Post-fundoplication Symptoms Research Articles

International Society for Diseases of the Esophagus consensus on management of the failed fundoplication.

Fundoplication is a durable, effective, and well-accepted treatment for gastroesophageal reflux disease. Nonetheless, troublesome postoperative symptoms do occasionally occur with management varying widely among centers. In an attempt to standardize definition and management of postfundoplication symptoms, a panel of international experts convened by the Guidelines Committee of the International Society for Diseases of the Esophagus devised a list of 33 statements across 5 domains through a Delphi approach, with at least 80% agreement to establish consensus. Eight statements were endorsed for the domain of Definitions, four for the domain of Investigations, nine for Dysphagia, nine for Heartburn, and four for Revisional surgery. This consensus defined as the treatment goal of fundoplication the resolution of symptoms rather than normalization of physiology or anatomy. Required investigations of all symptomatic postfundoplication patients were outlined. Further management was standardized by patients' symptomatology. The appropriateness of revisional fundoplication and the techniques thereof were described and the role of revisional surgery for therapies other than fundoplication were assessed. Fundoplication remains a frequently-performed operation, and this is the first international consensus on the management of various postfundoplication problems.

Laparoscopic fundoplication and new aspects of neural anatomy at the oesophagogastric junction.

BackgroundIn fundoplication, mobilization of the distal oesophagus and proximal stomach is essential to obtain a sufficient tension‐free intra‐abdominal oesophageal length for creation of an efficient antireflux barrier. Most surgical literature and anatomical illustrations do not describe nerve branches running from the diaphragm to the stomach. After observing small nerve branches at laparoscopic fundoplication, penetrating the left crus of the diaphragm lateral to the hiatus and apparently running into the stomach, an anatomical cadaver study was undertaken to identify the origin and target organ of these nerves.MethodsFifty‐three human cadavers (23 men, 30 women; age range 35–103 years) were dissected with special attention to the nerves that penetrate the left crus of the diaphragm. The entire course of these nerves was documented with standardized drawings and photos.ResultsSmall nerve branches penetrating the diaphragm lateral to the left crus of the hiatus were found in 17 (32 per cent) of the 53 cadavers. In 14 of these 17 cadavers, one or two splanchnic nerve branches were identified, and in ten of the 17 the nerve branches were found to be phrenic nerves. In seven of these 17 cadavers, two different nerve branches were found and assigned to both splanchnic and phrenic nerves.ConclusionNerves penetrating the left crus with splanchnic origin or phrenic origin have been identified. Their function remains unclear and their relationship to postfundoplication symptoms remains to be determined.

Quality of life and gastric acid-suppression medication 20 years after laparoscopic fundoplication.

Laparoscopic fundoplication is an effective treatment for gastro-oesophageal reflux disease (GERD). We aimed to assess quality of life (QoL), long-term residual symptoms, patient satisfaction and use of acid-suppression medication at 5, 10 and 20 years after surgery. We identified a cohort of 100 patients who underwent laparoscopic fundoplication between 1993 and 1998. The validated QoL questionnaires Short Form health survey (SF-36), and Quality-of-Life in Reflux and Dyspepsia (QOLRAD), as well as a specific questionnaire regarding post-fundoplication symptoms, were sent to the patients at 5, 10 and 20 years after surgery. Furthermore, patients who reported using the acid-suppression medication after 20 years were interviewed by telephone regarding their reason for taking it. Eighty-eight percent of the patients responded at 5 and 10 years post-surgery. Twenty years following fundoplication, 68 (84% of those still alive) patients completed the questionnaires. The patients had equivalent health-related QoL scores in both the QOLRAD and SF-36 questionnaires after 10 and 20 years, and those scores were in line with a Swedish age-matched population. After 20 years, 87% were satisfied with the results, and 84% of the patients would recommend reflux surgery to a relative or a friend. At the telephone interview, 32% (22/68) confirmed using acid-suppression medication, but only half (11/68) used it because of reflux symptoms. The long-term, satisfying outcomes in GERD symptoms and QoL 5 and 10 years after surgery were maintained at a 20-year follow-up. Half of the patients used acid-suppression medication for reasons other than GERD symptoms.

Complications of Antireflux Surgery.

