Laparoscopic Antireflux Operations Research Articles

АНАЛИЗ ПОВТОРНЫХ ОПЕРАЦИЙ ПОСЛЕ ФУНДОПЛИКАЦИЙ

The purpose: to present the experience of repeated laparoscopic operations after previously performed traditional and laparoscopic fundoplication for hiatal hernia and gastroesophageal reflux disease, to study the reasons for the unsatisfactory results of fundoplications. Materials and methods. This study presents the experience of repeated operations in 78 patients with recurrent hiatal hernia and gastroesophageal reflux disease in the period 2000-2023 (33 men and 45 women aged 21 to 75 years) who had previously undergone laparotomic (15) and laparoscopic (63) fundoplication ) way. Of these, 15 (19.3%) patients were initially operated in our clinic, 63 (80.7%) - in other medical institutions. Results. All 78 patients were reoperated by laparoscopic approach. There were no lethal cases. The examination and analysis of surgical findings revealed the following technical errors made during previous operations: due to an incorrectly formed fundoplication cuff, the fundoplication cuff migrated to the mediastinum (40), the fundoplication cuff was fixed to the stomach cardia (11), and there was an excessive narrowing of the hiatus due to crurorrhaphy ( 5), excessive compression of the esophagus by the cuff (6) and its complete absence (6), the "telescope" phenomenon (7), insufficient mobilization of the fundus of the stomach (13). In case of recurrence, repeated laparoscopic operations were performed: bringing down the fundoplication cuff from the mediastinum with mobilization of the shortened esophagus (50), repeated crurorrhaphy and laparoscopic fundoplication according to Nissen (14), dissection of the gastrosplenic ligament (13), anterior crurorrhaphy with a mesh prosthesis (1). Conclusions. The analysis of repeated laparoscopic antireflux operations showed that they are feasible and less safe than laparotomic ones, but carry a higher risk of complications compared to primary ones and should be performed by experienced surgeons using the same access as the primary operation. The variety of causes of failures and complications of antireflux operations, the technical complexity of repeated operations and the problematic nature of their good results determine the expediency of concentrating patients with hiatal hernia and gastroesophageal reflux disease in specialized hospitals. Laparoscopic revision antireflux surgeries are feasible and less safe than laparotomic ones, but carry a higher risk of complications compared to primary ones and should be performed by experienced surgeons using the same approach as the primary surgery.

Hiatal hernia surgery: laparoscopic versus robotic approach?

Aim. Evaluate the advantages and disadvantages of laparoscopic and robot-assisted anti-reflux operations.General findings. Reflux esophagitis in the association with hiatal hernia on the third place in the structure of gastroenterological diseases. The development of minimally invasive surgical technologies has led to an increase in the number of laparoscopic and robot-assisted anti-reflux operations. The literature review includes 12 studies, the results of which were published from 2002 to 2020, with a total number of patients 1633. In most of them, when comparing laparoscopic and robot-assisted anti-reflux operations, the advantages of one or another technique were not revealed. In some studies, the high cost and duration of the operation were noted when using the da Vinci robotic surgical complex. Other studies have reported possible improvements in the treatment outcomes of patients with large or recurrent hiatal hernias due to the high precision of movement and improved visualization characteristic of therobot-assisted surgeries.Conclusion. It is necessary to conduct more researches on this problem to develop indications for the choice of a particular surgical approach, as well as to create a single transparent algorithm for the surgical treatment of patients with reflux esophagitis and hiatal hernia.

