Laparoscopic Redo Fundoplication Research Articles

A new approach to the treatment and classification of recurrent hiatal hernia and gastroesophageal reflux disease

Background. The incidence of disease relapse after primary antireflux surgical treatment ranges from 4 to 24 %, with up to 9 % of cases requiring revision surgery. Several studies demonstrate that the results of operations for recurrent hiatal hernia are less satisfactory compared to the primary procedure, especially after multiple interventions.Aim. To propose a technique for laparoscopic redo fundoplication using a novel method, to evaluate short-term and long-term results after repeated surgical treatment of patients with recurrent hiatal hernia and GERD, and also to propose a classification of relapses of GERD and hiatal hernia.Material and methods. The prospective study included data from 31 patients diagnosed with recurrent GERD and hiatal hernia. Laparoscopic redo fundoplication was used as a surgical method. Intraoperatively, technical errors of the previous operation were identified. The classification of relapses was conducted using the author’s method. Quality of life indicators using specialised questionnaires before surgery were: GERD-Q — 12.1 ± 2.82, GERD-HRQL — 26.12 ± 8.31, GSRS — 44.26 ± 10.21.Results. There were no access conversions. The average duration of the operation was 141.21 minutes, blood loss was 81.40 ml, intraoperative complications in 4 (9.7 %) patients were eliminated intraoperatively, postoperative complications according to Clavien-Dindo ≥ 3 were diagnosed in one patient (pneumothorax), performed drainage of the pleural cavity. In 18 (58 %) patients, technical errors were identified that were made during the previous antireflux intervention. Quality of life indicators using specialised questionnaires six months after surgery were: GERD-Q — 2.1 ± 1.31, GERD-HRQL — 4.31 ± 2.98, GSRS — 17.02 ± 6.18. During the follow-up examination, 27 (87 %) patients noted complete recovery, as well as the absence of the need for PPI and prokinetic therapy.Conclusion. The results of the study confirm the effectiveness, functionality and safety of laparoscopic redo fundoplication as the main treatment for this disease.

614. LAPAROSCOPIC RE DO FUNDOPLICATION

Abstract Background Laparoscopic fundoplication though an effective form of therapy for patients with refractory gastroesophageal reflux disease, can fail due to poor patient selection or compromised surgical technique. Re do laparoscopic fundoplication for failed anti reflux surgery is a challenging task prone to further failures if not properly done. Methods Retrospective analysis of consecutive patients who underwent laparoscopic redo fundoplication in a tertiary care center between January 2012 and March 2022. Results There were a total of 24 patients that underwent redo fundoplication during the study period. Wrap migration was noted in 8 (33.3%) patients while the wrap was too tight which led to dysphagia in 5 (20.8%) patients. Two patients had previously undergone laparoscopic redo fundoplication while one patient initially underwent open Nissen’s fundoplication. All the patients were managed successfully laparoscopically without any conversion. The median time interval between the first surgery and the redo operation was 8 months (3 months to 12 years). Symptomatic improvement was observed in 20 (83.3%) while 4 (16.7%) patients continued to have symptoms. Conclusion Laparoscopic redo fundoplication can yield satisfactory results in patients after initially failed anti reflux surgery when performed in experienced centers. Proper case selection and meticulous surgical technique to address the primary cause of failure is paramount.

Long-term results after laparoscopic revision fundoplication: a retrospective, single-center analysis in 194 patients with recurrent hiatal hernia.

