Laparoscopic Floppy Nissen Fundoplication Research Articles

Laparoscopic floppy Nissen fundoplication with valve calibration: a safe and efficient procedure.

A floppy Nissen fundoplication with valve calibration (FNF-VC) performed by laparotomy has been described, to reduce postoperative dysphagia and gas bloating after 360°-fundoplication. As laparoscopy is the gold standard for fundoplication, this study reports the first results of a modified FNF-VC adapted for laparoscopy (LFNF). Seventy-two consecutive patients, who underwent LFNF for refractory GERD between 2012 and 2021, were included. Postoperative outcomes and quality of life (QoL) by GERSS, GERD-HRQL, and GIQLI scores before and after surgery were assessed. The main symptoms were pyrosis (81%), regurgitation (39%), Ear-Nose-Throat symptoms (22%), and thoracic pain (24%). Hiatal hernia was present in 85% (n = 61) of the patients. There was no postoperative mortality, and the severe postoperative morbidity rate (Dindo-Clavien ≥ III) was 6%. After a median follow-up of 3.6years, only 8% of patients were still taking proton-pump inhibitors. Long-term residual dysphagia was noted in 15% of the patients, but none required reoperation or interventional endoscopic procedures. QoL improved, with a significant reduction in GERSS and GERD-HRQL scores and a postoperative GIQLI of 101.75 (75-117.5). This series reports the safety and efficacy of an FNF-VC adapted for laparoscopy to treat GERD with a limited rate of residual dysphagia.

Comparison of Early Outcomes of Laparoscopic Floppy Nissen Fundoplication and Laparoscopic Toupet Fundoplication in the Treatment of Type III and IV Hiatal Hernia

Objective: This study aims to compare the laparoscopic Floppy Nissen fundoplication technique (LFNFT) and the laparoscopic Toupet fundoplication technique (LTFT) used in treating Type III and IV hiatal hernias (HHs).
 Materials and Methods: This retrospective analysis was conducted after ethical approval. Patients who underwent Type III and IV hiatal hernia surgery were searched between January 2020 and May 2022. Patients who underwent LFNFT and LTFT for hiatal hernia repair were selected. Patients under 18 and patients who were followed up in our clinic after surgery were excluded from the study. The clinical and follow-up differences between the groups were evaluated statistically.
 Results: Of the 38 patients who met the study criteria, 27 (71.1%) were female. The mean age of all patients was 41.39±14.03 years (21-77). 10 (26.3%) patients had Type 3 HH, and the remaining patients (73.7%) had Type 4 HH. LFNFT was performed on 27 (71.1%) patients, and LTFT on 11 (28.9%). Complications developed in 14 (36.8%) patients in the postoperative follow-up, and the most common difficulty was gas bloating, with a rate of 13.1%. In comparing the groups, LTFT was preferred in the male patients (p=0.005) and younger patients (p

Laparoscopic floppy Nissen fundoplication: evaluation of outcome in 34 patients operated without prior oesophageal pH and manometry

Background: Aim of the study was to evaluate prospectively the outcomes of laparoscopic floppy Nissen fundoplication in cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD) and hiatus hernia without pre-operative 24 hours oesophageal pH and manometry study. Methods: Thirty-four patients with typical symptoms of GERD, from March 2009 to November 2019, were studied. The study was limited to patients with positive findings on upper GI endoscopy done by operating surgeon with typical symptoms (heartburn, regurgitation, and dysphagia) of GERD and hiatal hernia. Laparoscopic Nissen’s fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only 1 patient, who had negative endoscopic findings, underwent a 24-hour pH-monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome and quality of life after surgery.Result: Laparoscopic Nissen’s fundoplication is an effective long-term treatment for GERD and may be performed in patients with typical symptoms of GERD and hiatus hernia and endoscopic findings suggestive of reflux esophagitis and patient who wants to get rid of life long proton-pump inhibitors (PPI) and antacids medication.Conclusions: Preoperative oesophageal manometry and 24-hour pH monitoring are not mandatory for laparoscopic fundoplication if the patient selection is appropriate but may be required in selected patients with atypical symptoms.

