Serum S-100 protein: a potentially useful prognostic marker in cutaneous melanoma

BACKGROUND: A 360 degrees or Nissen fundoplication remains controversial in patients with disordered peristalsis, some surgeons preferring a partial wrap to minimise postoperative dysphagia. AIM: To evaluate symptoms and manometric outcome in patients with disordered peristalsis after Nissen fundoplication. PATIENTS: In an initial series of 345 patients studied prospectively, 31 patients who had undergone a Nissen fundoplication had disordered peristalsis. Using preoperative manometry, patients were classified as: equivocal primary peristalsis (eight patients); abnormal primary peristalsis (four patients); abnormal maximal contraction pressure (13 patients); abnormal primary peristalsis and maximal contraction pressure (six patients). METHODS: Postoperatively, patients underwent a barium meal, oesophageal manometry and standardised clinical review by a blinded scientific officer. RESULTS: Twenty eight (90%) patients had satisfaction scores of at least 8 out of a maximum of 10 and all would undergo surgery again. Whereas 15 (48%) patients had dysphagia scores greater than 4/10 preoperatively, only two (6%) had these scores at one year. Improved peristalsis was seen in 78% of postoperative manometric studies, and mean preoperative lower oesophageal sphincter pressure increased from 6.6 (range 0-21) mm Hg to 19 (4-50) mm Hg. CONCLUSIONS: These results are similar to the overall group of 345 patients and suggest that disordered peristalsis, and possibly even absent peristalsis, is not a contraindication to Nissen fundoplication as performed in these patients.     

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.     

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.     

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.     

Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication

It is unclear whether a partial or complete gastric fundoplication done laparoscopically will offer the best control of reflux with the fewest side effects. Prospective evaluation of laparoscopic Rosetti-Nissen (360) and Toupet (180) fundoplication was performed with assessment of clinical and manometric data. METHODS: Patients with severe gastroesophageal reflux referred for surgical correction underwent preoperative motility and upper endoscopy. A Rosetti-Nissen or Toupet fundoplication was then performed laparoscopically. Short gastrics were not divided. No bougie was used in the Toupet, which was sutured intracorporeally. A 2-cm, loose, floppy wrap about a 50-Fr bougie was performed in the Nissen. Eleven patients underwent Rosetti-Nissen and 11 Toupet fundoplication. Mean ages, duration symptoms, weight, and baseline LES, were not different. Preop esophagitis grades were similar, as were Visick Scores and presence of dysphagia. RESULTS: Visick scores at 6 months were better in the Toupet group than the Rosetti-Nissen (P = 0.07). Persistent Dysphagia in four, Gas-Bloat in two, and Odynophagia in one within the Rosetti-Nissen group accounted for the difference, and were not seen in Toupets. LES pressures differed significantly pre and postop (P < 0.001). The change in LES pressure was significantly different between Toupet and Rosetti-Nissen (chart). Seven patients had postop 24-h pH tests; all had no reflux. Three Rosettis have required revision to Toupet, with resolution of their symptoms. CONCLUSIONS: In patients with severe GERD, laparoscopic Toupet and Rosetti-Nissen control symptoms and esophageal pH similarly. LES pressures are higher postop in the Rosetti-Nissen. Dysphagia and gas-bloat are more prevalent in the Nissen group. Laparoscopic Toupet fundoplication may be superior to Rosetti-Nissen in reducing the frequency of side effects frequently associated with antireflux surgery, yet with equal control of reflux.     

Predictive value of symptom profiles in patients with suspected oesophageal dysmotility