After laparoscopic fundoplication, 10-20% of patients experience symptom recurrence-often due to resurgence of the hiatal hernia. The standard surgical treatment for such cases remains laparoscopic revision fundoplication. However, there is little data on the time frame and anatomic patterns of failed fundoplications. Additionally, few large studies exist on the long-term efficacy and safety of laparoscopic revision fundoplication. In a single-center, retrospective analysis of 194 consecutive revision fundoplications for recurrent reflux disease due to hiatal hernia, we collected data on time to failure and patterns of failure of the primary operation, as well as on the efficacy and safety of the revision. The median time to failure of the primary fundoplication was 3years. Most hiatal defects were smaller than 5cm and located anteriorly or concentric around the esophagus. Laparoscopic redo fundoplication was technically successful in all cases. The short-term complication rate was 9%, mainly dysphagia requiring endoscopic intervention. At a mean follow-up of 4.7years, 77% of patients were symptom-free, 14% required daily PPI, and 9% underwent secondary revision. Cumulative failure rates were 9%, 23%, and 31% at 1, 5, and 10years. The majority of failed fundoplications occur within 3years of primary surgery, with most patients exhibiting anterior or concentric defects. For these patients, laparoscopic revision fundoplication is a safe procedure with a low rate of short-term complications and satisfactory long-term results.

Laparoscopic Redo Fundoplication – Indications and Challenges: A Case Report with Review of Literature

Herein, we report the case of a 72 year old female patient who underwent surgery for hiatus hernia – Laparoscopic Nissen’s Fundoplication in some other hospital. She developed progressively worsening dysphagia in the postoperative period. Multiple sessions of Endoscopic balloon dilatation were attempted, but to no lasting symptomatic relief. She then underwent a successful redo laparoscopic surgery, after due investigations.

Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study.

Robotic-assisted redo fundoplication has some advantages compared to the laparoscopic approach in adults, although to date there are no studies in children. A retrospective case-control study was performed among consecutive children who underwent redo antireflux surgery between 2004 and 2020, divided into two groups: LAF group (laparoscopic redo-fundoplication) and RAF group (robotic-assisted redo-fundoplication). Demographics, clinical, intraoperative, postoperative and economic data were compared. A total of 24 patients were included (10 LAF group; 14 RAF group) without demographic or clinical differences. The RAF group presented lower intraoperative blood loss (52±19 vs. 145±69mL; p<0.021), shorter surgery time (135±39 vs. 179±68min; p=0.009) and shorter length of hospital stay (median 3days [2-4] vs. 5days [3-7]; p=0.002). The RAF group presented a higher rate of symptom improvement (85.7% vs. 60%; p=0.192) and lower overall associated economic costs (25800$ vs. 45500$; p=0.012). Robotic-assisted redo antireflux surgery may offer several benefits over the laparoscopic approach. Prospective studies are still needed.

552. LAPAROSCOPIC RE DO FUNDOPLICATION

Abstract Laparoscopic fundoplication though an effective form of therapy for patients with refractory gastroesophageal reflux disease, can fail due to poor patient selection or compromised surgical technique. Redo laparoscopic fundoplication is a challenging task prone to further failures. Retrospective analysis of consecutive patients who underwent laparoscopic redo fundoplication in a tertiary care center between July 2015 and March 2022. There were a total of 24 patients that underwent redo fundoplication during the study period. Wrap migration was noted in 8 (33.3%) patients while the wrap was too tight which led to dysphagia in 5 (20.8%) patients. Two patients had previously undergone laparoscopic redo fundoplication while one patient initially underwent open Nissen’s fundoplication. All the patients were managed successfully laparoscopically without any conversion. The median time interval between the first surgery and the redo operation was 8 months (3 months to 12 years). Symptomatic improvement was observed in 20 (83.3%) while 4 (16.7%) patients continued to have symptoms. Laparoscopic redo fundoplication can yield satisfactory results in patients after initially failed anti reflux surgery when performed in experienced centers. Proper case selection and meticulous surgical technique to address the primary cause of failure is paramount.