Short- and long-term results after laparoscopic floppy Nissen fundoplication in elderly versus non-elderly patients.

Background:Laparoscopic anti-reflux surgery could be of benefit in a subset of elderly patients with gastroesophageal reflux disease. However, there are few reports that have evaluated the long-term results. This study examined the effects of age on the short- and long-term (for at least 5 years) outcomes after laparoscopic Nissen fundoplication (LNF).Patients and Methods:Patients were divided into four groups as follows: young (18–49); adult (50–69); and elderly (70–84), and very elderly (85–91). The database (recorded prospectively) included operating duration, conversion, intra- and early post-operative complication and late outcomes. Mean follow-up was 14.5 years (range 5–24 years).Results:Five hundred and sixty-nine patients met the inclusion criteria: young n = 219 (38.4%); adult n = 248 (43.5%); elderly n = 91 (16.0%) and very elderly n = 11 (1.9%). Hiatal hernia (type I and III) was significantly less frequent in young and adult patients (P < 0.0001). The operation was significantly longer in elderly and very elderly patients (P < 0.001); the use of drains (P < 0.001) and grafts (P < 0.0001) for hiatal hernia repair was less in young and adult patients. The hospital stay, conversion (5.4%), intra-operative and early post-operative complications were not influenced by age. Dysphagia was evenly distributed among the groups. Forty-eight (8.4%) patients had recurrence: 15 in the young group (6.8%), 18 in the adult group (7.2%), 11 in the elderly group (12%) and 4 in the very elderly group (36.3%) (P < 0.0001).Conclusions:Age does not influence short- and long-term outcomes following LNF. Control of reflux in the elderly is worse than adult patients. Therefore, ageing is a relative contraindication to LNF.

Analysis of the efficacy of laparoscopic Toupet fundoplication treatment of hiatal hernia combined with gastroesophageal reflux disease

Objective To explore the efficacy of laparoscopic Toupet fundoplication treatment of hiatal hernia combined with gastroesophageal reflux disease. Methods Forty one patients' medical record information of hiatal hernia combined with gastroesophageal reflux disease that underwent laparoscopic Toupet fundoplication were collected in Xinjiang Uygur Autonomous Region People's Hospital from October 2012 to October 2015. Thirty six cases were adopted pure hiatal hernia suture, 2 cases were used biological patch repair, 1 case used Johnson PHY patch repair, 1 case used Bade patch repair, and 1 case used Tyco hiatal hernia dedicated anti-blocking patch repair. These patients were carried out 24 hours esophageal pH monitoring, esophageal manometry, gastroesophageal reflux disease questionnaire (GERDQ) score and postoperative complications before surgery and 6 months postoperative. The clinical efficacy of laparoscopic Floppy Nissen fundoplication treatment of hiatal hernia combined with gastroesophageal reflux disease was retrospectively analyzed. Results There was no perioperative deaths and serious complications during perioperation. The reflux symptoms were significantly improved postoperative. There was significantly lower in reflux time , the number of reflux (29.83±19.71), acid reflux time percentage , and DeMeester score (7.28±7.38) than the preoperative . GERD Q scale score (7.18±1.33) was significantly lower than preoperative (10.91±2.02) with statistically significant difference (P<0.05). lower esophagealsphincter (LES) pressure was significantly increased than preoperative . Residual pressure was significantly increased than preoperative . Relaxation rate was significantly reduced than preoperative . However, swallowing invalid was increased than preoperative , with statistically significant difference (P<0.05). The median follow-up was 10 months, and there was no recurrence during follow-up. Conclusions Laparoscopic Toupet fundoplication can effectively inhibit reflux symptoms, and increase LES pressure, which is worthy of promotion. However, there is slightly higher incidence of postoperative dysphagia. Key words: Laparoscopy; Fundoplication; Hernia, hiatal/CO/SU; Gastroesophageal reflux/CO/SU