Twenty Years of Antireflux Surgery. Retrospective of a Laparoscopic Surgery Center

Introduction: Non-oncological pathology of the esogastric junction (EGJ) is an area of interdisciplinary interest for many practitioners (endoscopist, gastroenterologist, surgeon, radiologist). This is due to the increased incidence of esogastric junction benign pathology, especially gastroesophageal reflux disease (GERD), currently considered the disease of the 21st century. The overall incidence of GERD is increasing annually. Meta-analyses show the prevalence of this pathology in Western countries of about 10-20%, compared to Asian countries where it is below 10%, in North America of 27.8%, and 25.9% in Europe (1,2,3). Material and Methods: The experience of our department in antireflux surgery represents 20 years (2002-2021) of activity, during this time 768 antireflux interventions were performed for GERD and hiatal hernias (HH). Patients selected for antireflux surgery initially underwent conservative treatment in accordance with applicable international protocols. Approximately 40% of all patients were unwilling to undergo conservative antireflux treatment, and these data are in line with the world literature statistic (4). Moreover, the symptoms of gastroesophageal reflux disease in 24.2% of cases appeared one month after the end of conservative treatment, and in 35.8% after 6 months. Results: The type of antireflux surgery in this period of activity was different and depended on the situation: the individual characteristics of the patient, different approaches to surgical techniques over different periods of time. Laparoscopic antireflux operations predominate in the majority of patients (96.6%) in the last 10 years, compared to previous years, where the rate of traditional interventions was 15-20. The complete fundoplication Nissen-Rossetti, due to the good control of GERD, has become an intervention of choice mainly for patients with GERD. Conclusions: 1. Early diagnosis of refractory forms to medical treatment requires referral of patients to laparoscopic antireflux surgery to avoid severe complications of GERD. 2. The minimally invasive approach to antireflux surgery today is a golden standard, and the use of a complete fundoplication ensures the high effectiveness of these interventions.

P-BN25 Redo-Antireflux surgery long term quality of life retrospective study

Abstract Background Gastro-oesophageal reflux disease (GORD) can have a significant effect on patients quality of life, especially in sever cases. Laparoscopic Antireflux surgery is the most common approach which offers promising long-term outcomes. However, Failure of antireflux procedures are reported in 5% to 10% of the patients who might require a redo-antireflux surgery (Redo-ARS). This study aims to assess the long-term outcomes of Redo-Antireflux surgeries regarding symptoms control and patient satisfaction. Methods Retrospective study for patients who underwent Redo-ARS with a single consultant in the south of England. Follow up was done using The GORD Health-Related Quality-of-Life (GORD-HRQL) scale and patients reported their scores before and after the redo-surgery. Exclusion criteria included follow up less than one year and failure of contacting the patient. Results All patients who underwent Redo-ARS between 2009-2019 were enlisted and 18 -out of the identified 22- were included in the study. Overall, There was a significant decrease in heartburn severity after the redo operation with a median reported severity of 4.5 preoperatively which decreased to 2 after the operation with a P value of 0.00062. This was observed in assessment of heartburn symptoms severity during sleep, laying flat, standing and after meals which all showed improvement after the operation with P values <0.005. There was no statistically significant improvement of dysphagia, odynophagia or bloating. The median follow up was 5 years. Conclusions Redo laparoscopic antireflux operations are technically challenging, however, significant heartburn symptoms control is feasible. Further evaluation of types of surgeries and patient selection can guide decisions regarding further management and guidelines.

Peculiarities of surgical treatment of patients with gastroesophageal reflux disease

Objective. To analyze the effectiveness of various methods of laparoscopic antireflux operations in patients with gastroesophageal reflux disease.
 Materials and methods. The results of treatment of 177 patients with gastroesophageal reflux disease from 2015 to 2021 were analyzed. Patients were divided into three groups: 1st - 62 patients who underwent laparoscopic antireflux surgery of our own modification (Patent of Ukraine No 59772); 2nd - 91 patients who underwent laparoscopic Nissen fundoplication; 3rd - 24 patients who underwent laparoscopic Toupet fundoplication. 
 Results. 36 months after surgery in the 1st group the recurrence rate of gastroesophageal disease was 1.6%, recurrence of hernia of the esophageal orifice - 1.6%, in the 2nd group - 7.7 and 3.3%, respectively; in the 3rd group - 12.5 and 8.3%, respectively.
 Conclusions. The application of a new integrated approach to the surgical treatment of gastroesophageal reflux disease reduces the number of postoperative complications (gas -bloat syndrome - 3 times, dysphagia - 5 times), the recurrence rate of gastroesophageal reflux disease - 5 times and recurrence of esophageal hernia - 2 times, improves the quality of life of patients 36 months after surgery in 2.6 times and increases the timeliness of diagnosis and facilitates the choice of differentiated treatment tactics.