378 REDO LAPAROSCOPIC FUNDOPLICATON IN A PATIENT WITH WRAP MIGRATION FOLLOWING TWICE FAILED NISSEN FUNDOPLICATION

Abstract Re-operation for wrap failure is a complex procedure required in 3–6% of patients. This video demonstrates a successful laparoscopic redo fundoplication in a patient who had previously undergone laparoscopic Nissen's fundoplication twice for GERD in another institution, first for GERD in 2014 and then for recurrence of reflux. Patient presented to us with dysphagia and regurgitation. The work-up revealed wrap migration into the right pleural cavity. A successful redo laparoscopic Toupet fundoplication was performed. Methods The video describes the procedure of laparoscopic re do fundoplication. Results Patient is doing well at a follow up of 16 months. Conclusion Re-do laparoscopic fundoplication can be successfully accomplished through laparoscopic approach. Video https://drive.google.com/file/d/1Perelnr0fwGIk1kiAexYvXnJY01cO98C/view?usp=sharing.

235 5-YEAR FOLLOW-UP OF A PROSPECTIVE CLINICAL TRIAL OF AN ENDOSCOPIC FULL-THICKNESS PLICATION DEVICE (GERDX™) FOR THE TREATMENT OF GERD

Abstract The gold-standard in the operative treatment of gastroesophageal reflux disease (GERD) is the laparoscopic fundoplication. Alternatively, endoscopic devices to rebuild the gastroesophageal valve were invented. The aim of our study is to assess the improvement of GERD symptoms and quality of life in patients five years after the endoscopic full-thickness plication with the GERDx™ device. Methods Between 2013 and 2016 a prospective trial was implemented with forty patients and an endoscopic plication due to reflux symptoms with a pathologic workup for GERD. Limitation for the use of GERDx™ was a 2 cm hiatal hernia. Follow-up workup was done with high resolution manometry (HRM), 24 h-pH-impedance-catheter gastroscopy and questionaires for quality of life (GIQLI) and reflux-symptoms (SCL). Results Median follow-up time was 57 months (36–74 months). There was a significant improvement of the DeMeester score, GIQLI and SCL between pre- and postoperative values in short-term as well as long-term follow-up. At least 55% of patients were assessed as failure of the plication device due to redo operations with laparoscopic fundoplication in 25% and/or necessary PPI use for GERD symptoms (40%). There is no pre- and postoperative significant difference in quality of life or reflux scores between successful and failed endoplications, but patients with laparoscopic redo operations showed significant higher DeMeester scores before and after endoscopic treatment. Conclusion There is a higher failure rate to the endoscopic full-thickness plication than to the laparoscopic fundoplication. A small group of well selected patients is eligible for the endoscopic GERDx™ device. In case of therapeutic failure a classic laparoscopic redo fundoplication is possible under more challenging operative conditions.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis.

The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF). Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair. A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%). LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

Laparoscopic redo fundoplication improves disease-specific and global quality of life following failed laparoscopic or open fundoplication.

Laparoscopic fundoplication is associated with failure rates of up to 30% and redo operation rates of 5-8%. Redo fundoplication improves patient symptoms, but its impact on patient quality of life remains unclear. We hypothesized that laparoscopic redo fundoplication improves disease-specific and global quality of life in patients with recurrent symptoms following failed laparoscopic or open fundoplication. Data for all patients undergoing a redo fundoplication between August 2009 and June 2014 were collected prospectively. Reflux symptoms and quality of life were assessed using the Gastroesophageal Reflux Symptom Scale (GERSS), the Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL), and the global quality of life Short Form-36 (SF-36) questionnaires obtained at 4weeks and 16months post-operatively. Forty-six patients underwent laparoscopic redo fundoplication during the study period for symptomatic hernia (n=11), GERD (n=18), or dysphagia (n=17). GERSS improved from 41 at baseline to 9 at late follow-up (p<0.001), and GERD-HRQL scores improved from 30 at baseline to 7 at late follow-up (p<0.001). Median dysphagia scores decreased from 4.5 to 1 (p=0.035). SF-36 scores demonstrated a significant improvement in general health (p=0.016) and emotional well-being (p=0.036) and a trend toward improved physical function (p=0.068) in the post-operative period, but these improvements were not statistically significant at longer-term follow-up. Overall, 82% of patients reported satisfaction with their operation, and 96% reported that they would have the operation performed again given the benefit of hindsight. While associated with long operative times and significant complications, laparoscopic redo fundoplication produces a durable improvement in reflux symptoms and disease-specific quality of life. These procedures also improve global quality of life in the short term and are associated with high patient satisfaction.