A Chinese randomized prospective trial of floppy Nissen and Toupet fundoplication for gastroesophageal disease

IntroductionTo evaluate the clinical outcomes of laparoscopic floppy Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) for the treatment of gastroesophageal disease (GERD). MethodsA total of 84 patients with GERD were randomized to either LNF (n = 43) or LTF (n = 41) between January 2010 and January 2013. The primary endpoint measures were the DeMeester score, distal esophageal amplitude (DEA), peristaltic frequency, lower esophageal sphincter pressure (LESP), short-term and long-term postoperative dysphagia and recurrence rate. The secondary endpoints were improvements in symptom scores and quality of life (QoL), and perioperative complications. ResultsLNF group had a lower DeMeester score and a higher LESP compared to LTF group after surgery (DeMeester score: P = 0.007; LESP: P = 0.027). The mean DEA and peristaltic frequency both improved significantly after surgery in 2 groups. There was no difference in the incidence of short-term adverse events (including dysphagia, heartburn, regurgitation et al.) between the two groups (P = 0.157). At the time of the latest follow-up, there was no difference in the incidence of symptomatic reflux symptom (heartburn and regurgitation) between the two groups (heartburn: P = 0.363; regurgitation: P = 1.000). A higher frequency of dysphagia was present in the LNF group compared with the LTF group (P = 0.023). DiscussionLNF is associated with an excessive elevation of LESP which may lead to further persistent dysphagia. Partial fundoplication may provide adequate reflux control, improve esophageal body motility and minimize complications associated with an ‘over-tight’ fundal wrap. ConclusionLTF seems to be as safe and effective on the long-term as LNF, but with a lower incidence of postoperative dysphagia (ChiCTR-TRC-13003945).

Dynamics of quality of life improvement after floppy Nissen fundoplication for gastroesophageal reflux disease.

IntroductionGastroesophageal reflux disease (GERD) has a negative impact on global quality of life (QOL) of patients. In patients affected by GERD, laparoscopic Nissen fundoplication is one of the most commonly performed laparoscopic procedures worldwide.AimTo prospectively analyze the dynamics of QOL as well as severity of pain in patients with GERD, before and after laparoscopic floppy Nissen fundoplication.Material and methodsThe study involved 104 consecutive patients operated on for GERD in whom laparoscopic floppy Nissen fundoplication was performed. QOL was assessed before surgery and 1, 3, 6, 12 and 24 months after. The following instruments were used: FACIT-G, FACIT-TS-G, GIQLI, GERD symptom scale.ResultsIt was found that symptom relief and quality of life improvement presented different dynamics in the postoperative course. Observations revealed relief of symptoms 1 month after surgery and improvement in QOL related to the gastrointestinal tract and pain 3 months after surgery. Global QOL increased significantly as late as 12 months after surgery.ConclusionsGastroesophageal reflux disease is a chronic disease of long duration, leading to impairment of quality of life. Patients, apart from typical symptoms of GERD, suffer from pain of significant severity. QOL improves significantly after surgery. Surgical treatment results in relief of GERD symptoms, which leads to gradual improvement of QOL.

Reply to: “Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications”

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Symptom analysis improves GERD diagnosis and may be helpful to define a successful surgical approach

