MEDLINE Abstracts: Laparoscopic Surgery for Gastroesophageal Reflux Disease

September 11, 2003

What's new concerning laparoscopic surgery for gastroesophageal reflux disease (GERD)? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Transplantation.

Chronic GERD can lead to the development of complications such as erosive esophagitis, stricture formation, and Barrett's esophagus, which increase the risk of esophageal adenocarcinoma. GERD is a common condition, associated with significant morbidity, and it is expensive to treat.

Current therapy is targeted at acid suppression to minimize mucosal injury and eliminate symptoms. Medical therapy for GERD has evolved from frequent use of antacids to once-daily proton pump inhibitor therapy. Despite the efficacy of these therapies in healing erosive esophagitis, symptom relief is incomplete and the need for continuous maintenance therapy is expensive. To date, the mainstay of surgical treatment for GERD is open or laparoscopic fundoplication.

Five-Year Comprehensive Outcomes Evaluation in 181 Patients After Laparoscopic Nissen Fundoplication

Anvari M, Allen C
J Am Coll Surg. 2003;196:51-57; discussion 57-58

Background: We conducted an objective follow-up of 181 patients after laparoscopic Nissen fundoplication during a 5-year period after surgery.
Study Design: Patients underwent 24-hour pH recording, esophageal manometry, and symptom score assessment for six gastroesophageal reflux disease symptoms preoperatively and at 6 months, 2 years, and 5 years after surgery.
Results: Laparoscopic fundoplication was associated with a significant (p < 0.0001) increase in lower esophageal sphincter pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours, and symptom score, 6, 24, and 60 months after surgery when compared with preoperative values. Twenty-one patients (12%) have experienced recurrence of reflux-type symptoms, but only six have required repeat surgery. Lower esophageal sphincter tone dropped between 6 months and 5 years after surgery, but was still an effective antireflux barrier. Patient satisfaction with surgery dropped over the 5-year followup but remained high, at 86%, after 5 years.
Conclusions: Laparoscopic Nissen fundoplication remains an effective antireflux procedure at 5 years.

Chrysos E, Tsiaoussis J, Zoras OJ, et al
J Am Coll Surg. 2003;197:8-15

Background: It has been proposed that partial fundoplication is associated with less incidence of postoperative dysphagia and consequently is more suitable for patients with gastroesophageal reflux disease (GERD) and impaired esophageal body motility. The aim of this study was to assess whether outcomes of Toupet fundoplication (TF) are better than those of Nissen-Rossetti fundoplication (NF) in patients with GERD and low-amplitude esophageal peristalsis.
Study Design: Thirty-three consecutive patients with proved GERD and amplitude of peristalsis at 5 cm proximal to lower esophageal sphincter (LES) less than 30 mmHg were randomly allocated to undergo either TF (19 patients: 11 men, 8 women; mean age: 61.7 ± 8.7 SD years) or NF (14 patients: 7 men, 7 women; mean age: 59.2 ± 11.5 years), both by the laparoscopic approach. Pre- and postoperative assessment included clinical questionnaires, esophageal radiology, esophageal transit time study, endoscopy, stationary manometry, and 24-hour ambulatory esophageal pH testing.
Results: Duration of operation was significantly prolonged in the TF arm (TF: 90 ± 12 minutes versus NF: 67 ± 15 minutes; p < 0.001). At 3 months postoperatively, the incidences of dysphagia (grades I, II, III) and gas-bloat syndrome were higher after NF than after TF (NF: 57% versus TF: 16%; p < 0.01 and NF: 50% versus TF: 21%; p = 0.02, respectively), but decreased to the same level in both groups at the 1-year followup (NF: 14% versus TF: 16% and NF: 21% versus TF: 16%, respectively). At 3 months postoperatively, patients with NF presented with significantly increased LES pressure than those with TF (p = 0.02), although LES pressure significantly increased after surgery in both groups, as compared with preoperative values. Amplitude of esophageal peristalsis at 5 cm proximal to LES increased postoperatively to the same extent in both groups (TF, preoperatively: 21 ± 6 mmHg versus postoperatively: 39 ± 12 mmHg; p < 0.001, and NF, preoperatively: 20 ± 8 mmHg versus postoperatively: 38 ± 12 mmHg; p < 0.001). Reflux was abolished in all patients of both groups.
Conclusions: Both TF and NF efficiently control reflux in patients with GERD and low amplitude of esophageal peristalsis. Early in the postoperative period, TF is associated with fewer functional symptoms, although at 1 year after surgery those symptoms are reported at similar frequencies after either procedure.

