Impact of laparoscopic nissen fundoplication with prosthetic hiatal closure on esophageal body motility: Results of a prospective randomized trial.

HYPOTHESIS: Prosthetic crural closure does not adversely influence esophageal body motility. In most patients, postoperative increased dysphagia resolves spontaneously during the first months after surgery. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatal closure and those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: Forty consecutive patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease. INTERVENTIONS: A 360 degrees Nissen fundoplication with simple sutured crura (n = 20; nonmesh group) vs the same procedure with posterior 1 x 3-cm polypropylene onlay mesh prosthesis (n = 20; mesh group). MAIN OUTCOME MEASURES: Recurrences; postoperative dysphagia rate; localization, length, and pressure of the lower esophageal sphincter (LES); results of 24-hour pH monitoring; esophageal body motility; peristalsis; and esophageal amplitude of contraction and interrupted waves. RESULTS: Preoperatively, both groups had pathological LES pressure and DeMeester scores. These values improved significantly (P < .01) after surgery and remained stable at 1 year after surgery. Patients in the nonmesh group had a significantly lower LES pressure 1 year after surgery compared with those in the mesh group. There were no significant differences in postoperative mean LES length (4.1 vs 3.8 cm), LES relaxation (93.4% vs 92.4%), and intra-abdominal LES length (2.1 vs 2.1 cm). Patients in the mesh group had fewer simultaneous waves and interrupted waves 1 year after surgery, but the difference between groups was not significant. There were no significant differences in interrupted waves and amplitude of contraction between groups 1 year after surgery. CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic crural closure does not impair postoperative esophageal body motility compared with laparoscopic Nissen fundoplication with simple suture hiatal closure, although it is associated with a higher rate of short-term dysphagia.

Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study.

BACKGROUND: Postoperative intrathoracic wrap migration is the most frequent morphological complication after laparoscopic antireflux surgery. Previous authors have studied the use of prosthetic materials for hiatal closure to prevent recurrence of hiatal hernia and/or postoperative intrathoracic wrap herniation. HYPOTHESIS: Patients with prosthetic hiatal closure have a higher rate of short-term dysphagia but a significantly lower rate of postoperative intrathoracic wrap herniation at follow-up. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatoplasty with those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: One hundred consecutive patients undergoing laparoscopic Nissen fundoplication for gastroesophageal reflux disease and hiatal hernia repair. INTERVENTION: Laparoscopic Nissen fundoplication with simple sutured crural closure (n = 50 [group 1]) vs laparoscopic Nissen fundoplication with simple sutured cruroplasty and onlay of a polypropylene mesh (n = 50 [group 2]). MAIN OUTCOME MEASURES: Recurrences; complications; results of esophageal manometry, 24-hour pH monitoring, esophagogastroduodenoscopy, and barium swallow test; and symptomatic outcome. RESULTS: Patients in both groups had similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring. At the 3-month and 1-year follow-ups, functional outcome variables (lower esophageal sphincter pressure and DeMeester score) improved significantly compared with the preoperative values. A higher postoperative dysphagia rate could be evaluated in group 2. An intrathoracic wrap migration occurred in 13 patients (26%) in group 1 vs 4 (8%) in group 2 (P<.001). CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic cruroplasty is an effective procedure to reduce the incidence of postoperative hiatal hernia recurrence and intrathoracic wrap herniation.

Are depressive persons capable of describing changes in their reactions without being able to explain them? A proof of a cybernetic hypothesis of depression.