We read with interest the article by Koch et al. [1] that randomly allocated 125 patients with documented chronic gastroesophageal reflux disease (GERD) to either laparoscopic floppy Nissen fundoplication (n = 62) or laparoscopic Toupet fundoplication (n = 63). Both procedures proved to be equally effective in improving quality of life and both typical and atypical reflux-related symptoms. The authors also indicated that laparoscopic Toupet fundoplication was characterized to have a high ability to belch and a reduced rate of postoperative dysphagia. The authors opted to use the current gold standard for GERD diagnosis (i.e., impedance-pH testing), and thus, they carefully and objectively defined the inclusion criteria for undergoing surgical fundoplication [2]. Indeed, they considered patients for surgery who had a total number of refluxes higher than 73 per 24 h, a DeMeester score higher that 14.7, or a positive association between symptoms and reflux events by means of the symptom index (SI). One-year postsurgery impedance-pH studies clearly showed a marked decrease of reflux episodes (total, acid, proximal, upright, and recumbent refluxes) and a DeMeester score that paralleled the large improvement of GERD symptoms and quality of life, thus supporting the usefulness of impedance-pH testing in selecting GERD patients for surgery [3]. However, even though this study provides relevant novel data on the potential application of impedance-pH technology for the surgical management of GERD patients, we believe that the interpretation of their findings would be improved if the results of symptom association analysis after surgery were also reported. Few data are reported about SI (i.e., only preoperative information, and without describing whether the association was positive for acid and/or nonacid reflux episodes), and no data are provided for symptom association probability (SAP), which is considered by several authors to be the best index demonstrating an association between symptoms and reflux events. Indeed, SAP is based on statistical parameters, is not generated by chance, and clearly explores the relationship between symptoms and refluxes [4]. Although SI has the advantage of being easy to calculate, it does not take into account the total number of reflux episodes with the likelihood risk that a symptom is found to be associated with reflux by chance [5]. Therefore, because impedancepH permits the measurement of all types of reflux and correlates them to symptoms, it increases the diagnostic yield by using a symptom association analysis mode such as SI or SAP [6–10]. In fact, previous studies have shown that GERD patients, particularly those found to have no mucosal injuries at upper endoscopy, frequently have a normal distal acid exposure time and therefore a low acidrelated DeMeester score [3, 11]. Using these parameters, it has been observed that GERD patients have symptoms associated not only with acid reflux but also with weakly acidic reflux; this may explain the increased proton pump inhibitor failure observed in endoscopy-negative patients [3, 12], thus supporting the use of alternative surgical or endoscopic therapies in this patient population [13, 14]. So far, data concerning the SI and SAP for acidic and weakly acidic reflux should be reported in order to know whether N. de Bortoli (&) I. Martinucci S. Marchi Gastroenterology Unit, Department of Translational Medicine and New Technology, University of Pisa, Pisa, Italy e-mail: nick.debortoli@gmail.com

Laparoscopic Floppy Nissen Fundoplication

There are few published reports on the outcomes of ≥ 10 years after a laparoscopic floppy Nissen fundoplication (LFNF). From April 1994 to January 2012, 567 patients underwent LFNF and the outcomes of 211 cases were determined (from April 1994 to October 2000). Outcomes at ≥ 11 years after surgery was available for 178 patients (84.3%) of which 167 (93.8%) had no heartburn or mild heartburn, 8 (4.5%) had moderate heartburn, and 3 had (1.7%) severe heartburn. Dysphagia was nonexistent or mild in 153 (85.9%), whereas the remaining 14.1% presented moderate to severe symptoms. Reports of 69.1% patients showed none or mild symptoms of abdominal bloating, that of 23% patients showed moderate discomfort, and reports of 7.8% showed severe bloating. Satisfaction score was 8.6 (of 10). A further surgical procedure was required for 7 patients (3.9%): 4 for recurrent reflux and 3 for dysphagia (2 for a tight wrap and 1 for a tight esophageal hiatus). Postoperative dysphagia sufficient for an endoscopic dilatation was observed in 4 patients (2.3%), where 3 were successfully managed with a single dilatation procedure and the last patient underwent several dilatations before adequate swallowing. LFNF is an effective long-term treatment for gastroesophageal reflux disease, yielding similar results to open fundoplication.

Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce. This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294). Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF. Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Single-Port Laparoscopic Floppy Nissen Fundoplication: A Novel Technique with the Aid of the Cerrahpasa Retractor®

Introduction: The retraction of the left lobe of the liver in the laparoscopic upper gastrointestinal procedures is a critical maneuver with its added possible complications. In our study, we utilized the Cerrahpasa retractor® for the retraction of the left liver with a different concept other than utilizing a suturing or silk lace techniques described in previous studies. We present a video of a laparoscopic floppy Nissen fundoplication (LFNF) performed through a single port with the aid of the Cerrahpasa retractor. Materials and Methods: We performed single-port LFNF on 22 patients with symptomatic gastroesophageal reflux disease between September 2009 and April 2011. One 12-mm and two 5-mm trocars were utilized through the SILS™ (Covidien AG, Norwalk, CT) port. The next step was the introduction of a hand-made needle liver retractor (Cerrahpasa retractor, trademark pending), from the midline just below the xiphoid process. The retractor is composed of two parts: the head and the wire. The wire is introduced through a hand-made Seldinger-type needle. The head is introduced through the SILS port, and the two parts are mounted together intracorporeally. Main steps of the operation were dissection of the hepatogastric and Laimer's ligament, dissection and closure of the hiatus, and construction of the short, floppy Nissen fundoplication. The short gastric vessels were not divided. In our technique, we do not fix the fundoplication. Results and Conclusions: All the procedures were performed without any perioperative complications. The mean duration of the operations was initially 110 minutes (initial five operations) and reduced to 60 minutes (last five operations) throughout the 8-month period. No drains were used. The postoperative period was uneventful. All the patients were given oral fluids 12 hours postoperatively and discharged after 24 hours. On the basis of the short term of follow-up, there are no postoperative complications encountered. Until now, the procedures described for retraction in single-port surgery utilize more or less a suturing or silk lace techniques1–3 that potentially could tear the liver or other anatomical structures easily. Alternative technique utilizing anything other than suturing or silk lace technique was described by Gianni et al,4 where the authors used Veress needle for the retraction of the liver. A publication similar to our technique was reported by Cuesta et al5 in 2008. In their study authors performed transumbilical laparoscopic cholecystectomy with the aid of a 1-mm Kirschner wire. The wire was used for gallbladder traction. The Cerrahpasa retractor utilized in this study to elevate the liver was 1 mm in diameter and made of stainless steel. For the use of this needle-retractor, no additional trocar was employed. In our technique, the potential of tearing the liver or other anatomical structures is minimal. We believe that, with the aid of our Cerrahpasa retractor, the problem of liver retraction in single-port laparoscopic surgeries is being solved by a simple and safe technique. No competing financial interests exist. Runtime of video: 5 mins 30 secs The first three cases of this technique were presented in the 17th Turkish National Surgical Congress on May 26–29, 2010, in Ankara, Turkey. This technique is being presented in SAGES TV since SAGES Annual Meeting in San Antonio, TX, March 30–April 2, 2011.

Single-Port Laparoscopic Floppy Nissen Fundoplication: A Novel Technique with the Aid of the Cerrahpasa Retractor

With the advent of single-port laparoscopy, the spectrum of abdominal surgeries performed is widening. The retraction of the left lobe of the liver in the upper gastrointestinal procedures is a critical maneuver with its added possible complications. In our study, we used the Cerrahpasa retractor (trademark pending by E. Eyuboglu and T. Ipek) for the retraction of the left liver in 22 patients with a different concept other than using the suturing or silk lace techniques described in previous studies. In our technique, the potential of tearing the liver or other anatomical structures is minimal. We believe that, with the aid of our Cerrahpasa retractor, the problem of liver retraction is being solved by a simple and safe technique.

How does dexamethasone influence surgical outcome after laparoscopic Nissen fundoplication? A randomized double-blind placebo-controlled trial