Heider TR, Behrns KE, Koruda MJ, et al
J Gastrointest Surg. 2003;7:159-163

Patients with gastroesophageal reflux disease (GERD) and disordered esophageal motility are at risk for postoperative dysphagia, and are often treated with partial (270-degree) fundoplication as a strategy to minimize postoperative swallowing difficulties. Complete (360-degree) fundoplication, however, may provide more effective and durable reflux protection over time. Recently we reported that postfundoplication dysphagia is uncommon, regardless of preoperative manometric status and type of fundoplication. To determine whether esophageal function improves after fundoplication, we measured postoperative motility in patients in whom disordered esophageal motility had been documented before fundoplication. Forty-eight of 262 patients who underwent laparoscopic fundoplication between 1995 and 2000 satisfied preoperative manometric criteria for disordered esophageal motility (distal esophageal peristaltic amplitude < or =30 mm Hg and/or peristaltic frequency < or =80%). Of these, 19 had preoperative manometric assessment at our facility and consented to repeat study. Fifteen (79%) of these patients had a complete fundoplication and four (21%) had a partial fundoplication. Each patient underwent repeat four-channel esophageal manometry 29.5 ± 18.4 months (mean ± SD) after fundoplication. Distal esophageal peristaltic amplitude and peristaltic frequency were compared to preoperative data by paired t test. After fundoplication, mean peristaltic amplitude in the distal esophagus increased by 47% (56.8 ± 30.9 mm Hg to 83.5 ± 36.5 mm Hg; P < 0.001) and peristaltic frequency improved by 33% (66.4 ± 28.7% to 87.6 ± 16.3%; P < 0.01). Normal esophageal motor function was present in 14 patients (74%) after fundoplication, whereas in five patients the esophageal motor function remained abnormal (2 improved, 1 worsened, and 2 remained unchanged). Three patients with preoperative peristaltic frequencies of 0%, 10%, and 20% improved to 84%, 88%, and 50%, respectively, after fundoplication. In most GERD patients with esophageal dysmotility, fundoplication improves the amplitude and frequency of esophageal peristalsis, suggesting refluxate has an etiologic role in motor dysfunction. These data, along with prior data showing that postoperative dysphagia is not common, imply that surgeons should apply complete fundoplication liberally in patients with disordered preoperative esophageal motility.

Graziano K, Teitelbaum DH, McLean K, Hirschl RB, Coran AG, Geiger JD
Surg Endosc. 2003;17:704-707

Background: Laparoscopic Nissen fundoplication as treatment for gastroesophageal reflux disease (GERD) in adults has a reported recurrence rate of 2-17%. We investigated the rates and mechanisms of failure after laparoscopic Nissen fundoplication in children.
Methods: All patients who underwent a laparoscopic Nissen fundoplication for GERD and who subsequently required a redo Nissen were reviewed (n = 15). The control group consisted of the most recent 15 patients who developed recurrent GER after an open Nissen, fundoplication.
Results: Between 1994 and 2000, laparoscopic Nissen fundoplication was performed in 179 patients. Fifteen patients (8.7%) underwent revision. The mechanisms of failure were herniation in four patients, wrap dehiscence in four, a too-short wrap in three, a loosened wrap in two, and other reasons in two. The reoperation was performed laparoscopically in five patients (33%). The failure mechanisms were different in the open patients: eight were due to slipped wraps; three to dehiscences; and two to herniations.
Conclusion: The failure rate after laparoscopic Nissen is acceptably low. A redo laparoscopic Nissen can be performed safely after an initial laparoscopic approach.

