Laparoscopic antireflux surgery and the thoracic surgeon: what now?

OBJECTIVE: Minimal invasive antireflux surgery is now a well accepted technique gaining a wide spread popularity. Simultaneously there is a growing tendency to fit all surgical candidates into one single type of operation, i.e. laparoscopic Nissen antireflux operation. This study evaluates the impact of this new technology on the strategy and practice of a major referral centre for antireflux surgery. METHODS: An analysis was made of indications for the different types of antireflux techniques performed between July, 1993 and 1995. If on Barium swallow the gastro-oesophageal (GO) junction proved to be reducible, a laparoscopic approach was proposed, if not, an open transthoracic access was preferred. RESULTS: One hundred and fifteen patients were operated. Fifty five patients underwent a minimal invasive approach: 49 Nissen (are the total fundoplication) and 3 Lind (are the partial fundoplication) operations through laparoscopy, 3 Belsey Mark IV through video assisted thoracic surgery (VATS). Sixty patients were treated by open surgery for following reasons: conversion to open surgery in 2 cases, redo surgery in 15 cases, previous other major abdominal surgery in 12, irreducible GO junction in 5, paraoesophageal or mixed type hernia in 12, Barrett and or oesophagitis IV in 4, combined antireflux surgery and feeding gastrostomy in 5, abdominal partial fundoplication by principle in 1, associated motility disorder in 1, combined reflux and gastric ulcer disease in 2, and severe emphysema in 1. In the laparoscopic series reflux control at 1 year post surgery as measured by 24 h pH study in 28 patients was obtained in 89.5%. One patient required a reoperation for symptomatic recurrence. CONCLUSIONS: (1) Laparoscopic antireflux surgery is a feasible and well accepted technique; (2) careful study of each individual patient is of paramount importance to choose the correct type of operation and access as well. Therefore, fitting every patient into a single type of operation, i.e. laparoscopic Nissen, should be avoided; (3) thoracic surgeons with a major interest in GO reflux disease should familiarize themselves with laparoscopic antireflux procedures.     

Results of laparoscopic Nissen fundoplication

BACKGROUND/AIMS: Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations. METHODOLOGY: Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation. RESULTS: Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%). CONCLUSIONS: The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.     

Radiological and orthopedic abnormalities in Satoyoshi syndrome

BACKGROUND: The advent of proton-pump inhibitors, and subsequently of the laparoscopic technique, can be assumed to have influenced the use of antireflux surgery in gastro-oesophageal reflux disease. METHODS: Data on antireflux operations carried out in Finland in 1988-93 were obtained from national statistics, and the number of operations performed laparoscopically in 1993 was ascertained by a questionnaire to all relevant units. The rates per 100,000 population in the catchment areas were calculated. RESULTS: Antireflux surgery almost always implied fundoplication. During 1993, 784 fundoplications and 43 other antireflux procedures were performed in Finland (total population around 5 million). The fundoplication rate per 100,000 population rose from 8.8 to 15.4 between 1988 and 1993. The increase was minimal (8.1-8.2) in 1990-91 when the first proton-pump inhibitor, omeprazole, was introduced, but remarkably greater (12.8-15.4) in 1992-93, when the laparoscopic technique became popular. Differences in fundoplication rates were six to tenfold between health service districts and even larger between hospitals. CONCLUSIONS: The numbers of antireflux operations in Finland were almost static when proton-pump inhibitors were introduced, but rapidly increased after the advent of the laparoscopic technique. Remarkable discrepancies were found in the incidence of fundoplication between different areas and hospitals.     

Laparoscopic hiatal reconstruction and use of harmonic scalpel instrument

The method of laparoscopic repair of hiatal hernia is accepted in surgery. Usually associated with Nissen fundoplication which is the most commonly performed antireflux operation. Within a ten-year period authors have done 90 antireflux operations, 52 was laparoscopic procedures. (30 operations for GERD, 10 for hiatal hernia, 12 for the combination of both.) A patient was submitted to operation with large hiatal hernia. He was treated laparoscopic way with success and good results. The Ultracision Harmonic Scalpel instrument helped their operation in many ways, and provided correct bloodless preparation of cardiac region. The authors demonstrate our procedure and the use of the Harmonic Scalpel. Their patient were completely pleased with the results after discharge, they are still under regular control.     

Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease

The Nissen fundoplication is the most common operative approach to the correction of gastroesophageal reflux disease (GERD) in the United States. This report describes our success in performing this anti-reflux procedure laparoscopically in 28 patients with symptomatic GERD refractory to conventional medical therapy. Our laparoscopic technique does not differ significantly from the traditional, open Nissen fundoplication. After surgery, all patients reported symptomatic relief, and none required medication for the control of reflux symptoms. Oral feedings were begun on the first postoperative day, and patients were typically discharged on the second day after surgery. All but two patients resumed normal eating within an average of 26 days. Two patients experienced longer term postoperative dysphagia, including one who had undergone a highly selective vagotomy concurrent with the antireflux surgery.     

Lifetime costs of surgical versus medical treatment of severe gastro-oesophageal reflux disease in Finland

BACKGROUND: Gastro-oesophageal reflux disease (GERD) can be effectively treated pharmacologically or surgically. As GERD is often a chronic condition, we compared the long-term costs of medical and surgical management. METHODS: The medical regimens were ranitidine (150 or 300 mg/day), omeprazole (20 or 40 mg/day), and lansoprazole (30 mg/day), with costs calculated for total life expectancy after diagnosis and for one-third of that time. Costs for open or laparoscopic surgery (Nissen fundoplication) included pre- and post-operative investigations, sick leave, and calculated financial loss due to fatal outcome. RESULTS: Costs were lowest with ranitidine, 150 mg/day, for one-third of the patient's lifetime and highest with lifelong omeprazole, 40 mg/daily. The cost of open or laparoscopic operation was less than that of lifelong daily treatment with proton pump inhibitors or ranitidine, 300 mg daily. CONCLUSION: In Finland, antireflux surgery for GERD is cheaper than lifetime treatment with proton pump inhibitors.     

Seven abdominal assessment signs every emergency nurse should know

BACKGROUND: Open or laparoscopic surgery for gastroesophageal reflux disease gives longterm freedom from symptoms in 83-100% of cases but has a certain percentage of complications. This study was undertaken to evaluate the early and late complication rates after primary or repeat antireflux operations. STUDY DESIGN: The records of all patients who underwent surgery for gastroesophageal reflux disease during a 32-year period at a university teaching hospital were reviewed retrospectively. Records for 793 adults (448 men and 345 women) aged 16-85 years (mean, 51) were retrieved for calculation of complication rates and statistical analysis. RESULTS: A total of 827 operations were performed: 793 primary and 41 for recurrent disease (2 patients were each reoperated on twice). There were 49 laparoscopic operations. Only two patients died (mortality, 0.3%), both after open operation. Morbidity was 24% after open surgery and 14% after laparoscopic operation. The total (early and late) complication rate was higher after reoperations than that after open or laparoscopic procedures. The overall complication rate in the open operations was similar in the first and the third decade of the study, namely, 24.6% and 26.1%, respectively. CONCLUSIONS: Surgical treatment of gastroesophageal reflux disease carries very low mortality when performed in a specialized unit. The main causes of morbidity after open operation are infectious complications. The incidence of complications is substantially lower after laparoscopic surgery than after open operation. Reoperation is seldom required, but it carries higher morbidity than the primary operations.     

The 100th birthday of Rudolf Nissen

Rudolf Nissen was born in Neisse, Schlesien, 9 September 1896. From 1921 to 1933 he was the favorite pupil of Ferdinand Sauerbruch in Munich and Berlin. 1930 he became professor of surgery at the Charité. The assumption of power by the Nazi-regime forced Nissen to resign his position and end his career in Germany. He took over the surgical chair in Istanbul, Turkey. Emigrating in 1939 to the USA, he held surgical positions in hospitals at New York and accepted in 1952 the chair of Surgery at the University of Basel, Switzerland. Nissen died in Riehen/ Basel on 22 January 1981. Nissen was a critical observant clinician, an efficient and popular physician, a teacher and a speaker. Of historical significance are pioneering works in thoracic surgery, the first successful pneumectomy in man, the classical works about the treatment of gastro-oesophageal reflux disease and hiatus hernia. The Nissen-Rossetti type of fundoplication has remained the standard procedure in Europe and the USA.     