Anti-reflux mucosectomy (ARMS) results in improved recovery and similar reflux quality of life outcomes compared to laparoscopic Nissen fundoplication.

Anti-reflux mucosectomy (ARMS) is a new endoscopic procedure involving a hemi-circumferential endoscopic mucosal resection (EMR) around the gastroesophageal junction. We aim to compare perioperative and quality of life outcomes of patients with reflux who underwent ARMS to a comparable group who underwent laparoscopic Nissen fundoplication (NF). A retrospective review of a prospectively maintained quality database was performed. All patients who underwent ARMS (n = 33) were matched with patients who underwent NF (n = 67). Clinical and quality of life (QOL) outcomes were collected preoperatively and up to two years postoperatively, measured by the Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Score. Outcomes were compared using the Wilcoxon rank-sum and Fisher's exact test. While 10 patients (30.3%) who underwent ARMS required additional laparoscopic anti-reflux operations, the ARMS group had shorter OR time (p<0.001), less estimated blood loss (p<0.001), shorter hospital stay (p<0.001), less pain at discharge (p = 0.007), earlier narcotic discontinuation (p<0.001), and earlier return to activities of daily living (p<0.001) compared to the NF group. There was no difference in 30-day complication rates, emergency room visits, or readmission rates between the groups. There was no difference between ARMS and NF groups in terms of GERD-HRQL, RSI, or Dysphagia scores at 3 weeks, 6 months, 1 year, or 2 years postoperatively. However, the ARMS group reported less symptoms of gas and bloating postoperatively at all time points (all p<0.05). Both groups reported increased dysphagia at 3 weeks postoperatively (p<0.01) but this did not persist at 6 months, 1 year, or 2 years. While ARMS had better perioperative outcomes compared to NF, reflux quality of life outcomes were comparable. ARMS can be an effective endoscopic intervention for GERD when performed on appropriately selected patients without limiting future laparoscopic anti-reflux interventions.

REDO LAPAROSCOPIC ANTIREFLUX SURGERY IN PATIENTS WITH HIATAL HERNIA

Summary. The purpose was to study the features and results of redo laparoscopic antireflux surgery in our clinic.&#x0D; Materials and methods. For the period from 2008 to 2019, in our clinic, laparoscopic antireflux operations were performed in 1164 patients. 54 patients underwent laparoscopic reoperation during the study period based on the following indications: recurrence of hiatal hernia (n = 38), recurrent reflux (n = 4), dysphagia (n = 8), severe pain (n = 5). All patients underwent repeated examinations in our clinic, telephone interviews, mailing of special questionnaires. All complaints were recorded, the quality of life was determined according to the GERD-HRQL questionnaire.&#x0D; Results. All redo operations were performed laparoscopically without conversion to laparotomy. Intraoperative complications were observed in 11.11 % of patients. Long-term follow up from 6 months to 6 years was observed in 90.74 % of patients. The quality of life of patients according to the GERD-HRQL questionnaire significantly improved in long-term follow-up (p &lt;0.001). Good results were observed in 91.84 % of patients after redo operations. The third operation was needed in 5.6 % of patients.&#x0D; Conclusion. Redo laparoscopic antireflux operations are technically difficult surgical interventions, and should be performed by surgeons with big experience in the antireflux surgery.&#x0D; Laparoscopic antireflux surgery provide good long-term results in 90 % of patients.

Ways to improve the results of laparoscopic antireflux operations in patients with big hiatal hernias.