Antireflux surgery anatomically restores the antireflux barrier and is a therapeutic option for proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease or PPI intolerance. Laparoscopic fundoplication is the standard antireflux surgery, though its popularity has declined due to concerns regarding wrap durability and adverse events. As the esophagogastric junction is an anatomically complex and dynamic area subject to mechanical stress, wraps are susceptible to disruption, herniation or slippage. Additionally, recreating an antireflux barrier to balance bidirectional bolus flow is challenging, and wraps may be too tight or too loose. Given these complexities it is not surprising that post-fundoplication symptoms and complications are common. Perioperative mortality rates range from 0.1 to 0.2% and prolonged structural complications occur in up to 30% of cases. Upper gastrointestinal endoscopy with a comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Management hinges on differentiating complications that can be managed with medical and lifestyle optimization versus those that require surgical revision. Reoperation is best reserved for severe structural abnormalities and troublesome symptoms despite medical and endoscopic therapy given its increased morbidity and mortality. Though further data are needed, magnetic sphincter augmentation may be a safer alternative to fundoplication.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as “failed”. In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term “dysfunction” could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a “complication”. Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

Randomized clinical trial of 270° posterior versus 180° anterior partial laparoscopic fundoplication for gastro-oesophageal reflux disease.

Partial fundoplications provide similar reflux control with fewer post-fundoplication symptoms compared with Nissen fundoplication for gastro-oesophageal reflux disease (GORD). The best choice of procedure for partial fundoplication remains unclear. The aim of this study was to compare the outcome of two different types of partial fundoplication for GORD. A double-blind RCT was conducted between 2012 and 2015 in two hospitals specializing in antireflux surgery. Patients were randomized to undergo either a laparoscopic 270° posterior fundoplication (Toupet) or a laparoscopic 180° anterior fundoplication. The primary outcome was postoperative dysphagia at 12 months, measured by the Dakkak score. Subjective outcome was analysed at 1, 3, 6 and 12 months after surgery. Objective reflux control was assessed before and 6 months after surgery. Ninety-four patients were randomized to laparoscopic Toupet or laparoscopic 180° anterior fundoplication (47 in each group). At 12 months, 85 patients (90 per cent) were available for follow-up. Objective scores were available for 76 (81 per cent). Postoperative Dakkak dysphagia score at 12 months was similar in the two groups (mean 5·9 for Toupet versus 6·4 for anterior fundoplication; P = 0·773). Subjective outcome at 12 months demonstrated no significant differences in control of reflux or post-fundoplication symptoms. Overall satisfaction and willingness to undergo surgery did not differ between the groups. Postoperative endoscopy and 24-h pH monitoring showed no significant differences in mean oesophageal acid exposure time or recurrent pathological oesophageal acid exposure. Both types of partial fundoplication provided similar control of GORD at 12 months, with no difference in post-fundoplication symptoms. Registration number: NTR5702 (www.trialregister.nl).

Long-term symptom control of gastro-oesophageal reflux disease 12 years after laparoscopic Nissen or 180° anterior partial fundoplication in a randomized clinical trial.

Laparoscopic 180° anterior fundoplication has been shown to achieve similar reflux control to Nissen fundoplication, with fewer side-effects, up to 5 years. However, there is a paucity of long-term follow-up data on this technique and antireflux surgery in general. This study reports 12-year outcomes of a double-blind RCT comparing laparoscopic Nissen versus 180° laparoscopic anterior fundoplication for gastro-oesophageal reflux disease (GORD). Patients with proven GORD were randomized to laparoscopic Nissen or 180° anterior fundoplication. The 12-year outcome measures included reflux control, dysphagia, gas-related symptoms and patient satisfaction. Measures included scores on a visual analogue scale, a validated Dakkak score for dysphagia and Visick scores. Of the initial 163 patients randomized (Nissen 84, anterior 79), 90 (55·2 per cent) completed 12-year follow-up (Nissen 52, anterior 38). There were no differences in heartburn, dysphagia, gas-related symptoms, patient satisfaction or surgical reintervention rate. Use of acid-suppressing drugs was less common after Nissen than after 180° anterior fundoplication: four of 52 (8 per cent) and 11 of 38 (29 per cent) respectively (P = 0·008). The proportion of patients with absent or only mild symptoms was slightly higher after Nissen fundoplication: 45 of 50 (90 per cent) versus 28 of 38 (74 per cent) (P = 0·044). The two surgical procedures provided similar control of heartburn and post-fundoplication symptoms, with similar patient satisfaction and reoperation rates on long-term follow-up.

