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PubMed2001

Esophagogastric dissociation versus fundoplication: Which is best for severely neurologically impaired children?

PURPOSE: Neurologically impaired children (NIC) often have swallowing difficulties, severe gastroesophageal reflux, recurrent respiratory infections, and malnutrition. Bianchi proposed esophagogastric dissociation (EGD) as an alternative to fundoplication and gastrostomy. The authors compared these 2 approaches. METHODS: Twenty-nine consecutive symptomatic NIC refractory to medical therapy were enrolled in a prospective study and divided into 2 groups: A (n = 12), NIC who underwent fundoplication and gastrostomy; B (n = 14), NIC who underwent EGD. Three were excluded because of previous fundoplication. Anthropometric (percentage of the 50th percentile/age of healthy children) and biochemical parameters, respiratory infections per year, hospitalization (days per year), feeding time (minutes), and "quality of life" (parental psychological questionnaire, range 0 to 60), were analyzed (t test and Mann-Whitney test) preoperatively and 1 year postoperatively. Complications were recorded. RESULTS: Compared with group A, group B presented a statistically significant increase of all anthropometric and nearly all biochemical parameters with a statistical difference in terms of respiratory infections, hospital stay, feeding time, and psychological questionnaire. In group A, 2 bowel obstructions, 1 tight fundoplication, 1 dumping syndrome, and 3 failures of fundoplication occurred. Group B presented 1 anastomotic stricture, 1 paraesophageal hernia, and 1 bowel obstruction. CONCLUSIONS: Compared with fundoplication and gastrostomy, EGD offered better nutritional rehabilitation, reduction in respiratory infections, and improved quality of life. EGD can be rightfully chosen as a primary procedure.

Adolescent↗
PubMed2002

Dilation after fundoplication: timing, frequency, indications, and outcome.

BACKGROUND: Dysphagia frequently develops shortly after fundoplication but is usually self-limited. This is an evaluation of the timing, frequency, indications, and outcome of dilation after fundoplication. METHODS: Two hundred thirty-three consecutive patients who underwent fundoplication were included. Preoperative motility, postoperative symptoms, endoscopic and radiographic data, timing and number of dilations, and caliber of the dilator used were evaluated in patients who required dilation. RESULTS: Twenty-nine of 233 (12.4%) patients underwent dilation(s). The mean time to dilation after surgery was 72 days (range 3 to 330 days). Ten of 29 (34.5%) required more than 1 dilation (mean 1.5, range 1 to 5). The mean diameter to which the fundoplication was dilated was 18.6 mm (range 15-20 mm). There were no complications. The indication for dilation was dysphagia in 20, chest pain 4, epigastric pain 1, globus 1, gas bloat 1, belching 1, and vomiting in 1 patient. Two patients were lost to follow-up. Dysphagia resolved with dilation in 12 of 18 (67%) patients. Of the 6 patients whose symptoms did not improve after dilation, 3 noted improvement after further surgery. Two patients with tight fundoplications still require periodic dilation. One patient had a stricture before surgery that persisted after surgery. Symptoms did not improve in any patient who underwent dilation for an indication other than dysphagia. CONCLUSIONS: Dilation after fundoplication was required in 12.4% of patients and was successful in most with dysphagia. Dilation shortly after surgery was safe and only a single dilation was required for most patients. Symptoms other than dysphagia did not respond to dilation.

Deglutition Disorders↗
PubMed2000

Esophagogastric junction pressure topography after fundoplication.

OBJECTIVES: This study compared the pressure topography after laparoscopic Nissen fundoplication to that of normal subjects and patients with hiatal hernia and reflux disease. METHODS: Seven patients with fundoplication, 7 normal subjects and 7 patients with hiatal hernia, were studied. The squamocolumnar junction and intragastric margin of the esophagogastric junction (EGJ) were marked with metal clips. Axial and radial characteristics of EGJ pressure were mapped relative to the hernia and clipped during concurrent fluoroscopy and manometry. Responses to inspiration and abdominal compression were also analyzed. RESULTS: Fundoplication modifies the EGJ by restoration of the hiatal component of EGJ pressure and elongation of the subdiaphragmatic component. Maximal EGJ pressure after fundoplication is mainly dependent on the extrinsic effect of the hiatal canal that compresses the esophagus; the resultant length of the EGJ reflects the length of the fundic wrap. Integrity of the EGJ after fundoplication is independent of the intrinsic lower esophageal sphincter itself. CONCLUSIONS: Fundoplication alters the pressure topography of the EGJ by reducing the hiatal hernia, tightening the hiatal orifice, and constructing a subdiaphragmatic wrap of variable length. Each effect depends on different technical aspects of the surgery with the potential of substantial variability in the resultant pressure topography.