The main aim of the study was to determine prospectively, in patients referred for oesophageal manometry, whether certain combinations of oesophageal symptoms are more likely than others to predict the presence of oesophageal dysmotility or a positive response to acid perfusion testing. In 524 consecutive patients, presenting predominantly with (non-cardiac) chest pain (n = 277), dysphagia (n = 186), or heartburn (n = 61), a standardized symptom assessment was completed before oesophageal manometry and acid perfusion testing. Half the patients in each group reported additional ('secondary') oesophageal symptoms as well as the predominant symptom. Oesophageal dysmotility was categorized in accordance with standard manometric criteria for achalasia, diffuse oesophageal spasm, nutcracker oesophagus, hypertensive lower oesophageal sphincter, or non-specific oesophageal motility disorder. In the predominant chest pain group, the prevalence of abnormal manometry was 33%; in the presence of secondary symptoms, especially dysphagia rather than heartburn, however, the prevalence was significantly (p < 0.01) increased. Also in the predominant chest pain group the prevalence of positive acid perfusion testing (44%) was significantly greater (p < 0.05) in those with than in those without secondary symptoms. In the predominant dysphagia group, the prevalence of abnormal manometry was higher than in the other two groups (56%; p < 0.001) but was not affected by the presence or absence of secondary symptoms; this latter finding was also true for the predominant heartburn group. The distribution of specific manometric disorders in any group was not related to the presence or type of secondary symptoms, although a combination of dysphagia and chest pain discriminated achalasia from other manometric disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

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.     

Air oesophagogram: a frequent, but not a specific sign of oesophageal involvement in connective tissue diseases

OBJECTIVE: This study investigates the role of the air oesophagogram in conventional chest X-rays for the diagnosis of oesophageal dysmotility in patients with connective tissue diseases. METHODS: Fifty-one patients with connective tissue diseases were studied by oesophageal manometry and lateral and posterior-anterior chest X-rays. The presence or absence of oesophageal air on chest X-rays were evaluated separately in the upper, middle and distal segment of the oesophagus. Forty-seven chest X-rays of patients without connective tissue diseases, who had undergone manometry for the evaluation of oesophagus-related symptoms and who had normal oesophageal function, were analysed as a control. RESULTS: A total of 23/51 patients with connective tissue diseases showed oesophageal dysfunction in manometry; 16/51 patients (31%) had air in two or more oesophageal segments on the lateral chest X-ray. There was a significant association of manometrically proven oesophageal dysmotility and air in two or three oesophageal segments (P < 0.05; sensitivity 48%, specificity 82%). However, the prevalence of an air oesophagogram showed no significant difference between patients with connective tissue diseases and the control group (10/47; 21%). CONCLUSION: The radiological sign of an air oesophagogram is neither sensitive nor specific enough to omit oesophageal motility studies in patients with connective tissue diseases.     

Nissen fundoplication for reflux esophagitis. Long-term clinical and endoscopic results in 109 of 127 consecutive patients

OBJECTIVE: This study evaluates the clinical and endoscopic long-term results of Nissen fundoplication in reflux esophagitis. SUMMARY BACKGROUND DATA: Nissen fundoplication has been reported to give good results in the treatment of gastroesophageal reflux with success rates up to 78-97%. Most of the previous studies on long-term results of fundoplication have, however, been based on interviews with only sporadic endoscopic examinations. METHODS: Of 127 patients consecutively treated with Nissen fundoplication for reflux esophagitis, 109 were available for follow-up after a median of 77 months. Upper gastrointestinal endoscopy was done in 105 cases, and all the patients with reflux symptoms or abnormal endoscopic observations were referred to esophageal 24-hour pH monitoring and manometry. RESULTS: No symptoms of gastroesophageal reflux were reported by 73 of the 109 patients, but dysphagia was present in 47. Endoscopy showed defective fundic wrap in 24 patients. Objective evidence of reflux was found in 24 patients (endoscopic esophagitis in 18 and pathologic 24-hour pH score without esophagitis in 6). Esophagitis was found in 14 of the 24 patients with defective wrap, but in only 4 of the 81 with infact wrap. CONCLUSIONS: Nissen fundoplication alleviated symptoms of gastroesophageal reflux and cured esophagitis in great majority of cases. The main determinant of outcome was the state of the fundic wrap.     

Re-operation for failed anti-reflux surgery

BACKGROUND: Between 1993 and 1995, 315 anti-reflux procedures were undertaken on our service. A previous antireflux procedure had been performed in 31 patients referred (10%). Previous surgery was, in the main (80%), a Nissen fundoplication. METHODS: Pre-operative investigations in all patients were manometry, 24h pH monitoring, oesophagoscopy and barium radiology. On this basis the causes of failure of the previous surgery were established as hiatal failure in 20 (65%), unrecognized oesophageal dysmotility in three (10%) and fundoplication failure (slipped and disrupted) in eight (25%). Contrary to standard recommendations for re-operation most re-operative surgery was performed transabdominally (94%). Complications occurred in 16%. RESULTS: Review was undertaken at a mean of 21 months following surgery, and 91% of patients reported a good to excellent symptomatic outcome. CONCLUSIONS: Transabdominal re-operative anti-reflux surgery has an acceptable complication rate and a surprisingly good symptomatic outcome in the medium term.     

