Laparoscopic Antireflux Surgery Research Articles

Laparoscopic Operation for Giant Hiatal Hernia

Type III hiatal hernia (giant hiatal hernia) is a mixture of type I (sliding hernia) and type II (paraesophageal hernia) hiatal hernias and sometimes causes severe complications if stomach necrosis has occurred. Therefore, surgical treatment is recommended. We discuss the available treatments for type III hiatal hernia and describe our procedure for laparoscopic antireflux surgery. We performed Nissen or Toupet fundoplication, depending on the esophageal function of each patient. Crural repair should be performed with calibration using a 56-Fr bougie to avoid postoperative dysphagia. As much as possible of the hernia sac should be removed to prevent hernia recurrence. Some authors have reported that laparoscopic antireflux surgery for type III hiatal hernia is a technically challenging and controversial procedure. However, the outcomes at our hospital have been excellent, and the level of patient satisfaction has been high.

Laparoscopic Nissen fundoplication combined with posterior gastropexy in the surgical treatment of gastroesophageal reflux disease (GERD)

We read with interest the work by Tsimogiannis et al. [1], whose prospective randomized trial supported the use of a posterior gastropexy as a component to laparoscopic Nissen fundoplication. The level of evidence they reported is crucial to standardizing the technique of laparoscopic antireflux surgery. To date, evidence has largely been either observational or retrospective in nature despite the fact that antireflux surgery has been described for half a century. The inclusion of a gastropexy to prevent herniation of the fundoplication into the chest can be attributed to Rudolph Nissen [2] in 1961. Shortly thereafter, in the late 1960s, Lucius Hill [3] pioneered the repair that bears his name by demonstrating a successful posterior gastropexy that entailed anchoring the gastroesophageal junction to the median arcuate ligament. By 1977, after using this approach for 559 patients undergoing surgery for hiatal hernia, Dr. Hill [4]reported only 5 (0.89%) recurrences with 95% follow-up assessment. We applaud the authors for finally providing level 1 evidence that a posterior gastropexy has a positive impact on the results of the operation without worsening dysphagia. We in fact use a posterior gastropexy routinely during our laparoscopic Nissen fundoplications, even after lung transplantation [5]. Furthermore, in addition to the gastropexy described by Tsimogiannis et al. [1], we routinely place two stitches, one on each side of the fundoplication, to pexy the fundoplication and the esophagus to the diaphragm. These ‘‘apical’’ stitches incorporate the top of the fundoplication, the esophagus, and the uppermost portion of the crus, and at the same time pexy the fundoplication so as to avoid telescoping of the esophagus through the repair.

Uso de próteses na correção cirúrgica das hérnias hiatais

RACIONAL: Uma das principais complicações após a fundoplicatura laparoscópica é a migração do fundo gástrico para o tórax, com ou sem ruptura da válvula. Isso pode ocorrer como consequência de fechamento inadequado do hiato diafragmático, por ruptura das suturas realizadas ou por laceração das fibras musculares manipuladas. OBJETIVO: Estudar a utilização da tela de Prolene® ou de Dacron® para reforçar o fechamento do hiato diafragmático. MÉTODOS: Foram operados 15 pacientes (6 homens e 9 mulheres) com idade média de 46 anos (22 a 78) tendo-se realizado operação laparoscópica anti-refluxo, utilizando-se tela Prolene® ou Dacron® para reforçar a crura hiatal. Os pacientes foram operados sob anestesia geral, por videolaparoscopia utilizando cinco trocárteres. RESULTADOS: O tempo médio de operação foi de 120 minutos. Não ocorreu nenhum óbito. O tempo pós-operatório médio foi de 3,5 dias. Os pacientes retornaram à suas atividades habituais em torno do 10º dia do pós-operatório. O tempo médio de seguimento foi de cinco anos. Em apenas dois pacientes, nos quais foram utilizadas em um a tela de Dacron® e em outro Prolene®, ocorreu migração da tela para o lúmen esofágico ocasionando disfagia. CONCLUSÃO: Utilizar tela nas hiatoplastias videolaparoscópicas é boa alternativa para o fechamento dos defeitos diafragmáticos nas grandes hérnias hiatais, na correção da esofagite de refluxo associada ao esôfago de Barrett, ou em caso de recorrência da hérnia hiatal ou esofagite após correção cirúrgica prévia.