One- and ten-year outcome of laparoscopic anterior 120° versus total fundoplication: a double-blind, randomized multicenter study.

Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD) but can cause adverse effects like flatulence and dysphagia. The aim was to compare laparoscopic anterior 120° fundoplication (APF) to total fundoplication (Nissen) concerning flatulence and other adverse effects, in a randomized blinded study. Seventy-two patients were randomized to APF (n = 36) or Nissen (n = 36). Gastroscopy, 24-h pH monitoring and evaluation for symptoms and quality of life using questionnaires (GSRS, PGWB and 7-graded Likert scales) were performed preoperatively, at 1 and 10 years postoperatively. Patients and the researchers were blinded to operative method. When entering the study, most patients had mild-moderate reflux disease according to the symptom score, the 24-h pH measurements, and frequency and grade of esophagitis. At 1-year (n = 68) flatulence, dysphagia, heartburn and acid regurgitation did not differ between groups. More patients could belch (p = 0.005), and pH monitoring showed a higher time with pH < 4 in the APF group (p = 0.006). At 10 years (n = 61), the APF group reported less dysphagia (p < 0.001), more heartburn (p = 0.019) and more patients could belch (p = 0.012) and vomit (p < 0.001) compared to the Nissen. No difference remained at 10 years in pH monitoring (n = 23) between groups. Symptoms of heartburn and acid regurgitation were less than preoperatively in both groups (p < 0.001). No revisional operations were performed. Both procedures offer good long-term control of reflux symptom, with modest post-fundoplication symptoms. Anterior 120° fundoplication results in less dysphagia, better ability to belch and vomit than total fundoplication at 10-year follow-up. The results suggest that APF could be an alternative to Nissen fundoplication in the surgical treatment of mild-moderate GERD.

Complete vs partial fundoplication in children with esophageal atresia

PurposeThe purpose of the study was to compare outcomes after partial vs complete fundoplication in patients with prior esophageal atresia repair. MethodsAll patients undergoing fundoplication following esophageal atresia repair at a tertiary care pediatric hospital from 1987 to 2006 were retrospectively reviewed. All children had at least 1 year of follow-up postfundoplication. ResultsOf 47 children, 31 (66%) had a partial fundoplication and 16 (34%) had complete fundoplication. Demographics, presence of tracheoesophageal fistula, early complications of esophageal atresia repair, gastroesophageal reflux symptoms before fundoplication, and operative details of fundoplication were statistically similar between groups, except for the frequency of hiatus repair during fundoplication (23% vs 69%, P = .004). Patients were followed for a median of 4.98 years (range, 1-17.8 years). Postfundoplication symptoms of vomiting (39% vs 31%), dysphagia (45% vs 38%), retching (10% vs 25%), abnormal findings on barium study, and need for reoperation (19% vs 13%) were not statistically different between groups. However, a greater proportion of children undergoing partial fundoplication achieved long-term symptom- and medication-free recovery (52% vs 13%, P = .012). ConclusionsOur data suggest that partial fundoplication is associated with a greater likelihood of symptom- and medication-free recovery than complete fundoplication in children with previously repaired esophageal atresia.

Surgical therapy of gastro-oesophageal reflux disease

Surgery should always be looked upon as complementary to medical therapy in the long-term management of patients with chronic GORD. Available medical therapies are effective and adequate for the control of disease manifestations in the great majority of GORD patients. For patients who have a suboptimal disease control under medical therapy and in those who for various reasons want to discuss an alternative to medical long-term therapy, the following message can be transmitted. Anti reflux surgery is a well-documented effective long-term therapeutic alternative to control GORD. The outcome after surgery is dependent on the experience and quality of the surgeon. These operations are safe but mortality can never attain a zero level and the morbidity has to be realised. Anti reflux surgery has to be centralised within each country. With the aim of optimising the outcome of anti reflux surgery, the surgeon has to perform and master a delicate act of balance on the choice between various fundoplication procedures. On one hand we have the total fundoplication with its proved efficacy regarding reflux control but with it associated somewhat more frequent mechanical side-effects. The posterior partial fundoplication has obvious advantages with less postfundoplication complaints without compromising the level of reflux control and can therefore often be recommended. Most studies present very promising results following anterior partial fundoplications. The spectrum of postfundoplication symptoms can be minimised provided that the surgeon fully comprehend the mechanism of action of these procedures and adhere to technical perfectionism. Evaluation and management of failures after anti reflux surgery have to be centralised within each country.