Desai KM, Frisella MM, Soper NJ
J Gastrointest Surg. 2003;7:44-51; discussion 51-52

A wide spectrum of endoscopic findings exists in patients with gastroesophageal reflux disease (GERD). This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients who had GERD with and without preoperative endoscopic esophagitis. From 1992 to 2001, a total of 414 patients who underwent LARS with 6 months or more of follow-up were prospectively entered into a database. Among these patients, 84 (20%) had no endoscopic evidence of esophagitis on preoperative endoscopy (group 1), whereas 330 (80%) did have esophagitis (group 2). Perioperative outcomes, GERD symptom relief, and the use of acid-reducing medication were assessed. Preoperative DeMeester scores in groups 1 and 2 were 44 ± 29 and 61 ± 62 (P < 0.05) and mean esophageal peristaltic amplitude was 86 ± 32 mm Hg vs. 60 ± 42 mm Hg, respectively (P < 0.05). Although procedure time was significantly shorter in group 1, other perioperative outcomes were similar. At postoperative follow-up, the use of proton pump inhibitors was reduced in both groups (86% to < or =14%). With the exception of postoperative dysphagia, there was no difference in GERD symptom relief between groups 1 and 2. The presence or absence of preoperative esophagitis has minimal effect on favorable symptomatic outcomes after LARS. Thus LARS is an effective treatment option for patients, irrespective of endoscopic evidence of esophagitis, leading to excellent symptom relief and a marked reduction in the use of proton pump inhibitors.

ME, Garrett WV, Nisar A, Boyle NH, Slater GH
Br J Surg. 2003;90:560-562

Background: The aim was to assess the acceptability and safety of day-case laparoscopic fundoplication for gastro-oesophageal reflux disease (GORD).
Methods: This prospective study commenced in December 1999 and lasted for 18 months. All patients had proven symptomatic GORD. Inclusion criteria were American Society of Anesthesiologists grade I or II with adequate home support. A standard anaesthetic, analgesic and antiemetic protocol was used. Patients were contacted by telephone on the night of discharge and arrangements were made for a nurse to visit the following day. Postoperative pain and nausea were assessed using visual analogue scores (scale 0-10) on a self-completion questionnaire.
Results: Twenty patients were included. There were no postoperative complications. All patients were discharged on the day of surgery. Median time to discharge was 6 h 30 min (range 4.5 to 9 h). One patient reattended casualty the following morning but none required readmission. There was no significant difference in median pain or nausea scores the evening after surgery or the next morning. All patients were satisfied with the information given and aftercare provided. All would recommend it to a friend and 19 of 20 would undergo the procedure as a day case again.
Conclusion: This study suggests that day-case laparoscopic fundoplication is feasible. Patients find it acceptable and it appears safe.

Ray S
Surg Endosc. 2003;17:378-380

Recently, several studies were published regarding the safety and feasibility of laparoscopic Nissen fundoplication as an outpatient procedure. However, in these studies the patients were discharged within 24 h and considered to be outpatients. In our study, the author performed 310 procedures on an outpatient basis at a hospital or free-standing surgery center. The study analyzed intraoperative complications, readmission after discharge, length of dysphagia, resumption of regular diet, effectiveness, and the use of antireflux medications after the procedure. The study concluded that with the outpatient procedure, there is no increase in morbidity, mortality, readmission, or long-term effectiveness, as compared with inpatient procedures. Outpatient laparoscopic Nissen fundoplication makes the procedure much more attractive to most patients.

Short-term Symptomatic Outcome and Quality of Life After Laparoscopic Versus Open Nissen Fundoplication: A Prospective Randomized Trial

Heikkinen TJ, Haukipuro K, Sorasto A, et al
Int J Surg Investig. 2000;2:33-39

Background: Laparoscopic operation has replaced conventional operation in the treatment of reflux disease. This change has been mostly based on excellent results from highly experienced antireflux surgeons rather than on randomized clinical trials. AIMS: The objective of this study was to compare the short-term symptomatic outcome and patient quality of life costs after laparoscopic (LNF) or open Nissen fundoplication (ONF) in a community hospital setting with less experienced surgeons.
Methods: Forty-two patients with documented gastroesophageal reflux disease (GERD) were randomized to either LNF or ONF. Symptomatic outcome using a custom questionnaire and the Gastrointestinal Quality of Life Index (GIQLI) were measured pre- and postoperatively at one and three months.
Results: Esophagitis was cured among all patients in LNF group compared to 90% in the ONF group. The symptoms observed preoperatively were significantly improved in both groups, except for dysphagia and flatulence. Dysphagia was more common after LNF. The GIQLI (scale 0-144) was equally normalized in both groups. The mean GIQLI-change among all patients was 37.9 points. Patient satisfaction did not differ between the groups.
Conclusions: LNF and ONF are effective methods in the operative treatment of GERD in short-term and result in a significant improvement in patients gastrointestinal symptoms and quality of life.

