Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area.

BACKGROUND: The closure of the hiatal crura has proven to be a fundamental issue in laparoscopic antireflux surgery. In particular, the use of prosthetic meshes for crural closure results in a significantly lower rate of postoperative hiatal hernia recurrence with or without intrathoracic migration of the fundic wrap. The aim of the present study was to evaluate different methods of crural closure depending on the size of the hiatal defect by measuring the hiatal surface area. METHODS: Fifty-five consecutive patients (mean age = 53 years) with symptomatic gastroesophageal reflux disease (GERD) were scheduled for laparoscopic antireflux surgery (LARS) in our surgical unit. Intraoperatively, the length, breadth, and diameter of the hiatal defect was measured using an endoscopic ruler. In every patient, the hiatal surface area (HSA) was calculated using an arithmetic formula. Depending on the calculated HSA, hiatal closure was performed by (1) simple sutures, (2) simple sutures with a 1 x 3-cm polypropylene mesh, (3) simple sutures with dual Parietex dual mesh, or (4) "tension-free" polytetrafluoroethylene BARD Crurasoft mesh. RESULTS: Twenty-six patients (47.2%) underwent laparoscopic 360 degree "floppy" Nissen fundoplication. The remaining 29 patients (52.8%) with esophageal body motility disorder underwent laparoscopic 270 degree Toupet fundoplication. Mean calculated HSA in all patients was 5.092 cm2. Thirty-two patients (58.2%) with a smaller hiatal defect (mean HSA = 3.859 cm2) underwent hiatal closure with simple sutures (mean number of sutures: = 2.0). In 12 patients (21.8%) with a mean HSA of 7.148 cm2, hiatal closure was performed with a 1 x 3-cm polypropylene mesh in addition to simple sutures. Five patients with a mean HSA of 6.703 cm2 underwent hiatal closure with Parietex mesh, and in the remaining six patients, who had a mean HSA of 8.483 cm2, the hiatus was closed using BARD Crurasoft mesh. For a mean followup period of 6.3 months, only one patient (1.8%) developed a postoperative partial intrathoracic wrap migration. CONCLUSION: Measurement of HSA with subsequent tailoring of the hiatal closure to the hiatal defect is an effective procedure to prevent hiatal hernia recurrence and/or intrathoracic wrap migration in laparoscopic antireflux surgery.

Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap.

BACKGROUND: Postoperative dysphagia after laparoscopic antireflux surgery usually is transient and resolves within weeks after surgery. Persistent dysphagia develops in a small percentage of patients after surgery. There still is debate about whether postoperative dysphagia is caused by the type or placement of the fundic wrap or by mechanical obstruction of the hiatal crura. This study aimed to investigate patients who experienced recurrent or persistent dysphagia after laparoscopic antireflux surgery, and to identify the morphologic reason for this complication. METHODS: A sample of 50 patients consecutively referred to the authors' unit with recurrent, persistent, or new-onset of dysphagia after laparoscopic antireflux surgery were prospectively reviewed to identify the morphologic cause of postoperative dysphagia. According to their radiologic findings, these patients were divided into three groups: patients with signs of obstruction at or above the gastroesophageal junction suspicious of crural stenosis (group A; n = 18), patients with signs of total or partial migration of the wrap intrathoracically (group B; n = 27), and patients in whom the hiatal closure was radiologically assessed to be correct with a supposed stenosis of the wrap (group C; n = 5). The exact diagnosis of a too tight (group A) or too loose (group B) hiatus in contrast to a too tight wrap (group C) was established during laparoscopic redo surgery (groups B and C) or by x-ray during pneumatic dilation (group A). RESULTS: For all 18 group A patients, intraoperative x-ray during pneumatic dilation showed the typical signs of hiatal tightness. Of these, 15 were free of symptoms after dilation, and 3 had to undergo laparoscopic redo surgery because of persistent dysphagia. In all these patients, the hiatal closure was narrowing the esophagus. All the group B patients underwent laparoscopic redo surgery because of intrathoracic wrap migration. Intraoperatively, all the patients had an intact fundoplication, which slipped above the diaphragm. Definitely, only in 10% of all 50 patients (group C) presenting with the symptom of dysphagia, was the morphologic reason for the obstruction a problem of the fundic wrap. CONCLUSIONS: In most patients, postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap.

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome.

BACKGROUND: It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients. METHODS: From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 +/- 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 +/- 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients' satisfaction with surgery. The data of a complete 5-year follow-up are available. RESULTS: There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients' satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 +/- 11.6 points/EGD-negative vs 93.8 +/- 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 +/- 8.5 for EGD-negative vs 120.9 +/- 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 +/- 8.5). CONCLUSION: We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.

Long-term results of laparoscopic antireflux surgery.