Antireflux surgery: a current comparison of open and laparoscopic approaches

The technologic advances of laparoscopic surgery have recently resulted in a renaissance of antireflux surgery as a minimal invasive alternative to life long medical treatment in patients with gastroesophageal reflux disease. The now vast experience has shown that, in experienced hands, laparoscopic antireflux surgery is feasible, shortens the hospital stay and recovery period, and provides a cosmetically more satisfying result than the open procedures. The rate of intra- and postoperative complications of laparoscopic antireflux procedures is, however, not significantly lower than that reported after open procedures. The laparoscopic approach is even associated with some additional sources for complications, i.e., trocar injuries, perforations of the esophagogastric junction, and herniation of the repair into the chest with a significant rate of early reoperations. Short term and intermediate results of laparoscopic antireflux procedures appear comparable to those obtained with the procedures performed via a laparotomy. Whether this is also true for the long term outcome will have to be shown by the follow-up of the large series of laparoscopic antireflux procedures that have been performed in the recent years. Before these data are available, one should be careful not to widen the indications for antireflux surgery just because the procedure can now be performed laparoscopically.     

Comprehensive 1-year cost analysis of open antireflux surgery in Nordic countries. Nordic GORD Study Group. Gastro-oesophageal reflux disease

BACKGROUND: Antireflux surgery is a highly effective treatment option in patients with severe gastro-oesophageal reflux disease. However, because of the increasing pressure of cost containment within health care, cost aspects must also be added to the decision-making process. METHODS: The aim of this analysis was to assess the total cost of open antireflux surgery during the first year after operation in 178 patients with chronic reflux, who were recruited into a controlled, prospective clinical trial. The study was carried out in 17 hospitals in the Nordic countries. RESULTS: The cost of the operation represented more than 90 per cent of the direct medical costs which amounted to approximately US $5700. For a patient in the work force the indirect cost, i.e. loss of production, represented 47 per cent of the total cost, which was about US $10800. CONCLUSION: The total cost profile of open antireflux surgery has now been established prospectively and can form a basis for future comparisons.     

Vitamin E dose-response studies in humans with use of deuterated RRR-alpha-tocopherol

A prospective double-blind randomized trial was initiated to examine two types of laparoscopic fundoplication (Nissen and anterior). Thirty-two patients with proven gastroesophageal reflux disease presenting for primary laparoscopic antireflux surgery were randomized to undergo either Nissen fundoplication (N = 13) or anterior hemifundoplication (N = 19). Postoperative fluoroscopic and manometric examination was carried out concomitantly. Nissen fundoplication resulted in significantly greater elevation of resting (33.5 vs 23 mm Hg) and residual lower esophageal sphincter pressures (17 vs 6.5 mm Hg) and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than the anterior partial fundoplication. A smaller radiologically measured sphincter opening diameter was seen following Nissen fundoplication (9 mm) compared with anterior fundoplication (12 mm). Lower esophageal ramp pressure correlated weakly (r = 0.37, P = 0.04) with postoperative dysphagia. It is concluded that the type of fundoplication performed significantly influences postoperative manometric and video barium radiology outcomes. The clinical relevance of this requires further investigation.     

Has laparoscopy changed the surgical approach in gastroesophageal reflux? Apropos of an experience with 63 cases of gastroesophageal reflux treated by laparoscopy