Adult↗
PubMed2002

Floppy Dor fundoplication after esophagocardiomyotomy for achalasia.

BACKGROUND: When esophagocardiomyotomy (ECM) is performed for achalasia, a complementary antireflux procedure of the surgeon's choice is usually performed to minimize postoperative gastroesophageal reflux. This retrospective analysis describes patients after laparoscopic ECM, most of whom had a modified Dor fundoplication. METHODS: Between 1994 and 2001, 81 patients with achalasia of the esophagus had laparoscopic ECM. We have previously described the use of intraoperative endoscopy to verify completion of ECM in a cohort of 48 patients who had either Toupet fundoplication (n = 25) or floppy Dor fundoplication (n = 23). Since then floppy Dor fundoplication has been the preferred antireflux procedure for ease of performance and safety reasons. This article describes the floppy Dor fundoplication as we have performed it since 1997, anchoring the wrap to both crura of the hiatus. In addition, the anterior gastric wall is sutured to the anterior rim of the esophageal hiatus, avoiding creation of the paraesophageal hernia that occurs if the gastric wall abuts the entire the length of a long ECM. RESULTS: During the 1- to 70-month follow up period (mean 45 months), patients who were symptomatic were evaluated by radiographic, manometric, or endoscopic methods; pH studies were not done systematically. The 70% of patients who could be evaluated had postoperative quality of life and symptom assessment interviews that revealed willingness to repeat the operation. Overall satisfaction was high (8.4/10 where 10 is perfect); moderate dysphagia was seen in 11 (16%) 3 to 16 months postoperatively, but patients reverted to a satisfaction score of 8.2 after endoscopic dilation. Occasional heartburn was present in 15 (26%) patients with regular, 5-use proton pump inhibitors (PPI), including 1 with Barrett's esophagus. Others use these medications for gastric disorders. No patient has had cancer of the esophagus develop, but endoscopic surveillance has been inconstant. CONCLUSIONS: Swallowing was improved in patients without sigmoid esophagus and overall satisfaction was high. New-onset heartburn is an unpredictable problem that can be treated in most patients. Endoscopic dilatation may be required at intervals after ECM-fundoplication for bridging fibrosis at the cardia, but has not required reoperation, as a rule. Laparoscopic ECM is an attractive operation for achalasia.

Adolescent↗
PubMed1999

Immune response after laparoscopic and conventional Nissen fundoplication.

OBJECTIVE: To compare the changes in the immune responses of patients undergoing laparoscopic or conventional Nissen fundoplication. DESIGN: Prospective randomised clinical study. SETTING: University hospital, Finland. SUBJECTS: 20 patients undergoing Nissen fundoplication for symptomatic erosive oesophagitis. INTERVENTION: Laparoscopic Nissen fundoplication (n = 10) or conventional open Nissen fundoplication (n = 10). MAIN OUTCOME MEASURES: Leucocyte and differential counts; percentages of lymphocyte subpopulations (CD3, CD4, CD8, CD16 and CD20 positive lymphocytes); and monocytes (CD 14); phytohemagglutinin, concanavalin A and pokeweed mitogen-induced and unstimulated proliferation of separated lymphocytes; plasma interleukin-6 (IL-6), serum C-reactive protein (CRP), albumin, and cortisol concentrations; and group II phospholipase A2 (PLA2) activity. RESULTS: Laparoscopic fundoplication was associated with less tissue damage (IL-6, and CRP concentrations) than the conventional open operation. However, although there were pronounced changes in immune responses over time, there were no differences between the groups. CONCLUSION: Laparoscopic fundoplication seemed to cause less tissue damage than the conventional open operation, but this difference was not reflected in patients' immune responses.