The purpose of our study is to evaluate expediency of Platelet-Rich Plasma with self-fixated ProgripTM mesh use in hiatal hernia repair. The study was performed on 144 patients with gastroesophageal reflux with large hiatal hernias (the size of hernias 10-20 cm2 ), who underwent Nissen fundoplication and crurarrhaphia. All patients were divided into two groups: I group (71 patients) - we used non-absorbable self-fixating ProgripTM mesh for reinforcement of crurarrhaphia, II group (73 patients) – crurarrhaphia was done without mesh. In the patients of I group pieces of mesh were infiltrated by 2-4 ml of autologous PRP. Follow-up was completed in 128 (88,9%) patients with a mean follow-up duration of 39 months (range 12-60 months). There were no serious complications in the patients of both groups. During the 60 months of follow-up, 2 recurrences occurred in the mesh group and 14 recurrences appeared in the non-mesh group (p&lt;0.05). Patient satisfaction was significantly higher in the mesh group (p&lt;0.05). Our study has shown that the collagen content is reduced in patients with large HH. Thus, in such patients it is advisable to use mesh for crural reinforcement. The use of PRP provides a fast ingrowth of mesh, acts as catalyst to increase collagen synthesis and deposition, which promote to reduce the risk of recurrences.

Changes in Re-Operative Intervention for Failed Anti-Reflux Surgeries Over the Past 19 Years in Our Practice

Background: Parallel with the increasing number of laparoscopic anti-reflux operations there is increasing number of re-operative interventions for failed procedures. We have performed 316 re-operative procedures from Feb/1992 to Nov/2010. The aim of this study was to compare presenting symptoms, endoscopic findings and operative approaches over the years. Methods: A retrospective review of a prospectively maintained database was performed of patients who underwent re-operative intervention after one or more previous anti-reflux surgeries. After institutional board review the database and charts were reviewed and analyzed for presenting symptoms, pre-operative endoscopic findings and operative procedures. Results: There was a significant increase in the number of re-operative interventions over the years (first 5 yrs: 8 procedures, second 5 yrs: 63 operations, third 5 yrs: 105 operations, last 4 yrs: 140 operations). The procedure was the first re-operation in 289 cases, second in 25 cases, third in 1 case and in 1 case it was the fourth re-operation. We divided the 316 operations into two halves, the first 158 patients (Group 1) were operated on from 2/ 1/1992 to 6/5/2006, the second half (Group 2) was operated on from 6/15/2006 to 11/2/ 2010. The most common indications for a re-operative procedure were heartburn (27% and 26%) and dysphagia (33% and 28% in each group) and did not change over the years. Preoperative upper endoscopy revealed a recurrent sliding hiatus hernia (> 2cm) in 61 and 71 patients, disrupted fundoplication in 74 and 89 patients, twisted fundoplication or twocompartment stomach in 20 and 26 cases, slipped fundoplication in 56 and 54 patients and a paraesophageal hernia in 32 and 37 patients in each group respectively. There was no significant difference in the pattern of failure over the years. Re-operation consisted of redo-fundoplication in 141 and 81 patients; Roux-en-Y reconstruction (RNY) in 14 and 70 patients and esophagectomy was performed in 3 and 7 patients, respectively. A significantly higher number of procedures were done laparoscopicaly in the second group (108 vs 80, p=0.001). A large hiatus hernia (> 2 cm) with a slipped fundoplication was found in 29 and 38 patients in the two groups. In this subset of patients a significantly larger number of RNY reconstructions were performed in the second group (3 vs 20, p=0.0003), while gastroplasty was used more frequently in the first group (8 vs 0, p=0.0001). Discussion: While there has been no significant change in the presenting symptoms and anatomical derangements encountered in patients undergoing re-operative intervention for failed fundoplication, a larger number of cases have been completed laparoscopically with an increasing utilization of RNY construction.

Endoscopic Therapies for the Treatment of Reflux Disease

Endoscopic techniques for the treatment of reflux disease were first introduced in 2000 as an alternative to laparoscopic antireflux operations. Because of reports of long-term treatment failure with laparoscopic fundoplication and the fact that surgery is increasingly being reserved for the relatively small proportion of patients with complicated reflux disease, attempts to develop safe, effective, and durable endoscopic approaches to antireflux surgery continue. Techniques include radiofrequency ablation, injection therapy, and suturing/stapling techniques. Of these, the suturing/stapling techniques are most similar to the anatomic restructuring of the gastroesophageal junction provided by fundoplication. While early attempts at endoscopic suturing have been disappointing, significant advances in endoscopic instrumentation, a more complete understanding of the gastroesophageal junction anatomy, and improvements in the technical skills of the endoscopic surgeon have been realized. As a result, techniques now being tested, such as the endoluminal fundoplication, may prove more effective and durable than previous endoscopic antireflux procedures.