Age and body mass index: significant predictive factors for successful laparoscopic antireflux surgery

Laparoscopic antireflux surgery (LARS) is a feasible treatment for gastroesophageal reflux disease (GERD) patients, but it is unclear who will benefit from the surgery. This study investigated patients' GERDspecific quality of life (GsQOL) and analyzed the factors leading to the performance of successful LARS. Twenty-six (57.8%) of 45 consecutive patients who underwent LARS for GERD during the last decade were enrolled. All patients were evaluated by 24-h pH monitoring, esophageal manometry, esophagogastro-duodenoscopy and physical examinations. GsQOL was assessed by a visual analog scale, and the difference between the pre- and postoperative scores was defined as the visual analog scale improvement score (VASIS). The patients were classified into three groups based on the VASIS, and their clinical factors and surgical outcomes were compared. The high VASIS group patients (>70 VASIS; Excellent group) patients were significantly younger and obese in comparison to low the VASIS group (<30 VASIS; Poor group) consisting of older nonobese patients (P < 0.05). A multiple regression analysis revealed that age <60 years and body mass index (BMI) >25 kg/m(2) were significant factors that affected postoperative GsQOL. No other clinical or surgical factors had any influence on the postoperative GsQOL. These results suggest that age and BMI can be predictive factors for the performance of successful LARS.

Laparoscopic Antireflux Surgery in Patients with Throat Symptoms: A Word of Caution

A subset of patients undergoing laparoscopic fundoplication presents with atypical throat symptoms, and the benefit of surgery in these patients is debated. These patients can present with throat symptoms alone or in combination with typical reflux symptoms. We evaluated the clinical outcome in these patients and compared their outcomes with a larger group of patients who did not have throat symptoms before fundoplication. Outcome data for 893 consecutive patients who underwent a laparoscopic fundoplication from January 2002 to June 2008 were collected prospectively and managed on a database. Ninety-three patients with atypical throat symptoms were identified, and divided into subgroups with (n=66) and without (n=27) typical reflux symptoms (heartburn and/or regurgitation), and outcomes were compared with patients (n=800) who didn't have throat symptoms. Symptoms were assessed with analog symptom scores for heartburn and dysphagia, as well as satisfaction with the surgical outcome. Case records for patients with throat symptoms were also reviewed to obtain more detail about specific throat symptoms and their resolution. Cough was the commonest atypical symptom, followed by sore throat. Heartburn scores improved following surgery in all patient groups. Dysphagia was more common 3 months after surgery in patients without throat symptoms, although there were no differences for dysphagia at later follow-up. Following surgery satisfaction scores were highest in patients with atypical throat symptoms who also had typical reflux symptoms, and the scores were lowest in patients who only had atypical throat symptoms. Nearly twice as many patients who had throat and reflux symptoms reported improvement or resolution of symptoms, compared to patients who only had throat symptoms. Fundoplication achieves a good outcome in patients with atypical throat symptoms who also report typical symptoms of reflux. However, surgeons should be cautious about operating on the subgroup of patients with objective evidence of gastroesophageal reflux who describe throat symptoms but do not report heartburn or regurgitation. In this subgroup, expectations of a good outcome should be minimized.

Is Concomitant Cholecystectomy Safe During Laparoscopic Anti-Reflux Surgery?

The goal of this study is to prospectively evaluate the safety of concomitant cholecystectomy during laparoscopic anti-reflux surgery (LARS). A total of 1000 patients underwent LARS between May 2004 and August 2009. Patients who had a LARS procedure alone were defined as group A and those who had cholecystectomy during the LARS were defined as group B. All data, including demographics, operative details, perioperative complications, and outcomes, were recorded to the prospective database. Chi-square and t-test were used for statistical analysis. There were 934 (93.4%) patients in group A and 66 (6.6%) in group B. Cholelithiasis (n = 48) and gallbladder polyp larger than 10 mm (n = 18) were the indications for cholecystectomy. Demographic characteristics were similar among the groups. There were no mortality and conversion. The mean operating time was 50 minutes for group A and 80 minutes for group B (P = 0.0001). The mean hospital stay was 1 day for each group. The mean follow-up was 35 and 38 months for groups A and B, respectively (P = 0.195). Esophageal perforation, jejunal perforation, and pulmonary emboli were the major complications and were seen only in group A (P = 0.790). All other peroperative minor complications and postoperative dysphagia, bloating, and reflux recurrence were similar between the two groups (P > 0.05). LARS and cholecystectomy can be performed safely during the same session without increasing the rates of morbidity and recurrence of reflux.