Esophagitis↗
PubMed1995

Laparoscopic versus conventional fundoplication.

The operative and short-term results of 29 patients who had an open fundoplication were compared to 36 patients who had a laparoscopic fundoplication. The operative time was 2.8 +/- 0.4 and 3.1 +/- 0.3 h for the open and laparoscopic procedure, respectively. The length of hospital stay was 9.2 +/- 0.7 days for the open and 1.8 +/- 0.2 days for the laparoscopic. There were five complications in the open group and one in the laparoscopic group. The follow-up period was 3-32 months and all patients had a barium swallow and esophago-gastroduodenoscopy (EGD) for postoperative evaluation. All patients had resolution of esophagitis on follow-up endoscopy, were free of reflux symptoms, and no longer required antireflux medication. Laparoscopic Nissen fundoplication has an operative time that is comparable to the open procedure. The complication rate for laparoscopic fundoplication is acceptable. Patients undergoing a laparoscopic fundoplication have a shorter hospital stay compared to patients with an open procedure. The short-term outcome for the laparoscopic fundoplication group was excellent.

Adult↗
PubMed1996

Laparoscopic fundoplication.

Most reports on laparoscopic fundoplication are from large, tertiary referral medical centers. Presented here is an experience by a single surgeon (M.E.F.) in community hospitals with 74 cases. All patients had esophagitis. All but two patients were Visick grade IV off medication. All patients had an incompetent lower esophageal sphicter. Four with abnormally low esophageal contractions underwent a Toupet procedure; the rest had a Nissen fundoplication. The largest estimated blood loss was 300 cc. One case (1.4%) had to be converted intraoperatively to an open procedure because of bleeding from an iatrogenic liver laceration. There were two minor complications (a urinary tract infection and a pneumothorax) and one death (massive liver necrosis with an otherwise unremarkable post mortem, thus it was felt to be due to anesthesia). The mean length of hospital stay was 2.8 +/- 0.21 days. Eighty-nine percent of the operations totally relieved reflux. Nineteen patients (26%) had mild, early postoperative dysphagia, gas bloat, and/or early satiety. Four patients did not get any improvement in their reflux, three still require chronic medication, and one underwent a redo open fundoplication. Three early patients had severe, new-onset postoperative dysphagia secondary to too tight a fundoplication. Attention must be focused on creating a loose wrap, a "floppy" Nissen by routine division of the short gastric vessels and the use of a large dilator in the esophagus when the fundoplication is constructed. Laparoscopic fundoplication is technically feasible, safe, and effective in a community hospital and does not require a large, tertiary referral medical center.

Adolescent↗
PubMed1997

Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients.

OBJECTIVE: The authors evaluate reoperation for recurrent gastroesophageal reflux (GER) after a failed Nissen fundoplication. SUMMARY BACKGROUND DATA: Nissen fundoplication is an accepted treatment for GER refractory to medical therapy. Wrap failure and recurrence of GER are noted in 8% to 12%. METHODS: Medical records of 130 children undergoing a second antireflux operation for recurrent GER from January 1985 to June 1996 retrospectively were reviewed. RESULTS: One hundred one patients (78%) were neurologically impaired (NI), 74 (57%) had chronic pulmonary disease, and 8 had esophageal atresia. Recurrent symptoms included vomiting (78%), growth failure (62%), choking-coughing-gagging (38%), and pneumonia (25%). Gastroesophageal reflux was confirmed by barium swallow, gastric scintigraphy, and endoscopy. Operative findings showed wrap breakdown (42%), wrap-hiatal hernia (30%), or both (21%). A second Nissen fundoplication was performed in 128 children. Complications included bowel obstruction (18), wound infection (10), pneumonia (6) and tight wrap (9). There were two postoperative (<30 days) deaths (1.5%). Of 124 patients observed long term, 89 (72%) remain symptom free. Eight were converted to tube feedings. Twenty-seven required a third fundoplication, and 19 (70%) were successful outcome. Two with repetitive wrap failure due to gastric atony underwent gastric resection and esophagojejunostomy. CONCLUSION: Nissen fundoplication was successful in 91% of patients. In 9% with wrap failure, a second Nissen fundoplication was successful in 72%. Reoperation is justified in properly selectedpatients. Conversion to jejunostomy feedings is suggested for neurologically impaired after two wrap failures and a partial wrap in those with esophageal atresia and severe esophageal dysmotility. Repeated wrap failure due to gastric atony requires gastric resection and esophagojejunostomy.

