Anterior Partial Fundoplication Research Articles

The Contribution of Elevated Gastric Pressure to Prevention of Gastroesophageal Reflux in Several Different Antireflux Procedures

Although there are many studies evaluating the effect of elevated gastric pressure in total wrap and partial anterior and posterior wrap fundoplications, there are no ex vivo manometric studies evaluating the contribution of elevated gastric pressure to prevention of gastroesophageal reflux (GER) in Collis and uncut Collis procedures without fundoplication. An experimental study has been designed to determine the contribution of elevated intragastric pressure in the absence of in vivo anatomic and functional factors to the prevention of GER in Collis and uncut Collis without fundoplication procedures. The study was conducted on adult male New Zealand rabbits' esophagus and stomachs. The stomachs were divided into four groups: total wrap fundoplication group, partial wrap anterior fundoplication group, Collis without fundoplication group, and uncut Collis without fundoplication group. The minimum intragastric pressure (MIP) causing GER of each stomach before and after the procedure were measured with a two-way catheter introduced through the pylorus. The MIP values causing GER of the total wrap and partial anterior wrap fundoplication groups were found to be significantly higher compared with the basal intragastric pressures (P < 0.01). The MIP values causing GER of the Collis and uncut Collis without fundoplication groups were not significantly different compared with basal intragastric pressures (P > 0.05). The elevated gastric pressure is found to be insufficient to prevent GER in Collis and uncut Collis without fundoplication procedures. The efficacy of these procedures in preventing GER seems to be related to the anatomic and functional factors affecting in vivo circumstances.

Laparoscopic Antireflux Surgery

Although the long-term results of open fundoplication for gastroesophageal reflux disease are well documented, few reports exist on the long-term results of laparoscopic fundoplication. Retrospective study with clinical evaluation or mailed survey for patients unable to return to the hospital center. Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). Between January 1992 and December 1998, 2684 patients with gastroesophageal reflux disease underwent laparoscopic fundoplication in 31 hospital centers. Outcome data covering a period of 5 or more years after surgery were available for 1340 patients: 711 who underwent complete fundoplication, 559 who underwent partial posterior fundoplication, and 70 who underwent partial anterior fundoplication. Evaluation of clinical and quality-of-life actions used to treat the symptoms of gastroesophageal reflux disease. The overall residual severe dysphagia rate was 5.1% (n = 68). A further surgical procedure was required for 59 patients (4.4%) for a total of 63 interventions. Subsequent operation was performed laparoscopically in 32 cases (50.8%). Twelve of these procedures were for the repair of a paraesophageal hiatus hernia, 11 were for dysphagia (4 because of a tight esophageal hiatus and 7 for conversion of Nissen fundoplication to a posterior partial fundoplication procedure), 31 were for recurrent reflux (wrap undone), 2 were for intestinal obstruction (adhesiolysis), 1 was for incisional hernia, 1 was for abdominal abscess (drainage), and 1 was for gastroparesis (pyloroplasty). The recurrence rate was 10.1% (n = 136), and 122 patients (9.1%) resumed taking antisecretory medication. Gas bloat syndrome was present in 101 patients (7.5%). A total of 93.1% of the patients were satisfied (Visick classification, grades 1 and 2) and 6.9% were unsatisfied, with no difference among the 3 procedures. After 5 years of experience, laparoscopic fundoplication remains an effective antireflux procedure.

Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication

This double-blind, randomized study compared outcomes of laparoscopic Nissen total fundoplication and anterior partial fundoplication carried out by a single surgeon in a private practice. All patients with proven gastro-oesophageal reflux disease, regardless of motility, presenting for laparoscopic antireflux surgery were randomized to either Nissen total or anterior partial fundoplication. Primary outcome measures were dysphagia and abolition of reflux. Secondary outcome measures were Visick scores, bloating, patient satisfaction and reoperation rate. Complete follow-up was available for 161 (98.8 per cent) of 163 patients (84 Nissen, 79 anterior). There were no differences in mean heartburn scores between groups. Recurrent reflux was observed in ten patients after anterior fundoplication, but none after the Nissen procedure. Dysphagia scores for both liquids and solids were lower after anterior fundoplication. Four patients had persistent troublesome dysphagia after Nissen fundoplication compared with none after anterior fundoplication. There were no differences between groups in postoperative bloating. The overall reoperation rate at 2 years was 7 per cent, all achieved laparoscopically. Nissen fundoplication cured reflux in all patients up to 2 years, but 5 per cent required revisional surgery. Recurrent reflux was more common after anterior fundoplication, but dysphagia was rare. Patient satisfaction was excellent in both groups. Revisional laparoscopic surgery was safe and usually successful.