Influence of the size of the hiatus on the rate of reherniation after laparoscopic fundoplication and refundopilication with mesh hiatoplasty

Intrathoracic wrap migration is the most frequent morphological anatomic reason for failure of laparoscopic antireflux surgery (LARS). This study investigates whether the size of the esophageal hiatus is a factor in reherniation after LARS with mesh hiatoplasty and after primary failed hiatal closure. Fifty-four patients who underwent a laparoscopic 270° Toupet fundoplication with simple sutured crura and posterior onlay of Parietex mesh prosthesis between October 2003 and June 2008 were evaluated with respect to the occurrence of postoperative intrathoracic wrap migration/reherniation. Indication for mesh hiatoplasty was a hiatus with a hiatal surface area (HSA) of at least 5.60 cm(2) or slippage after the first LARS. The integrity of repair was assessed using a barium swallow test. Cinematography was performed at a median of 25.6 months (3-63 months after operation) and was completed in 49 of 54 patients (90%). Follow-up was completed in 24 patients who underwent primary LARS (group A) and 25 patients who underwent a laparoscopic refundoplication (group B). In group A, the occurrence of postoperative wrap reherniation was diagnosed in 20.8% of the patients, compared to 40% in group B. In both groups only one patient with recurrent hiatal hernia was symptomatic. In group A, patients who developed a recurrent hernia had a larger HSA than patients without postoperative reherniation. There was a huge difference in the size of the HSA between symptomatic and asymptomatic patients with reherniation. In comparison, group B patients had HSA of similar size in all described cases. In primary intervention, recurrence of hiatal hernia is more likely the larger the HSA is. The size of the hiatus is a major contributing factor to the possibility of reherniation. After failed primary hiatal closure, the size of the hiatal defect is no marker for the possibility of reherniation.

Feasibility of laparoscopic Nissen fundoplication after pediatric lung or heart–lung transplantation: should this be the standard?

Five-year graft survival in the pediatric lung transplant (LTxp) population is less than 50%, with obliterative bronchiolitis (OB) the leading cause of death at 1, 3, and 5 years post-transplant. Bronchiolitis obliterans syndrome (BOS), defined using spirometry values, is the clinical surrogate for the histological diagnosis of obliterative bronchiolitis. Surgical correction of documented gastroesophageal reflux disease (GERD) has been proposed as a means to potentially delay the onset of BOS and prolong allograft survival in adults before or after lung transplantation but only one such study exists in children. We have examined the safety and possible benefits of laparoscopic antireflux surgery in pediatric patients following lung (LTxp) and heart-lung transplantation (HLTxp). An Institutional Review Board (IRB)-approved retrospective chart review was performed to evaluate the outcomes and complications of laparoscopic antireflux surgery in pediatric lung and heart-lung transplant patients. Spirometry data were collected for BOS staging using BOS criteria for children. Twenty-five lung and heart-lung transplants were performed between January 2003 and July 2009. Eleven transplant recipients, including six double-lung and five heart-lung (HLTxp), with a median age of 11.7 years (range 5.1-18.4 years), underwent a total of 12 laparoscopic Nissen fundoplications at a median of 427 days after transplant (range 51-2310 days). GERD was determined based upon clinical impression, pH probe study, gastric emptying study, and/or esophagram in all patients. Three patients already had a gastrostomy tube in place and two had one placed at the time of fundoplication. There were no conversions to open surgery, 30-day readmissions, or 30-day mortalities. Complications included one exploratory laparoscopy for free air 6 days after laparoscopic Nissen fundoplication for a gastric perforation that had spontaneously sealed. Another patient required a revision laparoscopic Nissen 822 days following the initial fundoplication for a paraesophageal hernia and recurrent GERD. The average length of hospital stay was 4.4 ± 1.7 days. Nine of the 12 fundoplications were performed in patients with baseline spirometry values prior to fundoplication and who could also complete spirometry reliably. One of these nine operations was associated with improvement in BOS stage 6 months after fundoplication; seven were associated with no change in BOS stage; and one was associated with a decline in BOS stage. It is feasible to perform laparoscopic Nissen fundoplication in pediatric lung and heart-lung transplant recipients without mortality or significant morbidity for the treatment of GERD. The real effect on pulmonary function cannot be assessed due to our small sample size and lack of reproducible spirometry in our younger patients. Additional studies are needed to elucidate the relationship between antireflux surgery and the potential for improving pulmonary allograft function and survival in children which has been previously observed in adult patients.