Galvani C, Fisichella PM, Gorodner MV, Perretta S, Patti MG
Arch Surg. 2003;138:514-518;discussion 518-519

Background: If a patient develops foregut symptoms after a fundoplication, it is assumed that the operation has failed, and acid-reducing medications are often prescribed. Esophageal function tests (manometry and pH monitoring) are seldom performed early in the management of these patients.
Hypothesis: In patients who are symptomatic after fundoplication for gastroesophageal reflux disease, a symptom-based diagnosis is not accurate, and esophageal function tests should be performed routinely before starting acid-reducing medications.
Design: Prospective study.
Setting: University hospital.
Patients and Methods: One hundred twenty-four patients who developed foregut symptoms after laparoscopic fundoplication (average, 17 months postoperatively) underwent esophageal manometry and pH monitoring. Sixty-two patients (50%) were taking acid-reducing medications.
Main Outcome Measures: Postoperative symptoms, use of antireflux medications, grade of esophagitis, esophageal motility, and DeMeester scores.
Results: Seventy-six (61%) of the 124 patients had normal esophageal acid exposure, while the acid exposure was abnormal in 48 patients (39%). Only 20 (32%) of the 62 patients who were taking acid-reducing medications had reflux postoperatively. Regurgitation was the only symptom that predicted abnormal reflux.
Conclusions: These results show that (1) symptoms were due to reflux in 39% of patients only; (2) with the exception of regurgitation, symptoms were an unreliable index of the presence of reflux; and (3) 68% of patients who were taking acid-reducing medications postoperatively had a normal reflux status. Esophageal function tests should be performed early in the evaluation of patients after fundoplication to avoid improper and costly medical therapy.

Granderath FA, Kamolz T, Schweiger UM, Pointner R
Int J Colorect Dis. 2003;18:248-253

Background And Aims: Laparoscopic antireflux surgery has in recent years become the standard procedure for treating severe gastroesophageal reflux disease. Both laparoscopic antireflux surgery and open surgery cause failures which lead to repeat surgery in 3-6% of cases. We evaluated prospectively quality of life and surgical outcome following laparoscopic refundoplication for failed initial antireflux surgery.
Patients and Methods: We prospectively studied 51 patients undergoing laparoscopic refundoplication for primary failed antireflux surgery, with complete follow-up 1 year after surgery. In 20 cases the initial surgery used the open technique; four had surgery twice previously. In 31 cases primary procedure was performed laparoscopically. Indication for repeat surgery were recurrent reflux ( n=29), dysphagia (n=12), and a combination of the two ( n=10). Preoperative and postoperative data including 24-h pH monitoring, esophageal manometry, and quality of life (Gastrointestinal Quality of Life Index) were used to assess outcome.
Results: Forty-nine procedures (96%) were completed by the laparoscopic technique. Conversion was necessary in two cases with primary open procedure, in one patient because of injury to the gastric wall and in one severe bleeding of the spleen. Postoperatively two patients (3.9%) suffered from dysphagia and required pneumatic dilatation within the first postoperative year. Average operating time was 245 min after an initial open procedure and 80 min after an initial laparoscopic procedure. The lower esophageal sphincter pressure increased significantly from preoperatively 2.8±1.8 mmHg at 3 months (12.8±4.1 mmHg) and 1 year (12.3±3.9 mmHg) after repeat surgery. In these cases the DeMeester score decreased significantly from preoperative 67.9±10.3 to 15.5±9.4 at 3 months and 13.1±8.1 at 1 year after surgery. Mean Gastrointestinal Quality of Life Index increased from 86.7 points preoperatively to 121.6 points at 3 months and 123.8 points at 1 year and was comparable to that of a healthy population (122.6 points).
Conclusion: Laparoscopic repeat surgery for recurrent or persistent symptoms of gastroesophageal reflux disease is effective and can be performed safely with excellent postoperative results and a significant improvement in patient's quality of life for a follow-up period of 1 year.