Su1801 A Large, Single-Surgeon Experience With Laparoscopic Redo Fundoplication: Operative Technique and Long-Term Outcomes

Su1801 A Large, Single-Surgeon Experience With Laparoscopic Redo Fundoplication: Operative Technique and Long-Term Outcomes

Efficacy and Feasibility of Laparoscopic Redo Fundoplication

Nearly 15% of patients who undergo anti-reflux surgery report recurrent symptoms on long-term follow-up and may be candidates for redo anti-reflux surgery (redo-ARS). In the last 10years, several studies have evaluated the feasibility and short-term results of redo-ARS. The purpose of the present study was to critically review our experience with 102 redo fundoplications with short- to medium-term follow-up and special emphasis on subjective outcomes for redo-ARS. A retrospective chart analysis was done on consecutive 102 redo fundoplications performed between December 2003 and March 2008. The patients were divided into two groups, the open group (group A) and the laparoscopic (group B). Subjective symptom analysis was performed on an annual basis using a standard questionnaire. There was no significant difference in mean age, body mass index (BMI), or time since first surgery between the two groups. Significant differences were noted between operative time, estimated blood loss, and median hospital stay between the two groups. A total of 16 patients were found to have short esophagus and underwent Collis gastroplasty. Complications included 11 hollow viscus injuries seen in group A and 13 such injuries in group B. There was significant improvement in all symptom scores in the two groups, along with a significant decrease in the use of acid suppression therapy. In the open group 58% of patients rated their satisfaction as excellent compared to 90% in the laparoscopic group. This study clearly establishes the safety and efficacy of redo laparoscopic anti-reflux surgery with excellent outcomes after short- to medium-term follow-up.

Single-Incision Pediatric Endosurgical Nissen Fundoplication

Single-incision pediatric endosurgery (SIPES) is gaining popularity for routine ablative operations such as appendectomy and cholecystectomy in a number of centers. We have employed this technique for Nissen fundoplication for the first time as a major reconstructive procedure. This study describes the technical evolution of SIPES fundoplication at our center, discusses the challenges, and evaluates the outcome. After IRB approval was obtained, data were prospectively collected on all SIPES fundoplications performed in our hospital from September 2009 through August 2010. The surgical techniques, operative times, blood loss, complications, conversion rates, and outcomes were recorded. SIPES fundoplication was attempted in 10 children (ages 3 months to 11 years, median 21 months; weight 3.45-51 kg, median 9 kg). Fundoplication was performed as the sole procedure in 4, and combined with a gastrostomy in 6 patients in which case the gastrostomy was used as an additional trocar site. On average, total operative time was 104 ± 31 minutes, and reached a baseline around 90 minutes after five procedures. The mean estimated blood loss was 6 ± 5 mL, and postoperative length of stay 2.6 ± 1.4 days. Different trocars, liver retraction methods, and suturing techniques were employed. Extracorporeal knot tying was used in six operations. There were no intraoperative complications, but unplanned additional trocars or access sites were added in 2 cases, leaving 3 patients in which the procedure was carried solely through the umbilicus. Reflux symptoms subsided in all patients, but 1 patient had recurrence at 12 months postoperative and underwent conventional laparoscopic redo-fundoplication. Laparoscopic Nissen fundoplication can be accomplished successfully and safely using single-incision endosurgery in children with good antireflux efficacy and without leaving any appreciable scar. Extracorporeal knot tying appears to be superior to other methods. So far, the failure rate is not higher than in conventional laparoscopic Nissen fundoplication.