Pediatric Fundoplications: Too Much of a Good Thing?

Children with gastroesophageal reflux disease (GERD) refractory to medical treatment may benefit from a fundoplication. Unfortunately, postoperative complications are not uncommon and may result in failure of the fundoplication in up to 25% to 40% of all cases. Many children respond positively to proton pump inhibitors, and surgery may be associated with a failure rate and complications. On closer inspection, the benefit of surgery for GERD, in children, is debated. For pediatric patients, there have been no prospective randomized trials comparing fundoplication with proton pump inhibitors. In addition, there have been no prospective randomized control trials evaluating open versus laparoscopic fundoplications in children. However, in the adult population, there have been several prospective trials including the Nordic Gord study group, a randomized clinical trial comparing proton pump inhibitors with surgical therapy for reflux esophagitis, showing that both treatment arms after 7 years (antireflux surgery or omeprazole groups) were equivalent for treating GERD. Despite surgery being more effective in controlling overall disease symptoms, surgery did have specific postfundoplication complaints that remained a problem. Similarly, another prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for GERD at 7-year follow-up found that both optimal proton pump inhibitor therapy and laparoscopic Nissen fundoplication were effective treatment for GERD. The difference was that surgery did add additional benefit for those who had only partial symptom relief while on proton pump inhibitors. The Lotus trial from Europe, comparing the laparoscopic antireflux surgery with esomeprazole in the management of patients with GERD, shows, at the 3-year interim analysis, that both laparoscopic fundoplication and continuous esomeprazole therapy are similarly effective and well-tolerated therapeutic strategies, providing effective control of GERD. Thus, it appears, in adult literature, that proton pump inhibitors are equivalent to fundoplication in the randomized control trials in a prospective fashion. Unfortunately, for children we have no such trials. Perhaps we can rely on the adult literature and look back at our own children’s hospital series to evaluate truly the effectiveness of fundoplication over the years and see if we need to have a paradigm shift in our way of evaluating for GERD as well as offering possible management therapies that provide the most effective solution for some of these complex children with GERD. We wanted to review at our institution the evolution of evaluating children with GERD, their treatment, and their outcomes with an emphasis on the changing views as new evidence builds throughout the years for GERD outcomes. The purpose of this study is thus to elucidate the outcomes of fundoplication including identification of risk factors for abdominal reoperations at our institution. Other articles have looked at the outcomes of fundoplications as a need for reoperation with a redo fundoplication. However, we feel that the redo fundoplication only tells a portion of the entire story, and thus, we wanted to look at all surgical readmissions requiring abdominal surgery for children having had a fundoplication.

A Modified Approach to Laparoscopic Antireflux Surgery May Decrease Postoperative Dysphagia and Gas Bloat Syndrome

Laparoscopic antireflux surgery has passed the test of time to prove its efficacy and advantage over the traditional approach. Several modifications of the original Nissen fundoplication have been introduced and practiced by surgeons with variable outcomes. This modified technique of laparoscopic fundoplication, which we use, is basically a spiral wrap. It is constructed by using several specifically located Ethibond stitches to keep the gastroesophageal junction and a length of the esophagus inside the abdomen without esophageal stitching. Postoperative outcome including patient satisfaction was assessed clinically during follow-up visits. Patients with recurrent symptoms and complications were assessed by appropriate tests. All patients were seen at 6 weeks, 6 months, 12 months, and annually after the operation. Fifty-seven patients underwent laparoscopic antireflux surgery using the spiral wrap technique. Four patients reported occasional heartburn and only 1 patient developed regurgitation after 1 year from the operation. Nine patients developed early dysphagia and 2 patients had gas bloat syndrome at 6 weeks postoperative assessment. No dysphagia or gas bloat syndrome was confirmed after a year and no revisional surgery was reported. Modification of the classic fundoplication to spiral wrap is associated with acceptable morbidity and low incidence of postoperative dysphagia and gas bloat syndrome.

What is the utilization of the SAGES guidelines by its members?