Laparoscopic floppy Nissen fundoplication (LFNF) is an effective treatment for gastroesophageal reflux disease. The duration of convalescence, after noncomplicated LFNF, may depend on several factors of which pain, fatigue and sociocultural factors are the most important. Nausea and vomiting occur mainly on the day of operation. Glucocorticoids are well known for their analgesic, anti-inflammatory, immune-modulating and antiemetic effects. We therefore undertook the present study to investigate whether preoperative dexamethasone could improve surgical outcome in patients undergoing uncomplicated laparoscopic floppy Nissen fundoplication. From March 2005 to April 2008, 82 patients were randomized to receive dexamethasone (8mg) intravenously, 90min before skin incision or saline (placebo). Patients received a similar standardized anesthetic, surgical and multimodal analgesic treatment. The primary end points were pain and fatigue. Preoperatively and at several times during the first 24 postoperative hours, we measured C-reactive protein (CRP), interleukin-6 and 1 (IL-6, IL-1), pain scores and nausea, and the number of vomiting episodes were registered. Dexamethasone significantly reduced postoperative levels of CRP (p=0.01), IL-6 and IL-1 (p<0.05), fatigue (p=0.01) and overall pain during the first 24 postoperative hours (p<0.05) and the total requirement of analgesic (ketorolac) (p<0.05). Dexamethasone also reduced nausea and vomiting on the day of operation (p<0.05). Preoperative dexamethasone (8mg) reduced pain, fatigue, nausea and vomiting in patients undergoing uncomplicated LNF when compared with placebo.

Partial Splenic Infarction as a Complication of Laparoscopic Floppy Nissen Fundoplication

The division of the short gastric vessels (SGVs) is a common practice during laparoscopic floppy Nissen fundoplication (NF) to achieve an adequate mobilization of the gastric fundus. However, the terminal branches of splenic vessels can also be ligated during SGV division, resulting in splenic infarction (SI). The aim of this study was to evaluate our results with SI as a complication of laparoscopic floppy NF. All patients with direct laparoscopic evidence of SI during laparoscopic floppy NF, between August 1993 and August 2009 and under the care of two surgeons, were included in this retrospective study. Over the past 16-year period, 2100 patients underwent laparoscopic floppy NF, and splenic infarction was demonstrated in 20 cases (0.95%). There were 11 women (55%) and 9 men (45%), with a mean age of 35.2 years (range, 25-68). The classic pattern, in all cases, was a small area of infarction, less than 10-15% of the total splenic volume, localized mainly in the upper pole. There were no conversions. The mean length of hospital stay was 1.2 days (range, 1-2). During the follow-up period of 3 months, only 2 patients (10%) had persistent abdominal pain, in which computed tomography demonstrated the infarcted areas involving less than 15% of the splenic parenchyma. All cases were managed succesfully with observation alone. Based on the results, partial SI is a recognizable condition during laparoscopic floppy NF. Conservative therapy and close follow-up, without any unnecessary intervention, is an appropriate management that provides a favorable outcome.

Surgical management of hiatus hernia with chronic gastric volvulus: report of two cases

Totally intrathoracic gastric volvulus is an uncommon presentation of hiatus hernia. We report herein two patients of hiatus hernia repair with mesenteroaxial gastric volvulus who presented as so-called upside-down stomach, which resulted in excellent clinical outcomes. The two patients underwent an attempted laparoscopic floppy Nissen fundoplication. In patient 1, the duodenum severely adhered to the hernia sac and converted to an open Nissen fundoplication. The operating time for patient 1 and patient 2 was 224 and 232 min, respectively. No postoperative morbidities occurred. At a follow-up of 18 and 2 months, the two patients had not had a relapse or any of their prior symptoms. The repair of an esophageal hiatus hernia with chronic gastric volvulus can be accomplished successfully and safely with an open or laparoscopic approach. Because this condition occurs more frequently in the elderly, an attempt to perform laparoscopic surgery may contribute to minimal invasive treatment.

Left hepatic vein injury during laparoscopic antireflux surgery for large para-oesophageal hiatus hernia

Although the advent of laparoscopic fundoplication has increased both patient and physician acceptance of antireflux surgery, it has become apparent that the laparoscopic approach is associated with an increased risk of some complications and as well as the occurrence of new complications specific to this approach. One such complication occurred in our patient who had intra-operative left hepatic vein injury during laparoscopic floppy Nissen fundoplication for large para-oesophageal rolling hernia. With timely conversion to open procedure, the bleeding was controlled and the antireflux and the procedure were completed uneventfully. However, this suggests that even with an experience in advanced laparoscopy surgery, complications can occur. Clear understanding of the normal and pathologic anatomy and its variations facilitates laparoscopic surgery and should help the surgeon avoid complications. The incidence of some of these complications decreases as surgeons gain experience; however, new complications can arise due to the increase in such procedures.