Laparoscopic Heller myotomy with or without partial fundoplication: A matter of debate

To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia. Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17, and angle of His reconstruction in 15 cases represented the antireflux procedure of choice. There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy. To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His' angle reconstruction is a safe and effective alternative to the anterior fundoplication.

Barrett′s oesophagus: Is there a need for laparoscopic anti-reflux surgery?

Barrett′s oesophagus: Is there a need for laparoscopic anti-reflux surgery?

The effect of total and anterior partial fundoplication on antireflux mechanisms of the gastroesophageal junction

Background The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication. Methods Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension. Results Both types of fundoplication resulted in significant increases in LES resting ( P <0.001) and postdeglutition relaxation pressure ( P <0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state ( P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication ( P = 0.04). Conclusions Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.

Anterior partial fundoplication for gastroesophageal reflux disease.

This study examined the effect of anterior partial fundoplication on reflux symptoms and dysphagia in gastroesophageal reflux disease. Perioperative results in 249 patients were evaluated retrospectively for 93 conventional and prospectively for 156 laparoscopic procedures. The patients were followed up by standardized questionnaire. Median clinical follow-up period was 9 months (range 6-44) after laparoscopic and 88 months (range 15-194) following partial open fundoplication. The median operating time was 58 and 115 min for laparoscopic and open partial fundoplication. Intraoperative complications were rare (1%) for both approaches. After introduction of the laparoscopic procedure the morbidity rate was reduced (mean 3.2% vs. 1.3%) at a shorter postoperative hospital stay (10 vs. 5 days). No reflux symptoms were found in 71.4% patients after conventional and in 69% after laparoscopic partial fundoplication, dysphagia did not develop in 86% and 85%, respectively, and 66% and 82% received no medications. Among the patients with reflux symptoms 6.5% and 0.9% underwent revision surgery. Satisfaction with the surgical outcome was expressed by 78% and 85% of patients, respectively. Anterior partial fundoplication achieves effective medium- and long-term control of reflux symptoms. Technically easy to perform and associated with few complications, the procedure is superior to fundoplication with respect to the development of postoperative dysphagia and therefore represents a viable alternative to fundoplication.

Long-term outcome of myotomy and semi-fundoplication in achalasia

The basic principle behind the treatment of achalasia consists of alleviating swallowing disorders by reducing resistance in the lower esophageal sphincter without inducing gastroesophageal reflux. Only a few studies are available on long-term results after operative treatment. Fifty-one patients were studied with regard to long-term results after open transabdominal extramucosal myotomy of the distal esophagus along with partial anterior fundoplication (Dor procedure). Clinical data were collected by standardized interviews, and symptoms were assigned a score ranging from 0 to 3 according to severity and frequency. The pre- and postoperative symptoms were comparable in 50 patients. The median duration of follow-up was 88 months (range: 12-160 months). Operative time was a median of 80 min. Two esophageal mucosal tears were recognized intraoperatively and promptly repaired. Postoperative morbidity occurred in two patients (3.9%). Very good or good long-term results after surgical therapy were achieved in 49 patients (96.1%). Forty-seven patients (92.2%) have no or rare dysphagia. The frequency of regurgitation as well as chest pain was also significantly reduced after surgery. Forty-nine patients (96.1%) either maintained or gained weight. Preoperative duration of symptoms, follow-up, age, and gender had no influence on the results (p > 0.05). Two patients (3.9%) mentioned occasional heartburn. Five patients (9.8%) took or still take proton pump inhibitors postoperatively. Severe stage IV symptoms due to peptic stricture and dolichomegaesophagus required reoperation in one patient (2%). The results show that myotomy and the antireflux procedure (semifundoplication) lead to long-term relief of dysphagia without inducing reflux at a low operative risk. Since long-term results are as yet not available for minimally invasive surgery, it remains to be seen if this operative technique will become the primary surgical procedure for this disease.

Early experiences of robotic surgery in children

Laparoscopic surgery using a robotic system (Da Vinci) was recently introduced into surgical practice for adult patients. To investigate the feasibility of this system in pediatric surgery, laparoscopic fundoplication (Thal and Nissen), cholecystectomy, and bilateral salpingo-oophorectomy were performed. Eleven children with a mean age of 12 years (range, 7-16 years) underwent either laparoscopic anterior partial fundoplication (Thal, n = 8) or Nissen fundoplication (n = 3) for correction of gastroesophageal reflux disease in the presence of uncontrolled symptoms of regurgitation and pulmonary infection. Two children underwent laparoscopic cholecystectomy due to symptomatic cholecystolithiasis. One child underwent bilateral salpingo-oophorectomy due to a gonadoblastoma. Mean operating time for fundoplication was 146 min (range, 105-180 min), the operating times for cholecystectomy were 150 and 105 min, and that for salpingo-oophorectomy was 95 min. No complications were registered during either the robotic procedures or the postoperative courses. Compared to conventional laparoscopy, the three-dimensional high-quality vision, advanced instrument movement, and improved ergonomic position of the surgeon appear to enhance surgical precision. Robotic surgery in children using the Da Vinci system seems to be feasible and safe. However, the technique is limited due to the fact that instruments adapted to the size of small children are not available. Furthermore, the high costs and prolonged system setup are disadvantages.

Laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia.

Although surgical myotomy is considered the gold standard, many different treatments have been advocated for achalasia. There are now a number of reports of cardiomyotomy being performed laparoscopically. This is a prospective study of 82 patients (47 male and 35 female; median age, 47 years) who underwent laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia. Four of the 82 procedures required conversion to open surgery, all during the early stages of the series, and two required early reoperation for a postoperative problem. The median operating time was 80 min (range, 32-210). the median hospital stay was 3 days (range, 2-18), and normal physical activity was resumed after a median of 2 weeks (range, 3 days to 12 weeks). Follow-up ranged up to 8 years (median, 2). Postoperatively, symptoms of dysphagia (to both solids and liquids), heartburn, odynophagia, chest pain, regurgitation, and cough were significantly reduced in all patients. The median overall satisfaction score (graded from 0 to 10, with 10 representing total satisfaction) was 9 (range, 0-10), and 90% of patients were highly satisfied with the surgical outcome. Laparoscopic cardiomyotomy with anterior partial fundoplication achieves excellent symptomatic relief for patients with achalasia, and it can be performed with minimal morbidity.

Outcome of laparoscopic anterior 180-degree partial fundoplication for gastroesophageal reflux disease

Although Nissen fundoplication controls gastroesophageal reflux disease effectively, it is associated with an incidence of side effects. For this reason we have investigated the use of a laparoscopic 180-degree anterior fundoplication as a technique that has the potential to control reflux, but with less associated post-operative dysphagia and fewer gas-related side effects. Good short-term (6-month) outcomes have been previously reported within the context of a randomized trial. This report details the technique were used and describes the outcome of this procedure with longer follow-up in a much larger group of patients. The outcome for patients with gastroesophageal reflux disease who underwent a laparoscopic anterior 180-hemifundoplication was determined. Clinical follow-up was carried out prospectively by an independent scientist who applied a standardized questionnaire yearly following surgery. This questionnaire evaluated symptoms of reflux, postoperative problems including dysphagia, gas bloat, ability to belch, and overall satisfaction with clinical outcome. From July 1995 to May 1999, a total of 107 patients underwent a laparoscopic anterior hemifundoplication. Four patients underwent further surgery for recurrent heartburn, and persistent troublesome dysphagia occurred in one. At 1 year 89% of patients remained free of reflux symptoms, and at 3 years 84% remained symptom free. Of those with symptoms of reflux, approximately half of them had only mild symptoms. The overall incidence and severity of dysphagia for liquids and solids was not altered by partial fundoplication. Epigastric bloating that could not be relieved by belching was uncommon, and only 11% of the patients at 1 year and 10% at 3 years following surgery were unable to belch normally. Overall satisfaction with the outcome of surgery remained high at 3 years' follow-up. Laparoscopic anterior partial fundoplication is an effective operation for gastroesophageal reflux, with a low incidence of side effects and a good overall outcome.

Treatment of esophageal achalasia with laparoscopic heller myotomy and dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients

In this article we report our experience in 100 consecutive achalasia patients who were treated with laparoscopic Heller myotomy and Dor antireflux fundoplication, with particular regard to the technical problems encountered, the learning curve, and the long-term follow-up. The operation was completed laparoscopically in 94 patients, with a median operative duration of 150 minutes, and a continuous steady reduction in the operating time from the first patients to the last. In six patients the operation was completed through “open” access. Postoperative complications were recorded in six cases. Follow-up was completed in all 100 patients, with a median follow-up of 24 months. Overall, actuarial life-table analysis showed a probability of 90% that patients would be symptom free over a 5-year period. Radiologic assessment showed a significant reduction in the esophageal diameter, and manometry showed a significant reduction in the lower esophageal sphincter resting pressure and residual pressure. Twenty-four—hour pH monitoring showed postoperative reflux in 6.9% of the patients. Persistent dysphagia or chest pain was reported by eight patients, which constituted treatment failures. Seven of these eight patients were eventually treated with multiple pneumatic dilatations, which were successful in six cases. It was concluded that laparoscopic Heller myotomy with Dor fundoplication is a feasible and effective treatment for achalasia, with an actuarial success rate of 90% at 5 years.