The development and implementation of evidence-based clinical practice guidelines involves many challenges. The Society of the American Gastrointestinal and Endoscopic Surgeons (SAGES) has been at the forefront of guideline development for laparoscopic surgery since 1991, providing its membership with guidelines on the clinical application of procedures and the granting of privileges. The objective of this study was to assess the use of SAGES guidelines by its members. An electronic survey of SAGES members was conducted via e-mail in August 2007. Members were asked if they used the guidelines, how often, for what purposes and when, and to rank the frequency of use and the usefulness of each of the 26 guidelines. They also were asked to suggest topics for new guideline development and to provide comments. Two hundred thirty-nine SAGES members (4.1%) responded to the survey; 121 (50%) responders used the guidelines. Of these, 95% accessed the guidelines monthly or less often, 58% after hours, 52% during work hours, and 9% while on call. Reasons for guideline use included developing practice protocols (56%) and patient treatment paradigms (51%), creating education and training guidelines for staff privileges (35%), and credentialing new medical staff (25%). The most often used and most useful guidelines included clinical application guidelines on laparoscopic bariatric, antireflux, biliary, and colorectal surgery, laparoscopic appendectomy, and deep vein thrombosis prophylaxis. Some respondents indicated no knowledge of guideline existence and made requests for new guidelines. The results of this survey provided valuable information about current use of SAGES guidelines by its members. The pattern of use highlights the need for interventions that increase member awareness and adoption of these guidelines. Such efforts are currently underway.

Laparoscopic fundoplication for gastroesophageal reflux disease in infants and children

The number and types of minimally invasive surgical procedures being performed in children have increased exponentially in the last 15 years. Laparoscopic fundoplication is commonly performed for gastroesophageal reflux disease (GERD), although the population of patients who undergo this procedure is different in adults and children. In Japan, laparoscopic fundoplication has become a standard procedure, even for children with neurological impairment; however, its indications remain controversial. In this article we review the status of laparoscopic antireflux surgery for infants and children, looking at its indications, the procedures available, the complications, and the training required to perform the procedure safely and effectively.

W1111 Safety Profile in GERD Patients 5 Yrs After Laparoscopic Antireflux Surgery or Long-Term Treatment With Esomeprazole 20-40mg Daily in the Lotus Study

Background: Control of chronic GERD may be achieved by laparoscopic antireflux surgery (LARS) or chronic medical therapy. Few controlled studies have compared the long-term safety implications of these treatments. Patients and methods: Patients were randomized to either LARS (n=288, 248 of whom actually underwent the operation) or 20mg (or 40mg if required) daily esomeprazole (ESO; n=266) in this multicenter clinical study conducted in 11 European countries over 5 yrs (NCT00251927). Safety was evaluated by comparing changes in blood screening variables over time, and adverse event (AE) reporting. Histopathology data from the stomach and the esophagus will be presented elsewhere. Results: Data are presented in the Table. Serious AEs were reported to a similar extent in both treatment groups with no clinically relevant difference. The number of fatal events was low in both groups. Cardiac events (death/MI) were few (5 in the ESO and 4 in the LARS group), and no new such events appeared between years 3 and 5. Laboratory tests, including routine blood and liver variables, electrolytes, and also vitamin B12, folate, and homocysteine, showed no clinically relevant change over time. The pattern of biomarkers for bone metabolism (alkaline phosphatase, calcium, and vitamin D) was stable over 5 yrs, and did not differ between groups. Gastrin and chromogranin Awere elevated in themedical group, as expected following acid suppression, and seemed to level off at 5 yrs. Conclusions: No major concerns have arisen in safety data up to five yrs after LARS or daily esomeprazole treatment.

284 Laparoscopic Antireflux Surgery vs Long-Term Esomeprazole Treatment for Chronic GERD. Final Results After 5 Yrs of Follow up in the Lotus Study