INTRODUCTION: Indications for surgery in gastrooesophageal reflux disease (GERD) have decreased significantly since the introduction of proton pump inhibitors. At the same time there has been renewed surgical interest in this disease triggered by the development of laparoscopy. We present our results with laparoscopic treatment of GERD and the change in our surgical approach to the condition during the past few years. METHODS: All patients admitted to the surgical department underwent prior evaluation by a gastroenterologist. Indications for surgery were resistance to medical therapy in 30 cases, recurrence of GERD after cessation of treatment in 25 cases and personal preference of the patient when maintenance therapy was necessary in 6 cases. The data were reviewed and the patients contacted during the first trimester of 1998 to evaluate long-term results. RESULTS: 63 patients were operated on between 1991 and July 1997. Rossetti-Nissen fundoplication was performed routinely until March 1995. Thereafter, the type of antireflux surgery has been chosen according to the preoperative evaluation of the patients, including endoscopy, oesophageal manometry and gastric emptying studies. There was no mortality and, except for one case, only minor morbidity. Four patients required reoperation, two for severe gas bloat syndrome and two for recurrence of GERD. Overall, the long-term follow-up shows that 93 patients are satisfied or very satisfied with their outcome (Visick 1 or 2). 5% of the patients need daily medication for heartburn, 5% complain of occasionally disturbing dysphagia, and 12% of sometimes distressing gas bloat. More patients have gas bloat after the Rossetti-Nissen procedure than after the Nissen or Toupet fundoplications. CONCLUSIONS: The enthusiasm of surgeons for the laparoscopic approach to GERD has prompted renewed interest in the pathophysiology of the disease. Consequently, indications for surgery are better defined, surgical technique is chosen according to the individual patient based on objective preoperative studies and follow-up has improved. In this setting, laparoscopic fundoplication represents an effective treatment for GERD. It is associated with lower postoperative morbidity than open surgery and represents the first choice when surgery is indicated.     

Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs.44%; P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after surgery.     

Recent advances in antireflux surgery for gastroesophageal reflux diseases--from open surgery to laparoscopic surgery

Gastroesophageal reflux diseases (GERD) are common in the western countries and have been well studied about diagnosis and treatment. Nissen technique (a complete wrap) and Toupet technique (a partial wrap) are usually transabdominal fundoplication. Hill technique is a transabdominal posterior gastropexy. Allison technique is a transthoracic reduction method of the herniated cardia back into the abdomen, but is not frequently employed today. Belsey Mark VI technique is a transthroacic anterior plication. Collis gastroplasty is an esophageal lenghening technique and is used with standard repairs (Nissen, Belsey, and Hill). Good result rate of above mentioned surgery are about 90%. Recently, laparoscopic Nissen/Toupet technique are a standard antireflex surgery because of minimal invasiveness and more than 90% of good results. After introducing laparoscopic surgery the indication of antireflex surgery for GERD can be changed because of quality of life of patients and medicoeconomical reasons.     

Nissen fundoplication by laparoscopy

Short term results following laparoscopic Nissen fundoplication were evaluated in 31 patients with symptomatic gastroesophageal reflux. 6 were females and 26 males, and they ranged in age from 5 months to 64 years (mean: 4.9 years in 19 younger than 18 years, and 39.3 years in 12 adults). Most of the adults who complained of pain and heartburn underwent pH monitoring, endoscopy, and manometry as needed. Milk scan was the most useful diagnostic tool for the evaluation of the children, who suffered mainly from gastroesophageal-related pulmonary disease. Indications for laparoscopic operation were identical with those for conventional open Nissen fundoplication. 1 case of dysautonomia died postoperatively; the rate of complications, mostly minor, was 22.5%. 3 patients required conversion to open Nissen fundoplication due to cardiorespiratory instability secondary to pneumothorax in 2, and to esophageal perforation in the third. 5 adults developed temporary dysphagia. 3 children had only partial improvement in their pulmonary disease following the operation, while the other 15 had complete relief. The total time for the laparoscopic operation averaged 245 minutes in adults, and 228 in children. Discharge was usually on the fourth postoperative day in adults (mean: 6.0 days). Regurgitation and heartburn were cured in 10 out of 11 adults (91%). All parents of children were satisfied. Symptomatic outcomes following laparoscopic Nissen fundoplication compare favorably with those of open surgery with respect to mortality, complications, and outcome.     