Should adjuvant or neoadjuvant treatment be administered in esophageal cancer?

The Nissen fundoplication is not the proper antireflux procedure for patients with poor esophageal peristalsis as it does not strengthen impaired esophageal peristalsis. The aim of this study was to investigate if tailoring of antireflux surgery according to esophageal contractility is an effective treatment of gastroesophageal reflux disease (GERD) with a low incidence of postoperative dysphagia. The Toupet fundoplication was laparoscopically performed on 32 patients with poor esophageal peristalsis and the Nissen fundoplication on 17 patients with normal peristalsis. After a median follow-up of 15 months, only 1 of the 49 patients (2.04%) complained of heartburn. Acute esophagitis was found in none of them on endoscopy. Of 40 patients tested postoperatively, 2 (5%) underwent pathologic esophageal pH monitoring. Postoperative dysphagia was found in two patients (4.1%) compared with 25 (51%) preoperatively (p < 0.05). There was a significant reduction of dysphagia following the Toupet fundoplication. Both procedures increased the resting pressure of the lower esophageal sphincter (LES) significantly, which was more pronounced following the Nissen fundoplication. Relaxation of the LES was significantly better following the Toupet than after the Nissen fundoplication. There was significant improvement of esophageal peristalsis following the Toupet fundoplication. Tailored antireflux surgery is an effective strategy for treatment of GERD. The incidence of postoperative dysphagia is low owing to improvement of impaired esophageal peristalsis following the Toupet fundoplication. It may be due to the fact that the Toupet fundoplication causes less esophageal outflow resistance than the Nissen fundoplication.     

Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux

BACKGROUND: This prospective study assesses the outcome results in 100 consecutive patients with gastroesophageal reflux disease (GERD) treated with a laparoscopic Toupet fundoplication. METHODS: GERD was confirmed by 24-h pH study and/or esophagogastroduodenoscopy (EGD). Pre- and postoperative symptoms, operative times, and perioperative complications were recorded on standardized data forms. Early follow-up was at 3 months and late follow-up, including 24-h pH, manometry, and EGD was at 22 months. RESULTS: Preoperative symptoms included heartburn (92%), regurgitation (58%), water brash (39%), and dysphagia (39%). Mean operative time was 3.2 hours. There were no conversions to celiotomy and there were no mortalities. The perioperative complication rate was 14%; 6% (5/83) of patients reported heartburn at 3 months and 20% (15/74) at 22 months. Early and late dysphagia was 20% (17/83) and 9% (7/74), respectively; 24-h pH testing was abnormal in 90% of symptomatic patients (9/10), 39% of asymptomatic patients (12/31), and 51% overall. CONCLUSIONS: Despite early improvement in reflux symptoms following laparoscopic Toupet fundoplications, there is a high incidence of recurrent GERD. Symptomatic follow-up underestimates the true incidence of 24-h pH-documented reflux. Based on these results we cannot recommend the laparoscopic Toupet repair for GERD patients with normal esophageal motility.     

Examination of contact lens surfaces by Atomic Force Microscope (AFM)