Laparoscopic reoperation following failed antireflux surgery.

The aim was to determine the feasibility of laparoscopic revision surgery following previous open and laparoscopic antireflux operations. The outcome was determined for 27 patients (14 men, 13 women) who had undergone attempted laparoscopic revision between 3 months and 25 years after a previous antireflux operation. Median follow-up was 12 (range 3-48) months. Thirteen patients had previously had an open antireflux procedure (Nissen fundoplication, seven; transthoracic anatomical repair, five; Belsey procedure, one) and 14 a laparoscopic procedure (Nissen, 12; anterior partial fundoplication, two). The indications for revision were: recurrent reflux, 15; paraoesophageal hiatus hernia, six; troublesome dysphagia, six. Fifteen procedures comprised construction of a new Nissen fundoplication, six conversion from a Nissen to a partial wrap, three repair of a paraoesophageal hernia and three widening of the oesophageal hiatus. Revision was successfully completed laparoscopically in 12 patients following a previous laparoscopic procedure and in nine following a previous open operation. Median operating time was 105 min after previous open surgery and 80 min after laparoscopic surgery. No perioperative complications occurred in either group and a good outcome was achieved in 25 of the 27 patients. Laparoscopic reoperative antireflux surgery is feasible. Reoperation is likely to be more difficult following failure of an open procedure than a laparoscopic one.

Thal fundoplication for pediatric gastroesophageal reflux disease.

ALTHOUGH some gastroesophageal reflux (GER) is normal and some patients tolerate even large amounts of GER without any complications, a subset of patients have the complications of GER that result in a disease state known as gastroesophageal reflux disease, (GERD) which is a consideration for medical or surgical intervention. Medical treatment that alters esophageal motility, promotes gastric emptying, and reduces gastric acid production may ameliorate the symptoms of reflux. Many patients respond poorly to medical therapy or find the medications intolerable. Many are just not compliant. For GER complications such as recurrent pneumonitis, acute life-threatening events (ALTE), unremitting vomiting, and failure to thrive, surgical treatment offers a lasting cure (95+%). The partial anterior fundoplication as described by ThaI is our operation of choice. We believe it is as effective as a complete wrap in eliminating reflux and that it has fewer complications such as gas bloat and adhesive intestinal obstruction. Surgical treatment of GERD is perhaps more effective in children than in adults, and therefore surgery is used more often for pediatric patients with significant GER. All surgical fundoplication procedures are based on the principle of establishment of an intraabdominal portion of the esophagus coupled with plication of the stomach to the lower esophagus to establish an angle of His, thus creating an antireflux mechanism. The most commonly performed surgical procedure is the 360-degree wrap described by Nissen. l We prefer the 180-degree wrap described by ThaF (Table 1).

Is a gastric drainage procedure necessary at the time of antireflux surgery?

Gastroesophageal reflux is part of a generalized foregut motility disorder, which may also include delayed gastric emptying. With persistence of gastroesophageal reflux, or the presence of complications, including recurrent aspiration syndrome and esophageal stricture formation, surgical correction may be indicated. It is uncertain whether a procedure to resolve delayed gastric emptying is indicated at this time as well. Sixty-seven children with proven gastroesophageal reflux had preoperative gastric emptying assessed using 99Technetium-Sn-colloid labelled milk. Delayed gastric emptying was defined as a gastric residual activity of more than 40% at 2 hours after feeding. The antireflux operation was a partial anterior fundoplication. Postoperative milk scans assessed the effect of surgery on gastric emptying. Gastric emptying at 2 hours improved overall from a median of 22% before surgery to 17% after surgery. In 17 patients delayed gastric emptying was identified before surgery; in 15 of those it returned to within normal limits after surgery. In 50 children with normal gastric emptying before surgery (gastric residual activity at 2 hours 16%), 14 (28%) showed delayed gastric emptying in the postoperative scan. Delayed gastric emptying is common in children who undergo surgery for gastroesophageal reflux disease. A partial anterior fundoplication antireflux operation improves gastric emptying to within normal limits in the majority (88%) in this group, rendering a synchronous gastric drainage procedure unnecessary.

Is a Gastric Drainage Procedure Necessary at the Time ofAntireflux Surgery?