Adolescent↗
PubMed1998

Gastroesophageal reflux and Nissen fundoplication following percutaneous endoscopic gastrostomy in children.

BACKGROUND: Abnormal gastroesophageal reflux after percutaneous endoscopic gastrostomy is a serious problem in neurologically impaired children. Protective fundoplication has been advocated. Whether esophageal pH monitoring before percutaneous endoscopic gastrostomy will predict later problems with gastroesophageal reflux is unclear. METHODS: Eighty-five mostly neurologically impaired pediatric patients who underwent percutaneous endoscopic gastrostomy were studied retrospectively regarding complications, success of nutritional rehabilitation, and the incidence of pathologic gastroesophageal reflux. Follow-up period was 1 to 4 years. Twenty-four-hour esophageal pH monitoring was performed in 46 patients before percutaneous endoscopic gastrostomy. RESULTS: There were no deaths. Two major complications occurred that required surgical intervention, and 14 minor complications occurred related to the procedure. Z-scores for weight increased significantly after percutaneous endoscopic gastrostomy. pH probe results were normal in 22 patients (group 1). Five required medical treatment for gastroesophageal reflux after percutaneous endoscopic gastrostomy, but only 1 (5%) later required Nissen fundoplication. pH probe results were abnormal in 24 patients (group 2). Nineteen required medical therapy for gastroesophageal reflux, and 7 (29%) later needed fundoplication (p < 0.05, incidence of fundoplication group 1 vs. group 2). Improvement in Z-scores was similar in patients requiring and not requiring fundoplication. CONCLUSIONS: Percutaneous endoscopic gastrostomy is a safe and effective technique for long-term nutritional support in children. Abnormal gastroesophageal reflux is common. Normal findings in an esophageal pH study before percutaneous endoscopic gastrostomy may be predictive of a favorable outcome with respect to gastroesophageal reflux. This is in contrast to patients with abnormal results in pH studies before percutaneous endoscopic gastrostomy of whom a relatively large percentage may later require fundoplication. Improved nutritional status after percutaneous endoscopic gastrostomy does not appear to have an impact on the severity of gastroesophageal reflux.

Adolescent↗
PubMed1998

Laparoscopic fundoplication.

Symptomatic gastroesophageal reflux in children has been identified with increasing frequency over the last two decades. Agreement regarding the elements of a complete diagnostic work-up and the timing and specific surgical procedures for treating reflux has been difficult to achieve. Laparoscopic fundoplication is a routine procedure in some pediatric surgery centers. This surgical technique has the potential to reduce the pain and morbidity associated with open fundoplication. The outcomes after laparoscopic fundoplication have been equivalent to open fundoplication and are associated with faster recovery. Consensus regarding when to perform a partial fundoplication as compared to a complete fundoplication in addition to the appropriateness of gastric outlet procedures has not been achieved.

Child↗
PubMed2001

Intraoperative manometry to assess the esophagogastric junction during laparoscopic fundoplication and myotomy.