Introduction A once-only flexible sigmoidoscopy (FS) screening at age around 60 has been proposed as a cost-effective and acceptable method of reducing colorectal cancer (CRC) incidence and mortality. We undertook a large randomised controlled trial in a general population sample to compare CRC incidence and mortality rates following a single FS screen. Methods and baseline results Between 1994 and 1999, we sent a questionnaire to 375 744 men and women, aged 55 to 64 years, in 14 UK centres, asking whether they would have the FS screening if invited. Those who responded ‘yes definitely' or ‘yes probably' and were found to be eligible (n = 170 432) were randomised to the control or intervention arms of the trial in a 2:1 ratio. Of 57 254 people invited, 40 674 (71%) were screened. Following screening, 38 525 (95%) had either no pathology or only low-risk adenomas and were discharged and 2051 had high risk adenomas detected and underwent colonoscopy. Biannual updates on status (emigration, cancer diagnoses or deaths) were obtained by matching with the National Health Service Central Register, Office of National Statistics, UK cancer registries, and Hospitals Episodes Statistics records. Results of follow-up The median follow-up time to death, emigration or 31st December 2008 is currently 11 years. A total of 2491 participants developed CRC during 1.85 million person years of follow-up: 1523 developed a distal cancer (rectum or sigmoid colon), 894 developed cancer in the proximal colon, 34 developed cancer in both sites, and in 40 cases the site was not known. On an intent-to-treat analysis, a significant reduction in incidence of total and distal CRC was observed among those invited for screening. A greater reduction was seen among those who attended for screening. Colorectal cancer mortality rates were also reduced significantly. Adjustment for self-selection bias in attenders using Cuzick et al's method (Stat Med 1997;16:1017-29) made little difference to the rate ratios or significance. Conclusion By 11 years, total and distal colorectal cancer incidence rates were reduced significantly among people offered a single flexible sigmoidoscopy screen between ages 55 and 64 years, and so far no attenuation of effect has been observed. Detailed results will be presented.

Good training allows excellent results for laparoscopic Nissen fundoplication even early in the surgeon’s experience

Laparoscopic antireflux surgery is the gold standard for surgical treatment of gastroesophageal reflux disease (GERD), and a well-defined learning curve for the procedure has been described. This study aimed to assess whether the surgeon's experience has an effect on 1-year symptom scores and patient satisfaction. All the patients who underwent antireflux surgery were entered into a prospectively maintained database including 1-year postoperative symptom scores. The database was queried in June 2008 to identify patients who had been followed up for 1 year. To decrease variability, the patients with a large hiatal hernia (>5 cm), paraesophageal hernia, treatment with partial fundoplication, a required Collis gastroplasty, or treatment with a transthoracic procedure were excluded from the study. From September 2003 to March 2007, 215 consecutive patients underwent primary antireflux surgery. Of these 215 patients, 158 (93 women with a mean age of 50.9 ± 13.6 years; range, 18-87 years) met the inclusion criteria and were divided into three groups: early group (9/2003-10/2004), mid group (10/2004-12/2005), and late group (12/2005-3/2007). Experience significantly decreased the mean operative time (P < 0.05) and the hospital stay (P < 0.05). Additionally, the number of patients who required reoperative intervention also decreased with experience. There was no difference in the patient-reported symptom scores at 1 year for heartburn (mean, 0.3 ± 0.7), regurgitation (mean, 0.1 ± 0.4), or dysphagia (mean, 0.3 ± 0.6) (P > 0.05 for each). However, chest pain (mean, 0.2 ± 0.4) was significantly improved with experience (P < 0.05). The overall patient-reported mean satisfaction was 9.0 ± 1.9 (P > 0.05, scale, 1-10), and 14.5% (19/131) of the patients reported use of acid suppression medications. A high degree of 1-year symptom resolution and satisfaction can be achieved even early in a surgeon's experience provided there is adequate training and maintenance of strict adherence to technique.

Failed laparoscopic anti-reflux surgery and indications for revision. A retrospective study

Revisional anti-reflux surgery is required in certain patients for either early post-operative complications or recurrence of their original symptoms. The aim of this study is to review our revisional surgeries, learn the lessons and to highlight the treatment options for recurrent gastrooesophageal symptoms. Materials and methods Three hundred and fifty one patients underwent laparoscopic anti-reflux surgery through January 2000 to March 2006 at our minimal access unit. Thirty-seven patients were diagnosed with failure of anti-reflux surgery. Patient's data and follow up were retrieved from medical records. All recurrences were investigated for underlying cause and their managements were planned accordingly. Results Thirty-seven (10.54%) patients who developed early post-operative complications or recurrence of gastroesophageal symptoms were 25 women and 12 men. Heartburn was the commonest recurrent symptom. The majority of failures occurred in the first two years. Fourteen patients underwent revisional surgery while 23 patients were treated with acid reducing medications and showed a good response. The re-operation rate is 3.98%. There was no mortality and the total morbidity rate for revisional surgery is 7.14%. Conclusion Early surgical complications of the initial procedures are managed by revisional surgery and the results were satisfactory provided these complications are detected early. Chronic failure of anti-reflux surgery can be managed by revisional surgery or medications depending on clinical symptoms and patients preference.