Sandifer syndromea multidisciplinary diagnostic and therapeutic challenge, N. Lehwald, M. Krausch, C. Pranke, in: Eur J Pediatr Surg, 17/3. (2007(June)), 203

Sandifer syndrome, named after the neurologist Paul Sandifer, was first reported by M. Kinsborne in 1962, who noticed a disorder of the upper gastrointestinal tract with neurologic manifestations occurring in children and adolescents. Sandifer syndrome is a combination of gastroesophageal reflux disease with spastic torticollis and dystonic body movement with or without hiatal hernia. It is hypothesized that the positioning of the head provides relief from abdominal discomfort caused by acid reflux. The true pathophysiologic mechanisms are still unclear. The authors report a case of Sandifer syndrome in a 9-year-old boy with a history of chronic torticollis and dystonic episodes for 5 years, associated with abdominal symptoms. The cause of the dystonic body movements had not been found, although multiple neuropsychiatric diseases were suspected. The patient had been seen by physicians of many different specialities (including pediatrics; pediatric neurology; psychology; orthopedic surgery; and ear, nose, and throat), but the reason for the torticollis remained elusive. Unclear abdominal discomfort was the indication for endoscopy, which revealed severe gastroesophageal reflux disease with grade III esophagitis and a hiatal hernia leading to the diagnosis of Sandifer syndrome. After medical treatment and laparoscopic floppy Nissen fundoplication, the symptoms nearly resolved 3 months after surgery. Although few reports on this syndrome exist, Sandifer syndrome is probably underrecognized. Early surgery can resolve the symptoms.

Effect of Laparoscopic Fundoplication on Hypertensive Lower Esophageal Sphincter Associated with Gastroesophageal Reflux

For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently, the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50–61). Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7–86). Average LES pressure before the operation was 50.5 mmHg (range 35.6–81.3). Six weeks after operation, all patients were symptom free. DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure (24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure may be an etiologic factor in the development of hypertensive lower esophageal sphincter.

Sandifer Syndrome - A Multidisciplinary Diagnostic and Therapeutic Challenge

Sandifer syndrome, named after the neurologist Paul Sandifer, was first reported by M. Kinsbourne in 1962 who noticed a disorder of the upper gastrointestinal tract with neurological manifestations occurring in children and adolescents. Sandifer syndrome is a combination of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements with or without hiatal hernia. It is hypothesised that the positioning of the head provides relief from abdominal discomfort caused by acid reflux. The true pathophysiological mechanisms of the condition are still unclear. We report the diagnosis of Sandifer syndrome in a 9-year-old boy with a history of chronic torticollis and dystonic episodes for 5 years associated with abdominal symptoms. The cause of the dystonic body movements had not been found, although multiple neuropsychiatric diseases were suspected. The patient had been seen by many different specialities including Paediatrics, Paediatric Neurology, Psychology, Orthopaedic Surgery and ENT but the reason for the torticollis remained elusive. Unclear abdominal discomfort was the indication for an endoscopy that revealed severe gastro-oesophageal reflux disease with oesophagitis III degrees and a hiatal hernia which led to the correct diagnosis of Sandifer syndrome. After medical treatment and laparoscopic floppy Nissen fundoplication the symptoms nearly resolved 3 months after operation. Few reports of this syndrome exist, but Sandifer syndrome is probably underrecognised. Children with torticollis, dystonic episodes or atypical seizures should be evaluated for GERD and Sandifer syndrome. Early surgery, for example a laparoscopic floppy Nissen fundoplication or a Toupet procedure, can resolve the symptoms.