Short-term symptom and quality-of-life comparison between laparoscopic Nissen and Toupet fundoplications

Laparoscopic antireflux surgery is an established method of treatment of gastroesophageal reflux disease (GERD). This study evaluates the efficacy of Nissen versus Toupet fundoplication in alleviating the symptoms of GERD and compares the two techniques for the development of post-fundoplication symptoms and quality of life (QOL) at 12 months post-surgery. In this prospective consecutive cohort study, 94 patients presenting for laparoscopic antireflux surgery underwent either laparoscopic Nissen fundoplication (LN) (n = 51) from February 2002 to February 2004 or a laparoscopic Toupet fundoplication (LT) (n = 43) from March 2004 to March 2006, performed by a single surgeon (G. S. S.). Symptom assessment, a QOL scoring instrument, and dysphagia questionnaires were applied pre- and postoperatively. At 12 months post-surgery, patient satisfaction levels in both groups were high and similar (LT: 98%, LN: 90%; P = 0.21). The proportion of patients reporting improvement in their reflux symptoms was similar in both groups (LT: 95%, LN: 92%; P = 0.68), as were post-fundoplication symptoms (LT: 30%, LN: 37%; P = 0.52). Six patients in the Nissen group required dilatation for dysphagia compared with one in the Toupet group (LT: 2%, LN: 12%; P = 0.12). One patient in the Nissen group required conversion to Toupet for persistent dysphagia (P = 0.54). In this series, overall symptom improvement, QOL, and patient satisfaction were equivalent 12 months following laparoscopic Nissen or Toupet fundoplication. There was no difference in post-fundoplication symptoms between the two groups, although there was a trend toward a higher dilatation requirement and reoperation after Nissen fundoplication.

An Anterior or Posterior Approach to Partial Fundoplication? Long‐term Results of a Randomized Trial

Partial fundoplications have been popularized by their lower risk of mechanical side effects. The question then emerges whether a similar partial wrap should be done posterior or anterior to the distal esophagus? We therefore conducted a study to compare the long-term outcome of laparoscopic partial fundoplications constructed either as anterior (AF) or posterior (PF) repairs. Ninety-five patients were enrolled in a randomized clinical trial. After a mean follow up of 65 months, 43 AF and 45 PF patients remained in the study. The levels of reflux control and postfundoplication complaints were assessed by use of validated instruments. A posterior fundoplication was found to provide significantly better control of reflux related symptoms (heartburn p < 0.0001, acid regurgitation p < 0.0001). This was also reflected in a significantly lower number of reoperations and need for antisecretory drug therapy. The earlier postoperative difference in postfundoplication symptoms had disappeared. A laparoscopic posterior partial fundoplication offers a high and durable level of disease control with few side effects. The current anterior type of repair cannot be recommended due to insufficient reflux control.

DELAYED ONSET OF POST-FUNDOPLICATION COUGHING, GAGGING, AND CHOKING IS TEMPORALLY ASSOCIATED WITH GASTROESOPHAGEAL REFLUX (GER)