SUMMARY: Surgery for gastroesophageal reflux disease and achalasia is performed to alleviate symptoms by improving esophagogastric junction (EGJ) function. Intraoperative manometry was used to evaluate the pressure-length characteristics of the reconstructed EGJ during laparoscopic Nissen fundoplication and laparoscopic Heller myotomy. Intraoperative manometry was performed in 37 consecutive patients undergoing laparoscopic Nissen fundoplication (n = 22) or laparoscopic Heller myotomy (n = 15). Measurements were taken before surgery, after creation of the pneumoperitoneum, after completion of the myotomy in achalasia, and after creation of the fundoplication. Tracings were analyzed for pressure, length, and the integrated pressure-length relation (area under the curve [AUC]). Statistical comparison was made using paired t tests; intraoperative EGJ measurements did not correlate well with preoperative values for either pressure or length. Laparoscopic Nissen fundoplication significantly increased pressure, length, and AUC of the EGJ compared with prefundoplication values. Laparoscopic Heller myotomy significantly decreased EGJ pressure, length, and AUC. Creation of a Toupet fundoplication after myotomy did not significantly increase pressure, length, and AUC of the EGJ compared with postmyotomy values. Intraoperative manometry identified 2 of 15 achalasia patients (13%) with persistent areas of high pressure after initial myotomy that were corrected by extending the myotomy. Intraoperative manometry identifies mechanical changes created during EGJ surgery and may be a useful adjunct to improve outcomes of laparoscopic Nissen fundoplication and laparoscopic Heller myotomy.

Adult↗
PubMed2003

Effect of laparoscopic partial fundoplication on reflux mechanisms.

OBJECTIVES: Transient lower esophageal sphincter relaxations (TLESRs) are the main mechanism causing gastroesophageal reflux. Since 1994 we have performed laparoscopic partial instead of complete fundoplication as standard surgical treatment for therapy resistant reflux disease to minimize postoperative dysphagia. To better understand the management of gastroesophageal reflux, we conducted a prospective study of the effects of laparoscopic partial fundoplication on TLESRs and other reflux mechanisms. METHODS: From 1994 to 1999, 65 patients underwent laparoscopic partial fundoplication (180-200 degrees) and 28 of these patients (16 female, 12 male, mean age 43 +/- 2 yr [range, 26-66 yr]) agreed to participate in this prospective study on reflux mechanisms. Before and 6 months after surgery, all patients were evaluated by simultaneous recording of pH and lower esophageal sphincter characteristics, using sleeve manometry. RESULTS: After partial fundoplication basal LES pressure increased significantly (p < 0.05), from 14.3 +/- 1.2 mm Hg to 17.8 +/- 1 mm Hg. Partial fundoplication significantly (p < 0.05) decreased the number of TLESRs, from 3.4 +/- 0.8 to 1.6 +/- 0.3 per hour in the fasting period, and from 4.7 +/- 0.5 to 1.9 +/- 0.3 per hour postprandially. The percentage of TLESRs associated with reflux also decreased significantly (p < 0.05), from 45 +/- 7% to 27 +/- 6% after operation. The number of reflux episodes decreased significantly (p < 0.05), from 4.1 +/- 0.7 to 1.3 +/- 0.3 per hour postoperatively. The majority of these episodes were associated with TLESRs: 57% and 46%, pre- and postoperatively, respectively. CONCLUSIONS: Laparoscopic partial fundoplication significantly increased fasting and postprandial LES pressure and significantly decreased TLESR frequency. This resulted in a significant reduction in esophageal acid exposure, with preservation of postprandial LES characteristics.

Adult↗
PubMed2003

Reduced tLESR elicitation in response to gastric distension in fundoplication patients.

Transient lower esophageal sphincter relaxations (tLESRs) are vagally mediated in response to gastric cardiac distension. Nine volunteers, eight gastroesophageal reflux disease (GERD) patients, and eight fundoplication patients were studied. Manometry with an assembly that included a barostat bag was done for 1 h with and 1 h without barostat distension to 8 mmHg. Recordings were scored for tLESRs and barostat bag volume. Fundoplication patients had fewer tLESRs (0.4 +/- 0.3/h) than either normal subjects (2.4 +/- 0.5/h) or GERD patients (2.0 +/- 0.3/h). The tLESRs rate increased significantly in normal subjects (5.8 +/- 0.9/h) and GERD patients (5.4 +/- 0.8/h) during distension but not in the fundoplication group. All groups exhibited similar gastric accommodation (change in volume/change in pressure) in response to distension. Fundoplication patients exhibit a lower tLESR rate at rest and a marked attenuation of the response to gastric distension compared with either controls or GERD patients. Gastric accommodation was not impaired with fundoplication. This suggests that the receptive field for triggering tLESRs is contained within a wider field for elicitation of gastric receptive relaxation and that only the first is affected by fundoplication.

