Impact of complete gastric fundus mobilization on outcome after laparoscopic total fundoplication (original) (raw)
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The American Journal of Surgery, 2013
BACKGROUND: Late outcomes after laparoscopic Nissen fundoplication are only now becoming available. This study was undertaken to document late outcomes after laparoscopic Nissen fundoplication. METHODS: Five hundred ten patients underwent laparoscopic Nissen fundoplication .10 years ago and were prospectively followed. Preoperatively and postoperatively, patients scored the frequency and severity of symptoms (from 0 5 never/not bothersome to 10 5 always/very bothersome). Symptom scores before and after fundoplication were compared. Median symptom scores are presented. RESULTS: Early after fundoplication, significant improvements were noted in the frequency and severity of symptoms (e.g., for heartburn, from 8 to 0 and from 8 to 0, respectively, P , .001 for each). Late after fundoplication, significant improvements were maintained in the palliation of symptoms (e.g., frequency and severity for heartburn, 2, 1; respectively). At latest follow-up, 89% of patients were pleased with their symptom resolution. CONCLUSIONS: With long-term follow-up, laparoscopic Nissen fundoplication durably and significantly palliates symptoms of gastroesophageal reflux disease. This trial promotes the application of laparoscopic Nissen fundoplication.
Journal of Gastrointestinal Surgery, 2006
Laparoscopic fundoplication is the gold standard surgical treatment for gastroesophageal reflux disease, although some patients develop recurrence or collateral symptoms related to surgery. The aims of this study were to describe the long-term symptoms control in patients undergoing laparoscopic fundoplication, to analyze the patterns of failure and to correlate postoperative symptoms with anatomic and physiologic findings. Extensive preoperative and postoperative work-up including symptom questionnaire, barium meal, endoscopy, manometry, and 24-hour pH-metry were performed in 130 consecutive patients undergoing laparoscopic fundoplication. Mean follow-up was 52 months. After laparoscopic fundoplication, 117 patients (90%) were asymptomatic with Visick grade I and II symptoms reported by 124 patients (95%). On evaluation, 119 (92%) patients were satisfied and willing to repeat surgery. Two failure patterns, anatomic abnormalities (wrap migration into the chest or down onto the stomach with or without repair disruption) and functional (incompetence of antireflux mechanism), were reported in 17 patients. Reflux can be controlled in up to 90% of patients with gastroesophageal reflux disease with relatively few complications and a high degree of patient satisfaction. The most common cause of recurrent symptoms is an anatomic failure of the fundoplication. ( J GASTROINTEST SURG 2006;10:863-869) Ó
Surgical Endoscopy, 2003
Background: Recent reports have suggested that antireflux surgery should not be advised with the expectation of elimination of medical treatment. We reviewed our results with laparoscopic fundoplication as a means of eliminating the symptoms of gastroesophageal reflux disease (GERD), improving quality of life, and freeing patients from chronic medical treatment for GERD. Methods: A total of 297 patients who underwent laparoscopic fundoplication (Nissen, n = 252; Toupet, n = 45) were followed for an average of 31.4 months. Preoperative evaluation included endoscopy, barium esophagram, esophageal manometry, and 24-h pH analysis. A preoperative and postoperative visual analogue scoring scale (0-10 severity) was used to evaluate symptoms of heartburn, regurgitation, and dysphagia. A GERD score (2-32) as described by Jamieson was also utilized. The need for GERD medications before and after surgery was assessed. Results: At 2-year follow-up, the average symptom scores decreased significantly in comparison to the preoperative values: heartburn from 8.4 to 1.7, regurgitation from 7.2 to 0.7, and dysphagia from 3.7 to 1.0. The Jamieson GERD score also decreased from 25.7 preoperatively to 4.1 postoperatively. Only 10% of patients were on proton pump inhibitors (PPI) at 2 years after surgery for typical GERD symptoms. A similar percentage of patients (8.7%) were on PPI treatment for questionable reasons, such as Barrett's esophagus, ''sensitive'' stomach, and irritable bowel syndrome. Seventeen patients (5.7%) required repeat fundoplication for heartburn (n = 9), dysphagia (n = 5), and gas/ bloating (n = 3). Conclusions: Laparoscopic fundoplication can successfully eliminate GERD symptoms and improve quality of life. Significant reduction in the need for chronic GERD medical treatment 2 years after antireflux surgery can be anticipated.