Background: Early onset of post-fundoplication coughing, gagging and chocking is reported to be related to poor gastric compliance and accommodation. Delayed onset of such symptoms is of unclear etiology. Aims: 1) assess the role of GER in causing post-fundoplication gagging, choking or coughing 2) evaluate the effects of pH status on the GER in its temporal relation to these symptoms. Methods: Ten children (4M/6F, median age 17.3 months), were referred to our facility for delayed onset of coughing, gagging, and choking 26.1 ± 10.8 months after fundoplication. All patients underwent 24 hour combined pH and multichannel intraluminal impedance monitoring (pH/MII) monitoring. Symptom events (SEs): coughing, choking and gagging were recorded by a constant attendant and considered temporally associated with GER if occurred within 5 min of a GER event. Strengths of association were assessed using symptom indices (SI) and symptom sensitivity indices (SSI). Significance of SI and SSI values were at >50% and >10%, respectively. Results: Of the combined measuring time of 13,055 min, 85.2 min were spent in reflux; 38.0 min (44.6%) were acid-GER (AGER) and 47.2 min (55.4%) were non-acid-GER (NAGER). During the studies we detected 188 GER episodes, 54 (28.7%) AGER and 134 (71.3%) NAGER. Patients had 871 SEs; 769 (88.3%) coughing, 91 (10.4%) gagging, and 11 (1.3%) choking events. Of the total 871 SEs, 60 (6.9%) were found to be temporally-linked with GER by pH/MII; 48 (80%) coughing, 11 (18.3%) gagging, and 1 (1.7%) choking event. SI was <50% in all patients. 7/10 patients had a positive SSI; 1 (14.3%) with AGER only, 4 (57.1%) with NAGER only, and 2 (28.6%) with both AGER and NAGER. More patients had a positive SSI using pH/MII than would have been detected by pH monitoring alone (7/10 [70%] vs 3/10 [30%]). Conclusions: 1. in the delayed post-fundoplication phase coughing, gagging, and choking are temporally associated with either acid or non acid GER 2. pH/MII is superior to the standard pH monitoring in evaluating the etiology of post-fundoplication symptoms.

Why do patients develop post-fundoplication symptoms?: a perspective from a consultative gastroenterologist (CG)

Why do patients develop post-fundoplication symptoms?: a perspective from a consultative gastroenterologist (CG)

Long-term symptomatic follow-up after lind fundoplication

AIMS: Few published studies have detailed the long-term results of antireflux surgery. The aim of this study was to assess the long-term success of open Lind fundoplication in controlling the symptoms of gastro-oesophageal reflux disease. METHODS: One hundred and thirty-two patients with reflux symptoms underwent a primary Lind fundoplication between April 1986 and February 1994; all operations were supervised or performed by one surgeon. The median age at operation was 47 (range 17-77) years. All patients attended for follow-up in the early postoperative period. It was possible to conduct a telephone interview to assess long-term symptom control, at a median time of 9.5 (range 5-13) years following operation, in 112 of the 124 patients who were still alive. RESULTS: Ninety-one patients underwent oesophageal pH studies before and soon after operation. The oesophageal pH was less than 4 for a mean 14.9 per cent of the time before operation, falling to 2.4 per cent in the early postoperative period (P < 0.001, Wilcoxon test). At early postoperative assessment, two patients complained of mild reflux symptoms and 44 (33 per cent) complained of postfundoplication symptoms (dysphagia, epigastric bloating and early satiety). At telephone interview, 106 patients (95 per cent) were symptom free with regard to heartburn and regurgitation. Six patients have developed recurrent reflux symptoms, in four of whom symptoms are controlled by a proton pump inhibitor. Two patients have required further antireflux surgery, one within 2 months of the first procedure for severe dysphagia and the other for recurrent reflux. Significant postfundoplication symptoms persist (dysphagia with or without gas bloat) in three patients (3 per cent). CONCLUSIONS: Open Lind fundoplication appears to be effective in the long-term control of gastro-oesophageal reflux in 95 per cent of patients and represents a standard against which the long-term results of laparoscopic surgery will need to be compared.

Post-fundoplication symptoms: The role for endoscopic assessment of fundoplication integrity