Adult↗
PubMed2003

[Manometric evaluation of distal esophagus of rabbits submitted to open and laparoscopic fundoplication].

BACKGROUND: Total fundoplication used in gastroesophageal reflux treatment, may be performed according to two techniques: laparotomy and laparoscopy. AIM: To study the lower esophageal sphincter in rabbits submitted to open and laparoscopic fundoplication. MATERIAL AND METHODS: Electromanometry studies of esophagus were carried out in 40 male rabbits, through the pull trough technique and infusion of the catheters with distilled water. The pressure width (mm Hg) and the length (cm) of the lower esophageal sphincter were measured in basal conditions (moment 1). The 40 animals were divided into four groups of 10 animals, according to the following surgical procedure: group 1: open total fundoplication; group 2: median laparotomy and dissection of gastroesophageal junction; group 3: laparoscopy total fundoplication; group 4: pneumoperitonium and dissection of the gastroesophageal junction. In moment 2 (1 week after the surgery) the manometry of the esophagus was performed in every animals. RESULTS: In groups 1 (open fundoplication) and 3, an increase of pressure width and length of the lower esophageal sphincter was observed. In groups 2 and 4, the pressure width and length of the lower esophageal sphincter presented no significant alteration. CONCLUSIONS: The fundoplication affects the antireflux gastroesophagic barrier and it becomes more efficient, because the pressure and the length of the lower esophageal sphincter increased after the pos-operated step of the surgery. This effect was observed in the two studied techniques, the laparotomy and the laparoscopy.

Animals↗
PubMed2002

Intrathoracic migration of the wrap after laparoscopic Nissen fundoplication: radiologic evaluation.

OBJECTIVE: The purpose of our study was to evaluate the different types of postoperative herniation of the wrap into the thorax after laparoscopic Nissen fundoplication, to propose a clear radiologic definition, and to establish their respective frequencies. SUBJECTS AND METHODS: Two hundred twenty-six consecutive patients who underwent laparoscopic Nissen fundoplication were studied prospectively. All patients underwent an upper gastrointestinal series before surgery and on the first postoperative day. Radiologic follow-up performed yearly after surgery in 148 patients (65%) consisted of a double-contrast upper gastrointestinal series. Intrathoracic migration of the wrap was diagnosed on radiography when the intact fundoplication wrap herniated partially or entirely through the esophageal hiatus of the diaphragm. The kappa statistic was used to assess interobserver agreement. RESULTS: Of the 148 upper gastrointestinal series, 44 intrathoracic migrations (30%) were diagnosed. These examinations were reviewed and allowed us to differentiate two types of migrations. Type I (31 patients) consists of a paraesophageal hernia of a portion of the wrap through the esophageal hiatus with the esogastric junction remaining below the diaphragm. Type II (13 patients) is diagnosed when the entire fundoplication herniates through the hiatus with the gastroesophageal junction located at or above the level of the diaphragm. CONCLUSION: Intrathoracic migration is an important complication of laparoscopic Nissen fundoplication. Most migrations are small and asymptomatic. We propose a simple and reproducible radiologic definition of two different types of intrathoracic migration of the wrap observed after laparoscopic Nissen fundoplication.

Aged↗
PubMed2001

[Laparoscopic Toupet partial fundoplication as general surgical therapy of gastroesophageal reflux. 1-year results of a 5-year prospective long-term study].