The Evolution and Long-Term Results of Laparoscopic Antireflux Surgery for the Treatment of Gastroesophageal Reflux Disease

For nearly 2 decades, the laparoscopic correction of gastroesophageal reflux disease (GERD) has demonstrated its utility. However, the surgical technique has evolved over time, with mixed long-term results. We briefly review the evolution of antireflux surgery for the treatment of GERD, provide an update specific to the long-term efficacy of laparoscopic antireflux surgery (LARS), and analyze the factors predictive of a desirable outcome. PubMed and Medline database searches were performed to identify articles regarding the laparoscopic treatment of GERD. Emphasis was placed on randomized control trials (RCTs) and reports with follow-up >1 year. Specific parameters addressed included operative technique, resolution of symptoms, complications, quality of life, division of short gastric vessels (SGVs), mesh repair, and approximation of the crura. Those studies specifically addressing follow-up of <1 year, the pediatric or elderly population, redo fundoplication, and repair of paraesophageal hernia and short esophagus were excluded. LARS has varied in technical approach through the years. Not until recently have more long-term, objective studies become available to allow for evidenced-based appraisals. Our review of the literature found no long-term difference in the rates of heartburn, gas-bloat, antacid use, or patient satisfaction between laparoscopic Nissen and Toupet fundoplication. In addition, several studies have shown that more patients had an abnormal pH profile following laparoscopic partial as opposed to total fundoplication. Conversely, dysphagia was more common following laparoscopic total versus partial fundoplication in 50% of RCTs at 12-month follow-up, though this resolved over time, being present in only 20% with follow-up >24 months. We confirmed that preoperative factors, such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Last, no trial disfavored division of the short gastric vessels (SGVs), closure of the crura, or mesh repair for hiatal defects. LARS has significantly evolved over time. The laparoscopic total fundoplication appears to provide more durable long-term results than the partial approach, as long as the technical elements of the operation are respected. Division of the SGVs, closure of the crura, and the use of mesh for large hiatal defects positively impacts long-term outcome. Hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting are potential predictors of failure in LARS.

Laparoscopic Anti-Reflux Surgery Improves Daytime Somnolence

Laparoscopic Anti-Reflux Surgery Improves Daytime Somnolence

Laparoscopic antireflux surgery for GERD and its indication for NERD

Laparoscopic antireflux surgery for GERD and its indication for NERD

Anatomical failure following laparoscopic antireflux surgery (LARS); does it really matter?

Failure rates of laparoscopic antireflux surgery (LARS) vary from 2-30%. A degree of anatomical failure is common, and the most common failure is intrathoracic wrap herniation. We have assessed anatomical integrity of the crural repair and wrap using marking Liga clips placed at the time of surgery and compared this with symptomatic outcome. A prospective study was undertaken on 50 patients who underwent LARS in a single centre over a 3-year period. Each had an X-ray on the first postoperative day and a barium swallow at 6 months at which the distance was measured between the marking Liga clips. An increase in interclip distance of > 25-49% was deemed 'mild separation', and an increase of > 50% 'moderate separation'. Patients completed a standardised symptom questionnaire at 6 months. At 6 months' postoperatively, 22% had mild separation of the crural repair with a mean Visick score of 1.18, and 54% had moderate separation with a mean Visick score of 1.26. Mild separation of the wrap occurred in 28% with a mean Visick score of 1.21 and 22% moderate separation with a mean Visick score of 1.18. Three percent had mild separation of both the crural repair and wrap with a mean Visick score of 1.0, and 16% moderate separation with a mean Visick score of 1.13. Of patients, 14% had evidence of some degree of failure on barium swallow but only one of these was significant intrathoracic migration of the wrap which was symptomatic and required re-do surgery. The prevalence of some form of anatomical failure, as determined by an increase in the interclip distance, is high at 6 months' postoperatively following LARS. However, this does not seem to correlate with a subjective recurrence of symptoms.