BACKGROUND: Many studies on the autobiographical memory and the explanation of reasons for success and failure proved that persons suffering from major depression tend to overgeneralize. This study examines the hypothesis that changes of reactions caused by a depressive disorder can be described by the affected persons but not explained. SAMPLE AND METHODS: Persons suffering from major depression and persons with posttraumatic stress disorder or disturbance of accommodation with depressive mood (= reactive form of a depressive disorder) were presented with a list of modalities (behaviour, emotional and physical reactions) characteristic for depression. They were asked to identify modalities applicable to them and to describe and explain them. Their responses were analysed using a content analysis and assigned to the categories description and explanation. RESULTS: Persons with a major depression tended to use explanations or evaluations rather than descriptions for their depression-related modalities. Those persons suffering from a reactive form of depressive disorder tended to prefer evaluations. CONCLUSION: These results support the assumption that states of depression cause general descriptions of depression-relevant behaviour. The specific characteristics that have been perceived confirm the general concepts, which however make the patient prone to the respective selective perceptions. Persons suffering from a reactive form of depressive mood cannot be assumed to have this tendency of self-affirmation. Their depressive state may be maintained by perseverating general pessimistic schemes. LIMITATIONS: It must however be conceded that it was not possible to control the physical comorbidity methodically and to take its effects into consideration, even though only persons without serious illnesses were included in the samples. This study did not verify whether other clinical groups, like patients suffering from anxiety, show the same patterns of explaining and describing their problems. It should furthermore be reviewed how other actions, e.g. positive ones, are represented by depressive persons.

Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery.

BACKGROUND: One of the most frequent complications after laparoscopic antireflux surgery is estimated to be the intrathoracic herniation of the wrap into the chest. Therefore, in up to 5% of patients, revisional surgery is necessary. HYPOTHESIS: Patients who undergo laparoscopic refundoplication for postoperative intrathoracic wrap herniation using a circular polypropylene mesh for hiatal closure have a good to excellent functional outcome, during a complete follow-up of 1 year. DESIGN: Prospective nonrandomized trial of a consecutive sample. SETTING: University-affiliated community hospital. PATIENTS: Twenty-four patients undergoing laparoscopic refundoplication for persistent or recurrent symptoms of gastroesophageal reflux disease as a result of postoperative intrathoracic wrap migration. INTERVENTION: All patients underwent laparoscopic refundoplication with a circular polypropylene mesh for hiatal closure. MAIN OUTCOME MEASURES: Recurrences, complications, postoperative lower esophageal sphincter pressure, DeMeester score, esophagogastroduodenoscopy results, and barium swallow results. RESULTS: All refundoplications were completed laparoscopically. There were no intraoperative complications. Twenty-one patients underwent laparoscopic Nissen fundoplication; in 3 patients, a laparoscopic Toupet fundoplication was performed. Previous antireflux procedures included an open Nissen fundoplication (n = 5), a laparoscopic Nissen fundoplication (n = 15), and a laparoscopic Toupet fundoplication (n = 4). Postoperatively, one patient had severe dysphagia and had to undergo pneumatic dilatation once. During a follow-up of 1 year after surgery, no patient developed a recurrent hiatal hernia, with or without intrathoracic wrap herniation. The mean lower esophageal sphincter pressure increased significantly (P<.01) at 3 months (12.2 mm Hg) and 1 year (11.9 mm Hg) after refundoplication. The mean DeMeester score decreased significantly (P<.01) from 50.5 points preoperatively to 16.0 points at 3 months and 14.7 points at 1 year after refundoplication. CONCLUSION: Laparoscopic refundoplication with prosthetic hiatal closure is a safe and effective procedure for preventing recurrent intrathoracic wrap herniation, with good to excellent functional outcome for a complete follow-up of 1 year.

The outcome of laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication.