INTRODUCTION: A variety of laparoscopic antireflux operations exist for patients with gastroesophageal reflux diseases (GERD). Most surgeons operate using the concept of "tailored approach", which depends on esophageal motility. We have abandoned this concept because of the relatively high incidence of wrap-related complications in patients treated with laparoscopic Nissen fundoplication compared with patients treated with partial fundoplication. It is our policy to perform laparoscopic Toupet partial fundoplication in all patients suffering from GERD, independent of their esophageal motility. METHODS: In a prospective trial we have assessed and evaluated our 1-year results of the first 100 consecutive patients treated with Toupet partial fundoplication. All patients underwent esophagogastroscopy and 24-h pH manometry before operation. One third of patients (n = 34) underwent control manometry 8 weeks postoperatively. The patients were followed up clinically 1, 2, 6 and 12 months postoperatively. RESULTS: In this study group we achieved a healing rate in GERD of 97%. In 3% of patients GERD recurred. The median clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to 0.25 +/- 0.5 points 1 year postoperatively (P < 0.0005). The median fractional time with pH < 4 decreased from 17.8% +/- 12.5% preoperatively to 0.9% +/- 1.2% 8 weeks postoperatively (P < 0.0005). Because of persistent dysphagia 5% of our patients required postoperative dilatation therapy. The rate of reoperation and mortality was 0%. The total morbidity rate was 18%. In 50% of patients with preoperatively recorded esophageal motility disorder, an improvement of esophageal motility was found postoperatively. CONCLUSIONS: Our 1-year results encourage us to continue to perform laparoscopic Toupet partial fundoplication as the primary repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet partial fundoplication has proven to be a safe and highly successful therapeutic option in these patients.

Adult↗
PubMed2002

[Modifications of gastric distensibility as a function of the type of fundoplication. Experimental model in rats].

UNLABELLED: Gastric fundoplication to create an antireflux valve reduces gastric volume. The most widely used technique is Nissen's fundoplication (NF), but an anterior (AF) and posterior (PF) partial fundoplication are also used. This study examines the changes caused by these three techniques on the volume and the compliance of the stomach in vitro. MATERIAL AND METHODS: We used 4 groups of 10 rats Wistar each, weighing approximately 250-300 grams. One group was not manipulated (Control) whereas the other groups had NF, AF or PF respectively. The fresh stomachs were removed and progressively filled with saline by means of an infusion pump and the intragastric pressure was continuously measured with a pressure monitor. The volume of saline infusion required necessary to achieve pressure increments of 1 unit from 0 to 30 mmHg were measured and the results were compared with ANOVA. RESULTS: The three modalities of fundoplication reduced significantly gastric compliance since rats from the control group required 21.7 +/- 3.3 mL to reach intragastric pressure of 30 mmHg whereas 9.5 +/- 2.4 mL, 11.75 +/- 1.8 mL and 13.4 +/- 2.2 mL were required for the groups NF, AF and PF respectively. According to these results, the type of fundoplication which reduced the least the compliance was the posterior one. CONCLUSIONS: The use of fundus of the stomach to create an antireflux valve always implies a significant reduction of gastric compliance, which can favour gastric emptying and thus dumping syndrome. Even though important, this reduction was slightly less relevant after posterior fundoplication in this model. This evidence must be taken into account when choosing an antireflux technique.

Animals↗
PubMed1995

Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication.

BACKGROUND: Although recent reports have documented the safety and efficacy of laparoscopic fundoplication, none have compared outcomes to that of open Nissen fundoplication. STUDY DESIGN: Eighty-one patients had either open (n = 47) or laparoscopic (n = 34) Nissen fundoplication. Relief of symptoms was measured by a standardized questionnaire and scored by a modified Visick-Index. Physiologic outcome was assessed by postoperative pH monitoring and manometry in a subset of both groups. RESULTS: Primary symptoms were heartburn in 55 percent of the patients, regurgitation in 9 percent, dysphagia in 11 percent, and atypical in 25 percent of patients. Twenty-seven (84 percent) of 32 patients in the laparoscopic group and 31 (84 percent) of 37 patients in the open group were cured or improved. Operative time was significantly longer in the laparoscopic group (218 compared to 168 minutes). The period of hospitalization was shorter for the laparoscopic group (4.7 compared to 9.2 days, p < 0.0001). Postoperative pressures in the lower esophageal sphincter (LES) were significantly higher in the laparoscopic group (20.9 compared to 12.1, p = 0.006). Augmentation of sphincter length was similar for both groups. More patients in the laparoscopic group failed to relax their LES completely after fundoplication (32 compared to 71 percent, p = 0.1). CONCLUSIONS: Symptomatic outcome after laparoscopic fundoplication is similar to that of open surgery. Physiologic studies reveal a greater augmentation of LES pressure and a low prevalence of sphincter relaxation after laparoscopic fundoplication.

Adolescent↗