Laparoscopic Anti-Reflux Surgery is Effective in Obese Patients with Gastro-Oesophageal Reflux Disease

Obesity has long been regarded as a risk factor for the development of gastro-oesophageal reflux disease (GORD). It has been claimed that surgical efficacy of laparoscopic anti-reflux operations is decreased in obese patients. The aim of this study was to assess whether laparoscopic anti-reflux surgery is effective in obese patients with GORD compared to non-obese patients. A total of 366 patients (mean age 44 years; range, 12-86 years) underwent laparoscopic anti-reflux surgery between 1997-2003. Of these, 74 patients were considered obese; 58 patients had a body mass index (BMI) of 30-34 kg/m(2) and 16 were classified as morbidly obese with a BMI >or= 35 kg/m(2). Pre-operative symptomatic scoring, indications for surgery, pH studies, operative times and complications were compared between obese and non-obese patients. Symptomatic outcome and Visick score between the two groups were assessed at 6 weeks, 6 months and 1 year following surgery. Failure of medical treatment was the main reason for surgery in all groups. Operative time was longer in obese patients (mean time 93 min compared to 81 min; P = 0.0007), the main difficulty being gaining access because of their body habitus. All groups found the procedure to be effective in symptomatic outcome, 91% of obese patients compared to 92% of non-obese patients scored Visick I or II at 6 weeks' postoperatively. Similar Visick scoring was shown between the two groups at 6 months and 1 year, and in the morbidly obese group. The outcome of laparoscopic anti-reflux surgery is similar between obese and non-obese patients with no trend towards a worse outcome in the obese or morbidly obese. Obesity should not be seen as a contra-indication, although it may be more technically challenging in this group of patients. Good results can be achieved in obese patients.

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center. Data on patients undergoing antireflux surgery in our unit has been prospectively collected and includes more than 600 primary laparoscopic antireflux operations since 1993. Laparoscopic reoperations have been performed between 1996 and 2005 for patients suffering recurrent reflux, dysphagia or severe gas bloat symptomatic despite medical treatment. All patients underwent preoperative barium studies and endoscopy with selective manometry and pH studies. Symptomatic outcomes were evaluated at 6 weeks and 12 months with Visick scores. Anatomical results were assessed with barium studies at between 6 and 12 months. Thirty-five laparoscopic reoperations were performed in 20 women and 13 men (median age 56 years). Primary surgery had been performed in our unit in 27 (77%) and elsewhere in eight (23%). Median time from primary surgery was 28.5 months (5-360). Two patients underwent a second reoperation. Indication was recurrent reflux in 28 (80%), dysphagia in five (14%) and gas bloat in two (6%). Thirty-two of the 35 reoperations (91.4%) were completed laparoscopically, median operating time was 120.5 min (65-210) and median hospital stay 2 days. There was no mortality and there were only five minor complications. Twelve-month follow-up was available for 32 reoperations (91%). Overall good symptomatic outcomes were obtained in 26 (74%) Visick I or II at 6 weeks and 24 of 32 (75%) at 12 months. In reoperations for dysphagia/gas bloat there was a relative risk of 4.26 of a poor symptomatic outcome (Visick III or IV) at 12 months compared to those for recurrent reflux (P < 0.05, Fisher's exact test). Laparoscopic reoperation is feasible with low conversion rates and minimal morbidity for patients who have undergone previous abdominal or thoracic hiatal repair. Symptomatic outcomes are generally good, particularly if the indication is recurrent reflux.