JAMA Surgery, 2019
ImportanceRestoration of the esophagogastric junction competence is critical for effective long-term treatment of gastroesophageal reflux disease. Surgical repair results in such restoration, but mechanical adverse effects seem unavoidable. Minimizing these adverse effects without jeopardizing reflux control is warranted.ObjectiveTo determine whether partial fundoplication (PF) or total fundoplication (TF) is superior in laparoscopic antireflux surgery.Design, Setting, and ParticipantsIn this double-blind, randomized clinical trial of 1171 patients scheduled for laparoscopic antireflux surgery at a single university-affiliated center between November 19, 2001, and January 24, 2006, 456 patients were randomized and followed up for 5 years. Data were collected from November 2001 to April 2012, and data were analyzed from April 2012 to September 2018.InterventionsA 270° posterior PF or a 360° Nissen TF.Main Outcomes and MeasuresEsophageal acid exposure at 3 years after surgery.ResultOf the 456 randomized patients, 268 (58.8%) were male, and the mean (SD) age was 49.0 (11.7) years. A total of 229 patients were randomized to PF, and 227 patients were randomized to TF. At 3 years postoperatively, the median (interquartile range) esophageal acid exposure was reduced from 14.6% (9.8-21.9) to 1.8% (0.7-4.4) after PF and from 16.0% (10.4-22.7) to 2.5% (0.8-6.8) after TF (P = .31). Likewise, reflux symptoms were equally and effectively controlled. Early postoperative dysphagia (6 weeks) was common in both groups but then decreased toward normality. A small but statistically significant difference in favor of PF was noted in the mean (SD) scoring of dysphagia for liquids at 6 weeks (PF, 1.6 [0.9]; TF, 1.9 [1.3]; P = .01) and for solid food at 12 months (PF, 1.3 [1.0]; TF, 1.9 [1.4]; P < .001) and 24 months (PF, 1.3 [0.9]; TF, 1.7 [1.2]; P = .001). Quality of life was reduced before surgery but increased to normal values after surgery and remained so over 5-year follow-up, with no difference between the groups.Conclusions and RelevanceThe results from this randomized clinical trial suggest that although PF and TF could be recommended for treatment of gastroesophageal reflux disease, PF might be superior by inducing less dysphagia.Trial RegistrationClinicalTrials.gov identifier: {"type":"clinical-trial","attrs":{"text":"NCT03659487","term_id":"NCT03659487"}}NCT03659487
Hellenic Journal of Surgery, 2016
Gastro-esophageal reflux disease (GERD) is a very common medical disease. There is no consensus for optimal management of GERD. Proton pump inhibitors (PPI) are the most effective drug treatment for GERD. The number of antireflux procedures is on the rise, partly due to increased patient's expectations, and partly due to the advancements in minimal access surgery. There are few controversies surrounding role of laparoscopic fundoplication in the management of GERD, like whether surgery is superior to PPI; which modality is better, laparoscopic or open; whether complete wrap is better than partial, and whether division of short gastric vessels provides any advantage or not. This review article was undertaken to evaluate the role of laparoscopic fundoplication in the management of GERD and to find out answers to these controversial questions.