Surgical treatment of gastroesophageal reflux disease

Antireflux surgery is successful in 85-90% of eligible patients, with relief of symptoms, cure of oesophagitis and possibly prevention of progression of the dysplasia in a Barrett's oesophagus. The mortality in the latest publications is given as 0.05%. The morbidity, apart from recurrences, is not yet sufficiently known. Some 250 antireflux operations are performed annually in the Netherlands, fewer than 20% of the estimated requirement of 10 operations per 100,000 of the population per year, and also fewer than in Scandinavia. Nissen fundoplication (folding the fundus of the stomach around the entire circumference (360 degrees) of the oesophagus) is generally accepted as the standard primary operation. Nissen fundoplication during laparoscopy seems to be just as good. Results of randomized clinical trials will have to be awaited to prove this assumption. Belsey's operation (folding the fundus around 270 degrees of the circumference of the oesophagus via thoracotomy) is nowadays performed almost exclusively in recurrent reflux disease and in persistent dysphagia after a primary operation.     

Role of apoptosis in testicular tissue damage caused by varicocele

PURPOSE: During the last few years there has been an increasing interest in evaluating quality of life (QOL) data regarding surgical treatment. METHODS: The present study comments the efficacy of laparoscopic antireflux surgery after required Nissen fundoplication of 70 patients. Therefore, the German Gastrointestinal Quality of Life Index (GIQLI) was used to query the patients preoperatively and three times after surgery up to 1 year. RESULTS: Preoperatively, we found a low general GIQLI score (mean 92.7 points), which increased 6 weeks postoperatively (116.8 points), 3 months (124.8) and 1 year (mean 123.9 points) significantly and is now comparable to the healthy population (122.6 points). CONCLUSION: It is our opinion that the efficacy of the treatment of gastroesophageal reflux disease with required Nissen fundoplication can also be documented and discussed by using QOL.     

Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis

Nissen fundoplication is now the most common antireflux operation for gastroesophageal reflux disease. This study is a report on the laparoscopically performed floppy Nissen procedure. Two hundred consecutive patients were analyzed (84 women, 116 men, mean age 49 years, mean duration of symptoms 5 years) after laparoscopic Nissen fundoplication between 1992 and 1996. The main indications for surgery were daily heartburn, retrosternal pain, and regurgitation demanding continuous medical therapy. Eight patients (4%) had esophageal stricture, and 21 (11%) had Barrett's esophagus with intestinal metaplasia. All patients underwent upper gastrointestinal endoscopy, 24-h esophageal pH monitoring, and esophageal manometry before and 3 months after the operation. In addition, a questionnaire was completed an average of 2.2 years (range 1.0-4.6) after the operation. The results of the study were as follows: mortality was zero, and the morbidity rate was 5%. The mean hospital stay was 3.8 +/- 2.8 days, and sick leave was 14.3 +/- 10.4 days. Postoperatively, esophagitis was healed or significantly improved in all but 4 patients (98%), and 24-h pH and lower esophageal sphincter pressure were normal. After 2 years, 87% of the patients had Visick scores of I-II. It is concluded that laparoscopic floppy Nissen fundoplication provides an efficient and safe alternative for surgical treatment of gastroesophageal reflux disease.     

Evaluation of the antireflux mechanism following laparoscopic fundoplication

BACKGROUND: Laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastro-oesophageal reflux disease (GORD), but the underlying motility mechanisms that explain the success of this operation remain unclear. METHODS: Twenty patients with a history of GORD underwent stationary oesophageal manometry and prolonged ambulatory pH monitoring, both before and 3 months after fundoplication. RESULTS: Eighteen patients were completely cured of reflux symptoms and stopped all antireflux medication after operation. After fundoplication there was a significant increase (P < 0.01) in median resting lower oesophageal sphincter (LOS) pressure and length. Median residual LOS pressure during swallow-induced LOS relaxation also increased significantly after operation (P < 0.01). The number of reflux episodes decreased from a median of 48 to 3 after fundoplication (P < 0.01). The time at pH less than 4 decreased from 5.7 to 0 per cent in the supine position (P < 0.01), and from 9.8 to 0.2 per cent while upright (P < 0.001). CONCLUSION: Early subjective results at 3 months following laparoscopic antireflux surgery show improved symptoms. One of the mechanisms underlying the antireflux action of fundoplication is an increase in median residual LOS pressure at the gastro-oesophageal junction. This may be a purely mechanical effect of the fundic wrap extrinsic to the LOS.