It is well known that several patient-related factors are able to affect the surgical outcome such as quality of life or symptom relief after laparoscopic antireflux surgery. The aim of the current study was to evaluate and compare surgical outcome up to 1 year after laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication. Based on a three-level grading of subjective compliance with primary antireflux medication, a total of 140 patients undergoing antireflux surgery were divided into three subgroups: group 1/TC (totally compliant; n = 60), group 2/PC (partially compliant; n = 49); and group 3/NC (noncompliant; n = 31). Gastrointestinal Quality of Life Index (GIQLI), satisfaction with surgery, and the subjective degree of dysphagia as well as traditional outcome data (e.g., DeMeester score, lower esophageal sphincter pressure, side effects) were evaluated in all patients. As a result of surgery, only patients out of group 1/TC (GIQLI, preoperative 86.3 + 9.3 vs. 1 year postoperatively 123.1 + 7.2 points) and group 2/PC (GIQLI, preoperative 94.2 + 8.6 vs. 1 year postoperatively 120.8 + 7.8 points) showed a significant quality of life improvement that remained stable for at least 1 year (P < 0.05-0.01). In contrast, group 3/NC (GIQLI, preoperative 100.2 + 6.1 vs. 1 year postoperatively 117.2 + 9.8 points) patients had no significant quality of life improvement and patient satisfaction with surgery was less good when compared with that of the other groups. In these patients, also the subjective degree of postoperative dysphagia was significantly (P < 0.05-0.001) higher during the 1-year follow-up when compared with patients from group 1/TC or group 2/PC. A total of 42% of group 3/NC patients reported surgical side effects, whereas only 3% from group 1/TC and 10% from group 2/PC stated to be affected by any new symptoms (P < 0.0001). None of group 1/TC or group 2/PC patients suffered from recurrent symptoms or underwent laparoscopic reoperation. Of group 3/NC, a total of four patients (13%) needed any kind of additional intervention in relation to antireflux surgery (reoperation, n = 3; pneumatic dilatation, n = 1). There were no significant differences between the three groups when postoperative values of esophageal manometry and 24-hour pH monitoring were compared. What the current study does show is that the efficacy and the surgical outcome after laparoscopic antireflux surgery partly depends on the subjective degree of patient compliance with primary antireflux medication. Patients with no compliance in relation to former antireflux medication should generally not be refused antireflux surgery. But these patients should be evaluated with great care before surgery and should also be informed that surgical outcome may be affected in several aspects.

Failed antireflux surgery: quality of life and surgical outcome after laparoscopic refundoplication.

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.

Laparoscopic antireflux surgery for gastroesophageal reflux disease: experience with 668 laparoscopic antireflux procedures.

BACKGROUND AND AIMS: In the past decade laparoscopic antireflux surgery has become the standard operation for treating severe gastroesophageal reflux disease. Several studies have been published showing that it can achieve good to excellent results at short- and medium-term follow-up. We present our experience with 668 laparoscopic antireflux procedures. PATIENTS AND METHODS: Between September 1993 and July 2001 we performed 668 laparoscopic antireflux procedures (76% laparoscopic 360 degrees "floppy" Nissen fundoplications in patients with normal esophageal motility, 24% laparoscopic 270 degrees Toupet partial fundoplications in patients with poor esophageal motility or severely disordered peristalsis). Patients with achalasia were excluded from analysis. Preoperative and postoperative data including 24-h pH monitoring, esophageal manometry, and analysis of failure were prospectively reviewed. RESULTS: Overall complication rate was 7.6%. Conversion to open surgery was necessary in five patients (0.8%). Seventy-four laparoscopic redo procedures were performed due to failed primary intervention. There was no death. At a mean follow-up of 4.8 years (range 3-94 months) 24-h pH monitoring and esophageal manometry showed normal values in 93% of patients. CONCLUSION: Laparoscopic antireflux surgery is feasible and effective and can be performed safely without mortality and low morbidity with good to excellent functional and symptomatic results.

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: quality of life, symptomatic outcome, and patient satisfaction.

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluated using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery.

Expectations of patients with gastroesophageal reflux disease for the outcome of laparoscopic antireflux surgery.

Goals of gastroesophageal reflux disease (GERD) treatment are symptom relief, healing of esophagitis, prevention of complications, and prevention of relapses. The aims of the current study were to evaluate a selected group of patients referred to our Department of General Surgery for presurgical examination (N = 70: 41 males and 29 females) for their expectations about laparoscopic antireflux surgery and to compare these expectations with the official medical treatment goals. The leading expectations for laparoscopic antireflux surgery were as follows: (1) for 92.8%, abatement of GERD-related symptoms, especially heartburn, regurgitation, and pain; (2) for 84.3%, a return to normal daily activities and life such as eating and drinking habits, sleeping habits, or work-related aspects; (3) for 72.9%, an improvement in quality of life; (4) for 52.9%, a successful surgical intervention without any complications or side effects; and (5) for 48.6%, protection from a Barrett esophagus and cancer risk. In contrast, only two patients answered that they would expect normalization of pH values and healing of esophagitis. The data show that the majority of patients have clear expectations about laparoscopic antireflux surgery. These expectations are partly related to official medical treatment goals. In general, patient-related aspects of outcome concerning expectations should be included as a standard in all official goals of GERD treatment and also in medical outcome studies. One of these aspects should absolutely be patients' quality of life.