Kamolz T, Granderath F, Pointner R
Surg Endosc. 2003;17:880-885

Background: Several findings suggest that gastroesophageal reflux disease (GERD) has a significant impact on patients' quality of life. The aim of this prospective study was (a) to evaluate and compare quality-of-life data before and after laparoscopic antireflux surgery (LARS) in GERD patients with and without Barrett's esophagus (BE); and (b) to compare quality-of-life data of these patients to normative data for a comparable general population.
Methods: The Gastrointestinal Quality of Life Index (GIQLI) was administrated to 75 BE patients and to 174 patients with GERD without BE (Savary-Miller classification: grade 1: n = 49; grade 2: n = 69; grade 3: n = 56). The questionnaire was given to all patients preoperatively, 3months, 1 year, and 3 years after laparoscopic "floppy" Nissen fundoplication.
Results: Before surgery, BE patients (mean: 96.8 ± 9.3 points) had a better but not significant (p<0.06) general score of the GIQLI when compared with patients without BE (mean: 86.4 ± 10.1 points). This difference is solely based on the subdimension "gastrointestinal symptoms" which means that GERD symptoms are less intensively and frequently recognized in BE patients than in patients without BE. There are no other differences in the other four subdimensions of the GIQLI between both groups. Three months, 1 year, and 3 years after LARS, GIQLI was significantly (p<0.01) improved in both groups (BE patients mean after 3 years: 121.9 ± 8.2 points; non-BE patients mean after 3 years: 122.8 ± 9.3 points). This improvement was significantly better (p<0.05) in patients without BE than in BE patients. Before surgery, both groups scored significantly below average on all subscores of GIQLI compared to general population (mean: 122.6 ± 8.5 points). After surgery, there are no differences detectable.
Conclusion: As our data show, non-BE patients undergoing LARS achieve a better quality-of-life improvement than those patients with BE. However, after surgery GIQLI of both groups is comparable to the mean value of general population. This means that LARS is able to improve quality of life significantly in all GERD patients, with and without BE.

Velanovich V
J Gastrointest Surg. 2003;7:53-58

Psychoemotional disorders (PED) and chronic pain syndromes (CPS) are common problems. Many patients with these disorders also suffer from gastroesophageal reflux disease (GERD). It is unclear how PED/CPS affect outcomes of antireflux surgery; therefore, the purpose of this study was to determine if PED/CPS adversely affects the results of surgical therapy for GERD. All patients referred for surgical therapy for GERD completed both the GERD-HRQL symptom severity instrument and the SF-36 generic quality-of-life instrument prior to surgery. To be candidates for surgery, patients must have symptomatic GERD and objective evidence of pathologic reflux by upper endoscopy, esophageal manometry and 24-hour pH monitoring. Patients underwent either laparoscopic or open Nissen or Toupet fundoplication. Six to 24 months postoperatively, patients were evaluated for satisfaction and quality-of-life. Ninety-three percent of control patients compared to 25% of PED/CPS patients were satisfied with surgery (P < 0.001). Dissatisfaction in PED/CPS patients was generally due to persistent or new somatic complaints. Median total GERD-HRQL scores improved for both groups, although postoperative scores were worse in the PED/CPS group. PED/CPS patients had significantly worse SF-36 scores both preoperatively and postoperatively compared to control patients. SF-36 scores improved in four of eight domains in control patients and none in the PED/CPS patients. In conclusion, PED/CPS patients are generally dissatisfied with antireflux surgery. Although some patients do benefit from surgery, careful patient selection is required.

Laparoscopic fundoplication is associated with significant perioperative morbidity and mortality. Therefore, less invasive techniques are desirable. Recently, endoscopic procedures have been developed that may be an alternative to laparoscopic procedures in some patients with mild, uncomplicated GERD.

Endoscopic procedures can be performed on an outpatient basis without the risks of general anesthesia. Morbidity of wound infection and hernia formation is avoided with the absence of abdominal incisions, and these procedures are less painful. These procedures, including endoscopic suturing devices, focal radiofrequency coagulation in the cardia, and bioimplants, are promising new technologies that are likely to find clinical application in subsets of patients with GERD. While many of these techniques have shown good results in preliminary studies, long-term results are not yet available and therefore all such procedures should be considered experimental.

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