BACKGROUND: Reduction of acid secretion is an important aspect of medical treatment of reflux esophagitis. Truncal vagotomy and drainage procedures used in conjunction with antireflux procedures to reduce acid secretion in patients with gastroesophageal reflux were unsatisfactory. This study reviews the results of parietal cell vagotomy used in conjunction with a 360-degree fundoplication to determine if reduction of acid by this form of vagotomy was beneficial to patients with gastroesophageal reflux. METHODS: Between March 1973 and May 1993, 94 private and 64 Veterans Administration patients underwent parietal cell vagotomy and Nissen type fundoplication for esophageal reflux. Esophagogastroduodenoscopy (EGD), gastric analysis, cine-esophagogram, and 24-hour esophageal pH and motility studies were performed preoperatively on VA patients. Private patients underwent EGD, cine-esophagogram, and sometimes pH and motility studies. Similar studies were performed postoperatively if the patient permitted. The major technical alteration made during the study was the addition of posterior gastropexy to the operations performed between March 1978 and January 1987. Patients were considered failures if dysphagia and reflux symptoms were moderate but operation not contemplated (Visick III) or symptoms were severe and reoperation had been performed or was contemplated (Visick IV). RESULTS: There were no operative deaths. There were 25 operative failures; dysphagia contributed to failure in 4, reflux in 11, and dysphagia and reflux in 10 patients. Reoperation was required in 6 patients. There was no statistical difference in acid secretion inhibition for patients with or without postoperative reflux symptoms. The cumulative probability for operative failure was 9.3 +/- SE 4.2% for patients who underwent posterior gastropexy and 22.9 +/- SE 4.6% (P <0.02) for those who did not. CONCLUSIONS: Parietal cell vagotomy with Nissen fundoplication is a safe operation. The exposure created by PCV protected the vagi from injury. The study design made it impossible to determine whether PCV improved the results of fundoplication but the failure rate was significantly (P <0.02) reduced by the addition of posterior gastropexy. This may have lessened the risk of disintegration of the wrap that might be more likely to occur after PCV.     

Treatment of advanced gastroesophageal reflux disease with Collis gastroplasty and Belsey partial fundoplication

OBJECTIVE: To examine the factors affecting outcome in patients with advanced gastroesophageal reflux disease. DESIGN: Retrospective analysis. SETTING: University tertiary referral center. PATIENTS: Thirty-seven patients with advanced gastroesophageal reflux disease and no previous antireflux surgery. INTERVENTIONS: Thirty patients underwent Collis gastroplasty for esophageal lengthening and Belsey partial fundoplication. Seven patients with esophageal stricture and global loss of esophageal body motility who underwent primary esophagectomy and reconstruction were used as a comparison group. OUTCOME MEASURES: Symptomatic outcome in all 37 patients was assessed by questionnaire at a median of 25 months (range, 5-156 months) after surgery. In a subset of 11 patients undergoing the Collis-Belsey procedure, outcome was measured using 24-hour pH and results of motility studies. RESULTS: The Collis-Belsey procedure was successful in relieving symptoms of gastroesophageal reflux in 21 (70%) of the 30 patients. The outcome was excellent or good in 16 (89%) of 18 patients who presented with symptoms other than dysphagia, but only in 5 (42%) of 12 patients with dysphagia (P = .01). The outcome was particularly poor if dysphagia was associated with a previously dilated esophageal stricture. Persistent or induced dysphagia was the reason for failure in all but 1 patient. Results of 24-hour esophageal pH studies were returned to normal in 8 (73%) of 11 patients undergoing postoperative evaluation. Contraction amplitudes in the distal esophagus and the prevalence of simultaneous contractions in these segments did not change after the operation. All 7 patients who underwent primary esophagectomy were classified as having an excellent or good outcome and were relieved of their reflux symptoms, including dysphagia. Six of these could eat 3 meals per day and enjoyed an unrestricted diet. CONCLUSIONS: The outcome of the Collis-Belsey procedure in patients with advanced gastroesophageal reflux disease without dysphagia is excellent. It is less so in patients with dysphagia as a preoperative symptom. Esophagectomy can provide a good outcome in patients who have a combination of dysphagia stricture and a profound loss of esophageal motility.     