Laparoscopic redo fundoplication for intrathoracic migration of wrap

Laparoscopic fundoplication is fast emerging as the treatment of choice of gastro-esophageal reflux disease. However, a complication peculiar to laparoscopic surgery for this disease is the intrathoracic migration of the wrap. This article describes a case of a male patient who developed this particular complication after laparoscopic total fundoplication. Following a trauma, wrap migration occurred. The typical history and symptomatology is described. The classical Barium swallow picture is enclosed. Laparoscopic redo fundoplication was carried out. The difficulties encountered are described. Postoperative wrap migration can be suspected clinically by the presence of a precipitating event and typical symptomatology. Confirmation is by a Barium swallow. Treatment is by redo surgery.

Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children

Purpose Recurrent gastroesophageal reflux is a common complication after fundoplication and is often treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication. Methods The medical records of all patients in whom laparoscopic revision fundoplication was attempted over a 7 1/2-year period were reviewed. Results Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of first-time redo operations and 68% of second revisions with average operative times of 2.2 ± 1.0 and 2.6 ± 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%) and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with dissection or visualization. No patients required intraoperative transfusion. No patients required reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the 72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth. Conclusion Revision laparoscopic fundoplication is a technically challenging operation but can usually be completed and is characterized by a low rate of complications.

Medium- and long-term outcome of laparoscopic redo fundoplication

For a small subset of patients, laparoscopic fundoplication fails, typically resulting in recurrent reflux or severe dysphagia. Although redo fundoplications can be performed laparoscopically, few studies have examined their long-term efficacy. Using a prospectively maintained database, the authors identified and contacted 41 patients who had undergone redo laparoscopic fundoplications at the University of Washington between 1996 and 2001. The median follow-up period was 50 months (range, 20-95 months). Current symptoms were compared with those acquired and entered into the authors' database preoperatively. Patients also were asked to return for esophageal manometry and pH testing. All redo fundoplications were performed laparoscopically. There were no conversions. The most common indication for redo fundoplication was recurrent reflux. The most common anatomic abnormality was a herniated wrap. Heartburn improved in 61%, regurgitation in 69%, and dysphagia in 74% of the patients. Complete resolution of these symptoms was achieved, respectively, in 45%, 41% and 38% of these same patients. Overall, 68% of the patients rated the success of the procedure as either "excellent" or "good," and 78% said they were happy they chose to have it. For those who underwent reoperation for gastroesophageal reflux disease, distal esophageal acid exposure according to 24-h pH monitoring decreased after redo fundoplication from 15.7% +/- 18.1% to 3.4% +/- 3.6% (p = 0.041). Although not as successful as primary fundoplication, a majority of patients can expect durable improvement in their symptoms with a laparoscopic redo fundoplication.

Outcome of laparoscopic redo fundoplication

We have read with interest the recently published article Outcome of Laparoscopic Redo Fundoplication by Dutta et al. [2]. In this article,the authors review their experience with 28 consecutive patients who underwent laparoscopic revisional fundoplication for primary failed antireflux surgery. On the basis of objective outcome parameters such as results from 24 h of pH monitoring and esophageal manometry,this study shows that laparoscopic refundoplication can be a safe and effective procedure for patients who have failed primary antireflux surgery. A significant decrease in acid reflux and a significant increase in lower esophageal sphincter pressure was achieved for these patients. Additionally,patients showed a significant decrease in gastroesophageal reflux disease symptoms after refundoplication. The field of laparoscopic redo fundoplication is challenging. Therefore,the authors should be congratulated for their excellent results. It has been reported that objective outcome parameters improve after laparoscopic refundoplication [3,4]. However,we believe that long-term evaluation of functional outcome parameters as well as symptomatic outcome and patientrelated factors such as quality of life and patient satisfaction are needed to prove the effectiveness of laparoscopic redo fundoplication. The authors describe a mean follow-up period of 22 months,although they finally evaluated objective criteria 6 months postoperatively. Like other authors [5,6],we totally agree with Dutta et al. [2] that intrathoracic wrap herniation is the most frequent anatomic morphologic complication after laparoscopic fundoplication. Therefore,most authors recommend a sufficient hiatal closure during primary laparoscopic antireflux surgery [1]. In the current study, the authors included four patients whose morphologic cause for reoperation was postoperative wrap herniation. In this group,hiatal hernia,described as the most common cause for reherniation,was not repaired at the initial procedure. It would be interesting to know whether there have been more patients without primary hiatal repair who had no postoperative reherniation of the wrap.