Laparoscopic Fundoplication in Elderly Patients With Gastroesophageal Reflux Disease

It is unclear if age should be considered a factor in the choice of treatment for gastroesophageal reflux disease (GERD) and if fundoplication in elderly patients is as safe and effective as it is in younger patients. We hypothesized that the outcome of laparoscopic antireflux operations in patients younger than 65 years is similar to that of patients 65 years and older. Retrospective review of findings from a prospectively acquired database. University-based tertiary care center. Three hundred four consecutive patients underwent laparoscopic fundoplication for GERD. Two hundred forty-one patients were younger than 65 years (group A; median age, 46 years), and 63 patients were 65 years or older (group B; median age, 69 years). Presence, duration, and severity of GERD symptoms; presence of a hiatal hernia or esophageal stricture; duration of operation; incidence of complications; and length of hospital stay. Elderly patients more often had regurgitation and respiratory symptoms in addition to heartburn. Hiatal hernias were more common among elderly patients (77% vs 51%). The duration of the operation was similar for the 2 groups. The incidence of intraoperative and postoperative complications was low and similar in the 2 groups. The median hospital stay was 24 hours for each group. Heartburn resolved in approximately 90% of patients in each group. Elderly patients more often had hiatal hernias and respiratory symptoms. Laparoscopic antireflux surgery was as safe in elderly patients as it was in younger patients, and clinical outcomes were as good.

Early post operative clinical and functional results after laparoscopic antireflux procedure in GERD patients with hiatal hernia

Introduction/aims: GERD complicated with hiatal hernia constitutes a technically more difficult approach and it may influences the functional results of therapy. The authors analyzed the clinical outcomes and early follow up results of laparoscopic antireflux operations for GERD patients with or without hiatal hernia.

Laparoscopic reoperation following unsuccessful antireflux surgery in childhood

We determine the feasibility of laparoscopic revision surgery in children following previous open and laparoscopic antireflux operations. To give an objective overview about this topic, we analyzed the outcome of 15 children (8 girls and 7 boys) who had undergone attempted laparoscopic revision between 4 and 72 months (median 16 months) after a previous antireflux operation. Seven patients had previously undergone an open antireflux procedure (4 Nissen fundoplication; 3 Thal procedure) and 8 a laparoscopic procedure (5 Nissen; 3 Toupet's procedure). Two of these children were mentally handicapped. The indications for revision were: recurrent reflux, 5; valve migration, 5; valve dismount, 5. Eight procedures comprised construction of a new Nissen fundoplication and in 7 cases a Toupet's procedure was performed. Revision was successfully completed laparoscopically in 10 cases, 7 of 8 patients following a previous laparoscopic procedure and in 3 of 7 following a previous open operation. Operating time ranged between 70 and 140 minutes (median 90 minutes). No perioperative complications occurred in either group. All patients were discharged within 3 to 4 days after the redo procedure. Follow-up time varied between 6 months and 7 yrs. Preoperative symptoms were relieved in all patients and all antireflux medication has been discontinued, except in two cases that still had rare symptoms. Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with good results, in the hands of experienced endoscopic surgeons. Reoperation is likely to be more difficult following failure of an open procedure than after failure of a laparoscopic one. Concerning the type of procedure, redo surgery is more difficult to perform after Nissen's than after Toupet's or Thal's procedure.

Laparoscopic Reoperation Following Childhood Unsuccessful Antireflux Surgery in Childhood

We determine the feasibility of laparoscopic revision surgery in children following previous open and laparoscopic antireflux operations. To give an objective overview about this topic, we analyzed the outcome of 15 children (8 girls and 7 boys) who had undergone attempted laparoscopic revision between 4 and 72 months (median 16 months) after a previous antireflux operation. Seven patients had previously undergone an open antireflux procedure (4 Nissen fundoplication; 3 Thal procedure) and 8 a laparoscopic procedure (5 Nissen; 3 Toupet's procedure). Two of these children were mentally handicapped. The indications for revision were: recurrent reflux, 5; valve migration, 5; valve dismount, 5. Eight procedures comprised construction of a new Nissen fundoplication and in 7 cases a Toupet's procedure was performed. Revision was successfully completed laparoscopically in 10 cases, 7 of 8 patients following a previous laparoscopic procedure and in 3 of 7 following a previous open operation. Operating time ranged...