BACKGROUND: It is estimated that laparoscopic antireflux surgery has replaced the open approach in centers worldwide. Findings show it to be an established treatment option for chronic gastroesophageal reflux disease with an excellent clinical outcome and success rates between 85% and 95%. This prospective study aimed to evaluate surgical outcome and analysis of failure after 500 laparoscopic antireflux procedures followed up for as long as 5 years. METHODS: Between September 1993 and May 2000, 500 laparoscopic antireflux procedures were performed in our surgical unit. In 345 patients, a laparoscopic "floppy" Nissen fundoplication was performed, and in 155 patients, a Toupet fundoplication was carried out with standard mobilization of the upper part of the gastric fundus and with division of the short gastric vessels. Preoperative and postoperative data including 24-h pH monitoring, esophageal manometry, and analysis of failure were prospectively reviewed. RESULTS: Conversion to open surgery was necessary in two patients (0.4%). Morbidity was 7%, including 24 patients (4.8%) for whom a laparoscopic redoprocedure was necessary because of failed primary intervention. There was no mortality. During a follow-up period of 3 months to 5 years, 24-h pH monitoring and esophageal manometry showed normal values in 95% of the patients including patients who had undergone redosurgery. CONCLUSION: The results of the current study demonstrate that laparoscopic antireflux surgery is feasible and effective, and that it can be performed safely without mortality and with low morbidity, yielding good to excellent results over a follow-up period up to 5 years.

Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery?

BACKGROUND: Due to the widespread availability and acceptance of minimal-access surgery, laparoscopic antireflux surgery has become the standard procedure for the treatment of severe gastroesophageal reflux disease (GERD). However, open and laparoscopic antireflux procedures sometimes result in failure, so that redosurgery is required in some cases. The aim of this prospective study was to evaluate the surgical outcome and quality of life of patients who underwent refundoplication after the failure of primary open antireflux surgery. METHODS: Twenty patients with a mean age of 52 years (range, 33-69) underwent laparoscopic refundoplication after primary open antireflux surgery. Four of them had undergone surgery twice previously. Preoperative and postoperative data, including esophageal manometry, 24-h pH monitoring, and assessment of quality of life, were reviewed prospectively. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: In 18 patients (90%), the reoperation was completed successfully laparoscopically. Two others (10%) required conversion to an open procedure. One of them had an injury of the gastric wall; in the other case, severe bleeding of the spleen necessitated the conversion. The average operating time was 245 min. Preoperatively, the main symptoms were recurrent reflux in 14 cases and a combination of re-reflux and dysphagia in six cases. The anatomic findings were telescope phenomenon (n = 6), hiatal disruption (n = 10), and wrap breakdown (n = 4). Postoperatively, two patients suffered from dysphagia and required pneumatic dilatation. The lower esophageal sphincter (LES) pressure increased significantly from a preoperative value of 6.08 mmHg to 12.2 mmHg at 3 months and 11.9 mmHg at 1 year after surgery. The DeMeester score decreased from a preoperative value of 69.8 to 17.1 at 3 months and 14.6 at 1 year postoperatively. The GIQLI score increased from a preoperative value of 84.9 points to 119.6 points at 3 months and 120.1 points at 1 year. CONCLUSION: Laparoscopic refundoplication after the failure of a primary open intervention is an effective procedure that can be performed safely by experienced laparoscopic surgeon. The procedure yields excellent functional results and leads to significant improvement in the patient's quality of life.

[Outcome after laparoscopic antireflux surgery: fundoplication and re-fundoplication in the elderly]. / Ergebnisqualität nach laparoskopischer Antirefluxchirurgie: Fundoplicatio und Re-Fundoplicatio beim älteren Patienten.

PURPOSE: Treatment of gastroesophageal reflux disease (GERD) in the elderly follows the same principles as for any adult patient. The indication for laparoscopic antireflux surgery (LARS) often depends on the age of the patient. The aim of this prospective study was to evaluate the surgical outcome including quality of life after LARS and laparoscopic "redo-surgery" in patients older than 65 years. METHODS: Since 1993, 75 patients with a mean age of 71 years have been treated with laparoscopic "floppy" Nissen (n = 53) or Toupet (n = 22) fundoplication. Thirteen patients underwent laparoscopic redo-surgery after failed LARS. Quality of life (GIQLI) was assessed before surgery and 3 months and 1 year after surgery, with 24-h pH monitoring and esophageal manometry being performed. RESULTS: Intraoperative complications occurred in two patients with primary LARS, successfully managed laparoscopically. The conversion and mortality rate was 0%. In two patients postoperative complications occurred. Three months and 1 year after surgery 24-h pH monitoring and esophageal manometry showed normal values in all patients. GIQLI increased significantly after surgery and is comparable to that of healthy individuals. One patient suffered from severe dysphagia and required dilatation. In 13 patients who underwent laparoscopic refundoplication, redo procedure was completed laparoscopically in 12 patients. In one patient conversion was necessary because of severe bleeding from the spleen. Data of esophageal manometry and 24-h pH monitoring showed normal values in all patients after redo-surgery. Three months and 1 year after laparoscopic reoperation the general score of GIQLI increased significantly (p < 0.01) and reached a level equivalent to that of comparable healthy individuals. CONCLUSION: Laparoscopic fundoplication and refundoplication in the elderly patient is a safe and effective treatment in GERD and improves quality of life significantly. Age should not be longer a contraindication to LARS.

[Quality of life and subjective evaluation of outcome quality 3 years after laparoscopic antireflux surgery]. / Lebensqualität und subjektive Beurteilung der Ergebnisqualität 3 Jahre nach laparoskopischer Antirefluxchirurgie.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.