BackgroundGastroesophageal reflux is part of a generalized foregut motility disorder, which may also include delayed gastric emptying. With persistence of gastroesophageal reflux, or the presence of complications, including recurrent aspiration syndrome and esophageal stricture formation, surgical correction may be indicated. It is uncertain whether a procedure to resolve delayed gastric emptying is indicated at this time as well.MethodsSixty‐seven children with proven gastroesophageal reflux had preoperative gastric emptying assessed using 99Technetium‐Sn‐colloid labelled milk. Delayed gastric emptying was defined as a gastric residual activity of more than 40% at 2 hours after feeding. The antireflux operation was a partial anterior fundoplication. Postoperative milk scans assessed the effect of surgery on gastric emptying.ResultsGastric emptying at 2 hours improved overall from a median of 22% before surgery to 17% after surgery. In 17 patients delayed gastric emptying was identified before surgery; in 15 of those it returned to within normal limits after surgery. In 50 children with normal gastric emptying before surgery (gastric residual activity at 2 hours 16%), 14 (28%) showed delayed gastric emptying in the postoperative scan.ConclusionsDelayed gastric emptying is common in children who undergo surgery for gastroesophageal reflux disease. A partial anterior fundoplication antireflux operation improves gastric emptying to within normal limits in the majority (88%) in this group, rendering a synchronous gastric drainage procedure unnecessary.

Laparoscopic Esophageal Myotomy and Anterior Partial Fundoplication for the Treatment of Achalasia

Background. The purpose of this study was to determine the initial results of laparoscopic esophageal myotomy and anterior fundoplication in the treatment of 26 patients with achalasia. Methods. Operative time, complications, and length of hospitalization were recorded for each patient. Postoperative outcomes were assessed by a standardized patient questionnaire, 24-hour esophageal pH studies, and esophageal transit studies. Results. Twenty-six consecutive patients with class IV dysphagia underwent a laparoscopic esophageal myotomy and anterior partial fundoplication, with a single incidence of intraoperative esophageal perforation. The mean operative time was 3.5 hours. The median length of hospitalization was 5 days. Of the 21 patients for whom follow-up was available (median follow-up, 4 months), 19 (90%) were satisfied and 2 (10%) were somewhat satisfied with their surgery. After operation, 14 of the 21 patients (67%) reported no dysphagia (class I), whereas 6 (28%) had class II dysphagia (less than once per week) and only 1 (5%) had class III dysphagia (greater than once per week). Liquid-phase esophageal transit studies (n = 14) revealed a significant improvement in esophageal clearance in the supine position from 18% before operation to 44% after operation ( p = 0.006). Distal esophageal acid exposure was normal in 6 of 7 patients. Conclusions. These early results suggest that laparoscopic esophageal myotomy and anterior partial fundoplication provides efficacious treatment of achalasia.

Gastroesophageal reflux disease (GERD): Back to surgery?

Part 1 GERD - mechanisms and diagnosis: pathogenesis a possible role for helicobacter pylori in the pathogenesis of reflux oesophagus epidemiology clinical symptoms and prognosis endoscopic classification of reflux oesophagitis by the MUSE system diagnosis. Part 2 State of the art - lecture: solving the GORDian knot, I.M. Modlin et al. Part 3 GERD - nonoperative treatment: inhibition of acid secretion treatment of motility disorders interventional endoscopic therapy. Part 4 GERD and Barrett's oesophagus: the prognosis of Barrett's oesophagus and its relationship with GERD endoscopic surveillance of Barrett's oesophagus is there regression in Barrett's oesophagus?. Part 5 Surgical treatment of GERD: Nissen fundoplication - the gold standard long-term outcome after open fundoplication complications and late consequences of open fundoplication for GERD laparoscopic fundoplication - history of a trend-setting operation laparoscopic antireflux surgery - principles governing assessment of patients for endoscopic surgery and options for surgical treatment failure and pitfalls of Nissen repair. Part 6 International results of laparoscopic fundoplication: German experience with laparoscopic antireflux surgery laparoscopic Nissen fundoplication in the USA early results in the Swiss experience with laparoscopic fundoplication for GERD laparoscopic antireflux surgery in the United Kingdom and Ireland laparoscopic floppy Nissen fundoplication - the Groote Schuur hospital experience. Part 7 Safe performance of a laparoscopic fundoplication: laparoscopic treatment of gastro-oesophageal reflux - Nissen-Rosseti fundoplication safe performance of a laparoscopic Nissen fundoplication - standard technique II the technique of Nissen fundoplication laparoscopic Toupet partial fundoplication laparoscopic anterior partial fundoplication laparoscopic treatment of paraoesophageal hernia laparoscopic cardiomyotomy for achalasia. Part 8 Conclusion: gastro-oesophageal reflux disease (GERD) - back to surgery?, M.W. Buchler et al.