A study of 362 consecutive laparoscopic Nissen fundoplications

BACKGROUND: Open Nissen fundoplication has been shown to be a very effective operation in the treatment of intractable gastroesophageal reflux. Because of its technical rather than amputative nature, this procedure offers itself to a completely laparoscopic approach. Several studies have shown the feasibility; however, very few have dealt with the effectiveness of the laparoscopic approach. METHODS: Results of laparoscopic Nissen fundoplications performed during a 6-year period were reviewed including duration of operation, number of hospital days, number of conversions to open procedures, complications, and symptoms. All 362 patients had evidence of gastroesophageal reflux disease documented by radiographic, endoscopic, or pH monitoring testing before the operation. Patients with dysphagia or odynophagia underwent manometric evaluation before operation. Postoperative evaluation included esophagography and endoscopy at 2 to 3 months with an esophagogram yearly thereafter. Follow-up time was 6 months to 6 years. RESULTS: The mean time of operation decreased from 2.7 +/- 0.4 hours during the period from 1991 to 1994 to 1.8 +/- 0.3 hours from 1994 to 1997. During those same periods, the number of days of hospitalization decreased from 2.2 days to a mean of 1.5 days. Manometric studies done before the operation (n = 58) showed a pressure of 4 +/- 1.2 mm Hg compared with postoperative values (n = 39) of 14 +/- 1.8 mm Hg. The conversion rate was 0.8% (n = 3), and the complication rate of 1.9% (n = 7) included the 3 conversions, 2 pneumothoraces, 1 patient with postoperative bleeding, and 1 patient with a large abdominal wall hematoma. There were 5 failures of the procedure (1.2%). Thirteen patients (3.6%) described postoperative symptoms that persisted beyond 2 months, including bloating, flatulence, dysphagia, and diarrhea. CONCLUSIONS: With strict selection criteria and increasing experience and standardization of technique, laparoscopic Nissen fundoplication can provide both safe and effective results for patients with chronic symptoms of gastroesophageal reflux disease.     

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.     

Systemic clotting activation by low-grade endotoxaemia in liver cirrhosis: a potential role for endothelial procoagulant activation

Laparoscopic fundoplication is technically feasible in treating gastroesophageal reflux disease (GERD). Although medication is the primary treatment for GERD, not all patients respond completely or are able to adhere to a medical regimen. In the present series, 59 patients were laparoscopically treated for GERD at three centers using a standardized technique. All patients had been medically treated prior to referral, although 84 per cent had heartburn and 2 per cent had laryngitis despite 20 to 40 mg/day of omeprazole. Fifteen per cent of patients were intolerant of or would no longer take omeprazole. Patients were evaluated by esophageal manometry (in 100%) and 24-hour pH studies (in 66%). Seventy-six per cent of patients had lower-esophageal sphincter pressure <15 mm Hg. Five patients had low esophageal body peristaltic pressures (<35 mm Hg). These patients underwent Toupet partial fundoplication, whereas 54 patients underwent Nissen fundoplication. Mean operative time was 158 +/- 7 minutes, and three patients (5%) were converted to an open procedure. Operative complications were minor and occurred in 13 per cent. In 45 patients evaluated 1 year after surgery, heartburn had resolved in 98 per cent. Thirty-nine of 56 patients (70%) had mild early (<1 month postoperatively) dysphagia, and 9 (19%) had severe early dysphagia, which improved in 7 after nonoperative dilatation. Two of these had continued mild dysphagia. Two patients had severe dysphagia and were laparoscopically converted from Nissen to Toupet fundoplications, which resulted in marked improvement. Early gas bloat symptoms occurred in 45 per cent and dropped to 5 per cent at 1 year. Laparoscopic treatment of GERD is safe and effective in preventing reflux symptoms. Although mild dysphagia occurs after the procedure, this is transient in most patients. Patients with severe dysphagia can be treated with nonoperative dilatation or laparoscopic partial fundoplication and maintain the antireflux characteristics of the wrap.     

Efficacy of anterior, posterior and total fundoplication in an experimental model

BACKGROUND: This study examined the effect of different types of laparoscopic fundoplication on an incompetent lower oesophageal sphincter to test their effectiveness at preventing gastro-oesophageal reflux in the early postoperative period. METHODS: An experimental porcine model was used. Initial oesophageal myotomy ensured an incompetent lower oesophageal sphincter with free reflux of 'intragastric fluid'. Anterior, posterior or total fundoplication was then performed laparoscopically in 15 laboratory pigs (five in each group). Fundoplication competence and efficacy were determined 2 weeks after laparoscopic antireflux surgery by inflating the stomach with liquid through a gastrostomy cannula. Some animals were also studied at 4 and 6 weeks. Lower oesophageal sphincter pressure was determined using a water-perfused oesophageal manometry catheter incorporating a Dent sleeve. RESULTS: All three types of fundoplication produced similar increases in postoperative resting lower oesophageal sphincter pressure and restored adequate competence to the gastro-oesophageal junction. CONCLUSION: All three variants of laparoscopic fundoplication restore gastro-oesophageal competence in the early postoperative period.