Background: Fundoplication is now almost exclusively a laparoscopic procedure. The aim of this study was the comparison of the diagnostic usefulness of endoscopy and barium esophagram in the detection of fundoplication abnormalities. Methods: Twenty-two patients presented with symptoms post-laparoscopic (Nissen) fundoplication that included dysphagia (14 patients), heartburn (5 patients), dyspepsia (2 patients), and chest pain (1 patient). Barium esophagram and upper endoscopy were performed in all patients and the results were compared. Key features included presence of esophagitis, resistance to endoscope passage, location of the wrap relative to the diaphragmatic hiatus, location of squamocolumnar junction greater than 1 cm proximal to the wrap zone, and the appearance of the wrap (intact, loose, disrupted, or tight). Results: The key features explained symptoms in 20 of 22 patients. Endoscopy detected twice as many key features as radiography. Disruption of the wrap or excessive proximal location of the squamocolumnar junction proximal to the wrap zone were the most incriminating endoscopic findings. Resistance to endoscope passage was rarely encountered and the esophagram was more accurate in detecting an overly tight wrap. Conclusions: Endoscopic evaluation is more accurate than barium esophagram in detecting post-fundoplication abnormalities. The appearance of the fundoplication wrap and an abnormal proximal location of the squamocolumnar junction appear to be major endoscopic clues in diagnosis of post-fundoplication problems. (Gastrointest Endosc 2001;54:351-6.)

The past and present of antireflux surgery in children

The surgical management of gastroesophageal reflux disease (GERD) in infants and children has been prominent among the many interests and publications of Eric W. Fonkalsrud, whom this symposium honors. This paper attempts to review of some of Fonkalsrud’s contributions relative to (1) antireflux surgery in small infants and (2) the role of gastric outlet modification to reduce post-fundoplication symptoms and fundoplication failures. The occasional case of esophagitis not corrected by fundoplication also deserves brief comment.

Comparison between barium esophagram and upper endoscopy for the diagnostic evaluation of postfundoplication symptoms

Comparison between barium esophagram and upper endoscopy for the diagnostic evaluation of postfundoplication symptoms

Oesophageal and cardia function in patients with paraoesophageal hiatus hernia

The decision to add an antireflux procedure when a paraoesophageal hernia is repaired is still controversial. The aim of this study was to investigate oesophageal and cardia function in these patients to verify whether fundoplication was needed. Eighteen patients with paraoesophageal hernia were evaluated by oesophageal manometry, 24-h pH monitoring, endoscopy and barium swallow. All patients underwent surgery including antireflux fundoplication. Fourteen patients with sliding hernia plus reflux disease and 16 healthy volunteers formed the control groups. Patients with paraoesophageal hernia had a shorter lower oesophageal sphincter and a greater acid exposure than healthy controls (P < 0.05). Fifteen of 18 patients had either abnormal acid exposure and/or a defective lower oesophageal sphincter at manometry. Postfundoplication symptoms were observed in only one of 16 patients at 6 months' follow-up. Since 15 of 18 patients had abnormal acid exposure or were considered prone to developing gastro-oesophageal reflux disease because of a defective lower oesophageal sphincter, this study strongly supports the need to add an antireflux operation to hernia repair.

Successful management of severe gastroesophageal reflux disease with laparoscopic nissen fundoplication

Nissen fundoplication has been shown to be superior to medical treatment in the management of severe or complicated gastroesophageal reflux disease (GERD). Rapid advances in minimally invasive surgical technique and recognition of the advantages of reduced incision-related morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 70 patients undergoing laparoscopic Nissen fundoplication for severe GERD was undertaken. Rigid selection criteria for laparoscopic Nissen fundoplication included severe or refractory disease with documentation of abnormal esophageal acid exposure by 24-hour pH probe monitoring, documentation of a mechanically defective lower esophageal sphincter by esophageal manometry, and absence of severe esophageal and/or gastric motility disorders. Sixty-eight of 70 patients were completed laparoscopically with an intraoperative morbidity rate of 9%. Major postoperative complications occurred in 3 patients (4%) and included deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and trocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 7.0 days. All patients experienced relief of symptoms of reflux with mean follow-up of 7.7 months. Transient, mild dysphagia was experienced by 37% of patients, and persistent, severe dysphagia by 7%. The mean increase in lower esophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdominal sphincter lengths increased an average of 1.5 and 1.4 cm, respectively. These preliminary data suggest that laparoscopic Nissen fundoplication can be performed by experienced laparoscopic surgeons with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures. Rigid patient selection criteria will help identify the patients most likely to benefit from reconstruction of a mechanically defective lower esophageal sphincter. Adherence to established operative principles for Nissen fundoplication will reduce the incidence of significant postfundoplication symptoms.