Quality of life, surgical outcome, and patient satisfaction three years after laparoscopic Nissen fundoplication.

Quality of life data and patient satisfaction are important issues in estimating the outcome of laparoscopic antireflux surgery (LARS). Long-term of quality of life assessment has not yet received wide attention. The aim of this prospective study was to evaluate surgical outcome, including quality of life and patient satisfaction, after laparoscopic "floppy" Nissen fundoplication up to 3 years after surgery. Between 1994 and 1996, a total of 150 consecutive patients with severe gastroesophageal reflux disease underwent laparoscopic "floppy" Nissen fundoplication. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). The GIQLI questionnaire was given to the patients prior to surgery, and again 3 months, 1 year, and 3 years postoperatively. In addition, 24-hour pH monitoring and esophageal manometry were performed preoperatively and at each follow-up date. Finally, surgical side-effects and patient satisfaction with the surgical outcome were evaluated 3 years after LARS. Postoperatively lower esophageal sphincter pressure improved significantly in all patients, whereas pH values showed normal data in all but 5 patients. Before surgery, all patients had a poor quality of life (GIQLI score, 90.1 +/- 8.9 points). Postoperatively, GIQLI improved significantly (p < .01) and remained stable for at least 3 years, with a mean value of 123.7 +/- 9.8 points. This is comparable to 122.6 +/- 8.5 points of healthy individuals. Ninety-eight percent of the patients rated their satisfaction with surgical treatment as excellent or good and would undergo surgery again if necessary. Nine patients suffered from minimal surgical side-effects, but these did not significantly impair their quality of life. Laparoscopic reoperation was performed in 2 patients 3 months after initial surgery because of severe dysphagia. Both patients were free of symptoms 3 years after surgery. 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 with subjective judgment of the patient, including quality of life assessment.

Failed antireflux surgery: surgical outcome of laparoscopic refundoplication in the elderly.

BACKGROUND/AIMS: Antireflux surgery has a failure rate between 5 and 20%. Laparoscopic redo-surgery is feasible, but little is known about the surgical outcome in elderly patients. The aim of this prospective study was to evaluate early surgical experience and outcome, including quality of life, after laparoscopic refundoplication in patients older than 65 years. METHODOLOGY: Eleven patients, mean age of 71 years (range: 65-78), underwent laparoscopic redo-surgery. Six patients had the former antireflux procedure performed by the open technique, one having had it twice, one had both laparoscopic and open antireflux procedures, and in 4 the primary intervention was performed laparoscopically. Quality of life was evaluated by using the Gastrointestinal Quality of Life Index. All patients were evaluated prior to surgery, and at 3 months and 12 months after laparoscopic refundoplication, as well as with esophageal manometry and 24-hour pH-monitoring. RESULTS: Redo-procedures were completed laparoscopically in 10 patients. In one patient conversion to an open laparotomy was necessary because of severe bleeding from the spleen. One patient had an injury to the gastric wall, successfully managed laparoscopically. Postoperatively, one patient had moderate dysphagia for a period of two months, another had epigastric pain for the same period. Esophageal manometry and 24-hour pH-monitoring showed normal values in all patients after redo-surgery. Prior to redo-surgery, the mean Gastrointestinal Quality of Life Index was 85.2 points. Three months (mean: 119.8 points) and one year (mean: 119.2 points) after laparoscopic reoperation the general score increased significantly (P < 0.01) and attained the equivalent level of comparable healthy individuals (118.7 points). CONCLUSIONS: Laparoscopic refundoplication in the elderly patient is feasible, safe and an effective treatment after failed antireflux surgery. Older patients with failed antireflux surgery have poor quality of life. Laparoscopic redo-surgery improves quality of life significantly to the level of healthy individuals and normalizes objective outcome criteria without any long-term restrictions in daily life.

Laparoscopic antireflux surgery with routine mesh-hiatoplasty in the treatment of gastroesophageal reflux disease.