Management and outcome of complications after laparoscopic antireflux operations.

Perioperative complications of laparoscopic antireflux operations are infrequent and treatable and do not cause permanent disability. Retrospective review of all patients with laparoscopic antireflux operations for the management and outcome of all complications. University medical center. All 538 patients who underwent operation from January 20, 1993, through December 28, 1999. Complications were defined as any major or minor deviation from the standard postoperative clinical pathway. Minor complications did not require invasive treatment and were not expected to result in permanent disability. Major complications required invasive treatment or could result in permanent disability. The frequency of complications was also stratified into those that occurred during primary antireflux procedures and those that occurred during reoperations for previously failed procedures. Ninety-two complications occurred in 538 operations (17.1%). Sixty-eight patients (12.6%) experienced minor complications. Postoperative ileus was the most common complication (n = 37 [6.9%]), followed by pneumothorax (n = 13 [2.4%]) and urinary retention (n = 10 [1.9%]). Major complications were present in only 24 patients (4.5%) and occurred significantly more frequently after reoperations. Of these, dysphagia was the most frequent complication observed (n = 11 [2.0%]), followed by perforated viscus (n = 4 [0.7%]). Two patients (0.4%) died. All but 4 major complications resulted in full recovery. Major complications in laparoscopic antireflux surgery are rare, their treatment is straightforward, and permanent disability is uncommon. Complications occur twice as often during reoperations, highlighting the difficulty in performing these procedures. Although primary laparoscopic antireflux operations are performed by many general surgeons routinely, reoperations should be performed by a team experienced in laparoscopic esophageal surgery.

Laparoskopische partielle Fundoplicatio nach Toupet als generelle chirurgische Therapieform der gastrooesophagealen Refluxkrankheit 1-Jahresresultate einer auf 5 Jahre ausgelegten prospektiven Langzeitstudie

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

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.

An analysis of operations for gastroesophageal reflux disease: identifying the important technical elements.

Better understanding of the pathogenesis of gastroesophageal reflux disease in recent years has not been accompanied by appreciable advances in the design of antireflux operations. In many cases, operations are still being performed just as they were described 30 years ago. It is important now to go beyond the eponymous procedures traditionally associated with antireflux operations and to identify the technical elements that contribute to effective and durable fundoplications. To compare antireflux operations and identify the important technical elements. Retrospective study in a university-based tertiary care center. Two hundred one patients had laparoscopic fundoplications for gastroesophageal reflux disease. The first 22 patients underwent Nissen-Rossetti procedures (360 degree wrap; no division of short gastric vessels). Subsequently, 82 patients had a total (360 degree Nissen wrap) fundoplication and 97 patients had a partial (240 degree Guarner wrap) fundoplication (both with the short gastric vessels divided), with the choice between them based on the quality of esophageal peristalsis. The 3 groups of patients were similar in age, duration of symptoms, incidence of hiatal hernia, and incidence of esophagitis. Resolution of heartburn, incidence of postoperative dysphagia, and stability of the reconstruction. The resolution of heartburn was achieved for 15 patients (68%) who had the Nissen-Rossetti procedure, 73 patients (89%) who had a 360 degrees Nissen wrap, and 88 patients (91%) who had a 240 degree Guarner wrap. Postoperative dysphagia occurred in 3 patients (14%) having the Nissen-Rossetti procedure, 5 patients (6%) having a 360 degree wrap, and 2 patients (2%) having a 240 degree wrap. Herniation or disruption of the wrap occurred postoperatively in 9 patients (4.5%). Review of the videotapes of these 9 operations showed that important technical elements had been omitted in 8. Seven patients required a second operation. Laparoscopic antireflux operations control symptoms without producing adverse effects if the following technical elements are included: the hernia is repaired and the hiatus reduced to a normal size, the short gastric vessels are divided, a total or partial wrap is used based on the quality of esophageal peristalsis, and the wrap is anchored in the abdomen.