Minimally Invasive Surgical Techniques in Reoperative Surgery for Gastroesophageal Reflux Disease in Infants and Children

Fundoplication is commonly performed in children suffering from complications of gastroesophageal reflux disease (GERD). Recently laparoscopic fundoplication has become a standard of care for GERD in children. Published reports show that 2.3 to 14 per cent of children require reoperation after failed fundoplication. The purpose of this study is to show the feasibility of minimally invasive surgical (MIS) techniques to treat children after failed fundoplication. A retrospective chart review was performed for all patients who underwent laparoscopic redo fundoplication at Children's Healthcare of Atlanta at Egleston from July 1998 to July 2000. The patients' records were reviewed for age, diagnosis, type and time of initial operation, type and time of redo operation, operative time for redo operation, and complications. Seventeen children (age 3 months to 18 years) had operations for failed fundoplication attempted using MIS techniques. Six of these children were referred after their initial operation performed elsewhere. Nine (53%) were neurologically impaired. Ten (59%) have respiratory complications of GERD. The initial procedures were as follows: One open Nissen fundoplication, two open Thal fundoplications, 13 laparoscopic Nissen fundoplications, and one laparoscopic Toupet fundoplication. The reoperative procedures performed were revision of fundoplication and hiatal hernia repair (13) or hiatal hernia repair only (four). Two patients had concurrent gastric emptying procedures. One procedure was converted to open for technical reasons. One patient developed a pelvic abscess secondary to leakage around the gastrostomy tube. One child had erosion into the esophagus of a Dacron patch that was used to close a large hiatal defect. Thirteen patients began feeding by the first postoperative day. We conclude that MIS techniques can be applied to reoperative surgery for the treatment of GERD with an acceptable complication rate in this difficult group of patients. Reoperative patients appear to have the same benefits from MIS as patients undergoing their initial procedure.

Quality of life and subjective evaluation of outcome quality 3 years after laparoscopic antireflux surgery

Evaluation of quality of life data and patient satisfaction to estimate the outcome of laparoscopic antireflux surgery (LARS) is nowadays an important issue, the long-term outcome of this has not yet received much attention. In the present study we evaluated the outcome of quality of life data of 70 patients who underwent "floppy" Nissen fundoplication at our institute 3 years after surgery. Quality of life was evaluated with the Gastrointestinal Quality of Life Index (GIQLI). Additionally the subjectivity and objectivity of the quality of the procedure and possible side effects were evaluated with a questionnaire. Three years after laparoscopic Nissen fundoplication, patients gave their quality of life (GIQLI) in an overall score of 123.9 points. This is comparable to 122.6 points in the normal population. There was no difference detectable in the subdimensions of GIQLI. Ninety-eight percent of the patients estimated their satisfaction with the procedure as excellent or good and would undergo surgery again if necessary. Four patients suffered from minimal side effects from the procedure, but had no decrease in their quality of life. None of the patients needed antireflux medications postoperatively. Laparoscopic redo-fundoplication was performed in two patients 3 months after initial surgery because of persisting dysphagia. The efficacy and long-term outcome of treatment of gastroesophageal reflux disease with laparoscopic "floppy" Nissen fundoplication can be evaluated by objective testing, but also by subjective judgment of the patient and with an evaluation of quality of life.