The Treatment of Gastroesophageal Reflux Disease With Laparoscopic Nissen Fundoplication
Annals of Surgery, 1998
Gastroesophageal reflux disease (GERD), typically presenting as heartburn, regurgitation, or dysphagia, may lead to esophagitis, Barrett's metaplasia, and esophageal adenocarcinoma. It occurs when the antireflux barrier between the stomach and esophagus is impaired. In tertiary-care centers, approximately 50% of patients with reflux symptoms have erosive esophagitis, whereas nonerosive disease is encountered in 50-70% of patients in community-based practices. Though almost never lifethreatening, GERD impairs the quality of life and work productivity. The goals of management in GERD are to relieve symptoms, heal esophagitis (if present), and prevent complications. In view of the costs, lifelong medical therapy and limitations of surgery, a variety of endoscopic techniques have been developed for the treatment of this condition. The principle of this approach is to provide an option for patients who are unsatisfied with protracted pharmacologic therapy yet wish to avoid antireflux (laparoscopic) surgery with results adversely affected by morbidity and mortality, which are unacceptable for what is essentially a benign condition. Moreover, a remarkable proportion of surgically treated patients still require daily antisecretory drugs, and a third of patients suffer from new symptoms after surgery, such as dysphagia, belching, diarrhea, and nausea. The best candidates for surgery are patients with effective relief of symptoms with medical treatment who experience frequent relapses, those with large hiatal hernia, those requiring high doses of proton pump inhibitors (PPIs), and patients unwilling to stay on continuous medical treatment.
Annals of Surgery, 2013
Objectives: To evaluate the long-term effect of laparoscopic total fundoplication (LTF) on symptoms and reflux control in patients with combined (acidic and weakly acidic) (CR) or weakly acidic reflux (WAR), according to the gastric emptying (GE) rate. Background: After LTF, 12% to 15% of patients experience persistent reflux symptoms and 20% and 25% develop gas-related symptoms. Both WAR and inability to belch have been suggestive of these symptoms. Methods: Consecutive patients with CR and WAR selected for LTF were included in a prospective clinical study. Gastroesophageal function was assessed by clinical validated questionnaires, upper endoscopy, esophageal manometry, and 24-hour impedance-pH monitoring before and 12 and 60 months after LTF. Gastric scintigraphy was preoperatively performed in all patients to evaluate GE. This trial is registered with ClinicalTrials.gov (no. NCT01741441). Results: Between June 2002 and June 2007, a total of 188 patients with CR and WAR underwent LTF; 172 (91.5%) completed the 5-year protocol. Among them, 42 (24.4%) had preoperative mild/moderate delayed GE (DGE). Quality of life at 12 and 60 months improved in patients with normal GE (Gastroesophageal Reflux Disease Health-Related Quality of Life score 18.2/2.5, P < 0.001; Health-Related Quality of Life score from 52.1 to 68.3, P < 0.001) but not in DGE patients. Manometric values of "gastroesophageal junction" significantly increased at 12 and 60 months in all patients with normal GE, whereas the values returned to the baseline at 60 months in 66.7% of DGE patients. Acidic and liquid reflux episodes significantly reduced in both groups, whereas a significant reduction of WAR and mixed (gas + liquid) reflux episodes occurred only in patients with normal GE (P < 0.001). Conclusions: DGE affects long-term results of LTF in CR and WAR patients. Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinal condition in Western countries, and it accounts for about 75% of esophageal disorders.1 Laparoscopic total fundoplication (LTF) is the standard surgical treatment of GERD, with low morbidity and excellent long-term functional outcome.2 Nevertheless, 12% to 15% of patients have persistent reflux symptoms and 20% to 25% develop gas-related symptoms after LTF.3 Reflux symptoms, gas bloating, and inability to belch after the surgery have been associated with combined (acidic and weakly acidic) (CR) or weakly acidic reflux (WAR). To date, few studies 4-8 have evaluated functional outcome after LTF in patients with CR or WAR; the majority reporting only short-term results. Delayed gastric emptying (DGE) has been described in 25% to 59% of patients with functional dyspepsia and in up to 40% of patients with GERD.9 The correlation between poor long-term outcome after LTF and DGE is controversial,10,11 and the effect of DGE in patients with CR or WAR is poorly investigated. The aim of this study was to prospectively evaluate the relationship between DGE and the long-term outcome of LTF in terms of reflux and symptom control in patients with CR or WAR.