One of the most frequent complications after laparoscopic antireflux surgery is intrathoracic migration of the wrap ("slipped" Nissen fundoplication). The most common reasons for this are inadequate closure of the crura or disruption of the crural closure. The aim of this prospective study was to evaluate surgical outcomes in patients who underwent laparoscopic antireflux surgery with simple nonabsorbable polypropylene sutures for hiatal closure in comparison to patients who underwent routine mesh-hiatoplasty. Between 1993 and 1998, a group of 361 patients underwent primary laparoscopic Nissen or Toupet fundoplication with the use of simple nonabsorbable polypropylene sutures for hiatal closure. Since December 1998, in all patients (n = 170) who underwent laparoscopic antireflux surgery, a 1 x 3 cm polypropylene mesh was placed on the crura behind the esophagus to reinforce them. Functional outcome, symptoms of gastroesophageal reflux disease, and postoperative complications such as recurrent hiatal hernia with or without intrathoracic migration of the wrap have been used for assessment of outcomes. In the initial series of 361 patients, postoperative herniation of the wrap occurred in 22 patients (6.1%). Of these 22 patients, 17 of them (4.7%) had to undergo laparoscopic redo surgery. The remaining five patients were free of symptoms. In comparison to these results, in a second group of 170 patients there was only one (0.6%) who had postoperative herniation of the wrap into the chest. There have been no significant differences in objective data such as DeMeester scores or lower esophageal sphincter pressure between the two groups. Postoperative dysphagia was increased during the early period after surgery in patients undergoing mesh-hiatoplasty but resolved without any further treatment within the first year after laparoscopic antireflux surgery. We concluded that routine hiatoplasty with the use of a polypropylene mesh is effective in preventing postoperative herniation of the wrap and leads to a significantly better surgical outcome than closure of the hiatal crura with simple sutures, without any additional long-term side effects.

[Psycho-physiological aspects of gastroesophageal reflux disease]. / Psychophysiologische Aspekte der gastroösophagealen Refluxkrankheit.

It is well known that there is an interaction between physiological and psychological aspects of gastrointestinal diseases, also in esophageal symptoms. Based on this bio-psycho-social interaction, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) is really unknown. The present article reviews the basic pathophysiological factors of GERD including psycho-physiological aspects and presents potential concepts of multidisciplinary GERD treatment.

Quality of life and symptomatic outcome three to five years after laparoscopic Toupet fundoplication in gastroesophageal reflux disease patients with impaired esophageal motility.

BACKGROUND: Many centers practice a tailored approach to laparoscopic antireflux surgery in attempt to prevent postoperative side effects in gastroesophageal reflux disease (GERD) patients with an impaired esophageal motility. As a result of controversial findings reported in literature no worldwide accepted consensus exists regarding the appropriate indication for this tailored approach. The aim of this prospective study was to evaluate quality of life and symptomatic outcome in selected patients for a follow-up of 3 to 5 years. METHODS: A total of 155 patients with esophageal dismotility underwent laparoscopic Toupet fundoplication (LTF). Basic requirements for surgery included in all patients a detailed evaluation of symptoms and quality of life (Gastrointestinal Quality of Life Index [GIQLI]), esophagogastroduodenoscopy, 24-hour pH monitoring, and esophageal manometry. Patients were evaluated 6 weeks, 3 months, 1 year, and 3 to 5 years after LTF. RESULTS: GERD-related symptoms such as heartburn, regurgitation, dysphagia, or chest pain showed a significant improvement (P <0.05 to 0.001) in all gradings immediately after surgery. During the complete follow-up, a total of 4 patients (2.6%) required laparoscopic redo surgery because of recurrent GERD symptoms. Two patients (1.3%) were adequately maintained on short-term proton pump inhibitor therapy because of mild symptoms. All these patients have shown a pathological DeMeester score within the early period after surgery (3 months or 1 year control). Severe and persistent side effects have been present in 7 patients (4.5%), mild to moderate side effects in 11 patients (7.1%). Other side effects have been temporary and resolved spontaneously. GIQLI improved significantly (P <0.05 to 0.01) in all dimensions and persisted for at least 5 years with mean values comparable with healthy individuals. CONCLUSIONS: LTF is effective, well tolerated, and improves quality of life, improving long-term outcome with an acceptable rate of long-term side effects in GERD patients with moderate to severe esophageal dismotility for a follow-up period of 3 to 5 years.