nissen fundoplication (LNF; n = 104) or a laparoscopic Toupet fundoplication (LTF; n = 65), were evaluated 3 years and 5 years postoperatively. Six patients out of the initial study group (n = 175), including three from each group, were excluded from the main analysis because they had undergone laparoscopic re-fundoplication during the 1-year follow-up. Data from patients with repeat surgery have been analysed separately. In addition to administering the GIQLI, we evaluated patient satisfaction with surgery, possible surgical side effects or recurrent disease-related symptoms, the use of antireflux medication, and also surgical interventions in relation to initial antireflux surgery. In those patients, who were willing (n = 111) we also performed esophageal manometry and 24-hour pH monitoring 5 years postoperatively. RESULTS: At 3 years and 5 years postoperatively, the analysis of quality of life data showed that the GIQLI score remained stable in comparison with the 1-year follow-up data, with mean scores of 121 +/- 8.7 points in the LNF-group and 119.8 +/- 9 points in the LTF-group, at 5 years after surgery. Laparoscopic re-fundoplication was necessary in four patients due to a "slipping" Nissen (LNF group n = 1) or recurrent symptoms (LTF group, n = 3). In two patients in the LTF group herniation of a trocar incision was found. No patient suffered from severe surgical side effects. Patient satisfaction with surgery was rated as "excellent" or "good" in 97.9 % of patients. There were no significant differences between the groups concerning these data. The results of esophageal manometry and 24-hour pH monitoring also remained stable and showed normal values in all but two patients (in the LTF group), who suffered from mild and infrequent symptoms of recurrent heartburn without endoscopic signs of esophagitis. The outcome in patients who underwent laparoscopic re-fundoplication is comparable to the outcomes for those with a successful primary intervention. CONCLUSIONS: Both Nissen and Toupet laparoscopic fundoplication can significantly improve patients' quality of life during the 5 years following surgical intervention. Quality of life scores for both surgical groups were almost equal and postoperative outcomes were comparable to values in healthy controls. Patient satisfaction with surgical treatment was very high, even though repeat laparoscopic surgery was necessary in some cases. Patients who had a repeat procedure experienced nearly identical outcomes.

Female↗
PubMed1996

A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.

OBJECTIVE: The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. SUMMARY OF BACKGROUND DATA: Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. METHODS: Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. RESULTS: The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. CONCLUSIONS: Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.

Adult↗