Laparoscopic anti-reflux surgery : indications, techniques and physiological effects

Gastro-oesophageal reflux disease (GORD) is a highly prevalent chronic disorder in which retrograde flow of gastric contents into the oesophagus causes troublesome symptoms or lesions. Proton pump inhibitor (PPI) therapy controls reflux disease in 95% of the patients and the remaining 5% have PPI-refractory GORD. Patients with PPI-refractory GORD, unwillingness to take lifelong medication or extra-oesophageal manifestations are candidates for anti-reflux surgery. Candidates for antireflux surgery with erosive reflux disease on upper endoscopy and/or pathological reflux in supine or bipositional body position with a positive symptom-reflux association during 24-h pH metry, have a classic indication for antireflux surgery. The aims of this study were (I) to explore indications for laparoscopic antireflux surgery, (II) to compare fundoplication techniques and (III) evaluate physiological effects. Consecutive cohort studies proved that candidates for antireflux surgery with isolated upright reflux, oesophageal acid hypersensitivity, negative symptom-reflux correlation or non-erosive reflux disease benefit from laparoscopic Nissen fundoplication (LNF) as much as those with classic indications for surgery. Consequently, indications for antireflux surgery should be broadened and fundoplication should not be withheld from these patients. On the other hand, patients with poor oesophageal peristalsis or high supine acid exposure before surgery should be counselled about their higher chance of recurrent reflux after LNF. A cohort study in 2040 patients demonstrated that tailoring the degree of fundoplication based on preoperative oesophageal motility is probably not necessary, since oesophageal peristalsis before surgery has no impact on postfundoplication dysphagia. A small cohort study found that LNF for failed endoluminal EsophyX fundoplication provides satisfactory reflux control, but is associated with a risk of gastric perforations during LNF and a high rate of postfundoplication dysphagia. The ten-year results of a randomised clinical trial (RCT) in 146 patients demonstrated that laparoscopic anti-reflux surgery reduces the reoperation rate for incisional hernia (2.5%versus13.0%) with similar long-term effectiveness compared with conventional fundoplication. Surgeon experience, however, affected early outcome of laparoscopic fundoplication and this pleads for centralisation of expertise. LNF is the most frequently performed operation for GORD. Dysphagia and gas-related symptoms are the main side-effects of LNF and a study that preformed impedance monitoring before and after LNF demonstrated that the latter are caused by a reduction in the number of gastric belches that is accompanied by an increase in oesophageal belching. Partial laparoscopic anterior (LAF) and Toupet fundoplication (LTF) have been proposed to reduce these symptoms. The 5-year results of 4 RCTs in 425 patients demonstrated that 90 LAF provides inferior long-term reflux control compared with LNF. In contrast, 180 LAF reduced dysphagia and gas-related symptoms compared with LNF, with similar long-term control of reflux symptoms. In a meta-analysis of RCTs, LTF was associated with fewer reinterventions (3.1%versus7.0%), less dysphagia and fewer gas-related symptoms, with similar reflux control compared with LNF. A subsequent impedance study shed light on the physiological origin of these findings and found that LNF and LTF similarly control acid and weakly acidic reflux, with a smaller reduction of gastric belches. Therefore, 180 LAF and LTF should be considered the surgical procedure of choice for GOR

Effects of anti-reflux surgery on weakly acidic reflux and belching

Item does not contain fulltextBACKGROUND: Laparoscopic Nissen fundoplication (LNF) is the most frequently performed operation for gastro-oesophageal reflux disease (GORD). However, 12% of the patients have persistent reflux symptoms and 19% develop gas-related symptoms after LNF. Weakly acidic reflux and inability to belch have been alleged to cause these symptoms, respectively. The effect of LNF on weakly acidic reflux and (supra) gastric belching was evaluated. METHODS: In 31 patients upper gastrointestinal endoscopy, stationary oesophageal manometry and 24-h impedance-pH monitoring off acid secretion inhibiting drugs was performed before and 6 months after primary LNF for GORD that was refractory to proton pump inhibitors. Patients filled out validated questionnaires on GERD-HRQoL before and 3, 6 and 12 months after surgery. RESULTS: LNF reduced reflux symptoms (18.6-->1.6; p = 0.015). The procedure drastically reduced the incidence (number per 24 h) of acid (76.0-->1.6; p 5.7; p = 0.001) as well as liquid (53.4-->5.4; p1.9; p 25.7; p = 0.022). Proximal, mid-oesophageal and distal reflux were reduced to a similar extent. Persistent GORD symptoms were neither preceded by acid nor by weakly acidic reflux. The number of air swallows did not change, but the number of gastric belches (GBs) was greatly reduced (68.5-->23.9; p 46.0; p = 0.036). Reflux-associated SGBs were abolished after surgery (14.0-->0.4; p < 0.001). CONCLUSIONS: LNF similarly controls acid and weakly acidic reflux, but gas reflux is reduced to lesser extent. Persistent reflux symptoms are neither caused by acid nor by weakly acidic reflux. LNF alters the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). This explains the increase in belching experienced by some patients after LNF, despite the reduction in gastric belching. It can be hypothesised that the reduction in GBs after LNF incites patients to increase SGBs in a futile attempt to vent air from the stomach

Impact of surgeon experience on 5-year outcome of laparoscopic Nissen fundoplication

Item does not contain fulltextOBJECTIVE: To investigate the 5-year effect of surgeon experience with laparoscopic Nissen fundoplication (LNF). In 2000, a randomized controlled trial (RCT) was prematurely terminated because LNF for gastroesophageal reflux disease was associated with a higher risk to develop dysphagia than conventional Nissen fundoplication (CNF). Criticism focused on alleged bias caused by the relative lack of experience with the laparoscopic approach of the participating surgeons. DESIGN: Multicenter RCT and prospective cohort study. SETTING: University medical centers and tertiary teaching hospitals. PATIENTS: In the RCT, 74 patients underwent CNF and 93 patients underwent LNF (LNFI). The complete setup of the cohort study (LNFII) (n = 121) mirrored the RCT, except that surgeon experience increased from more than 5 to more than 30 LNFs per surgeon. INTERVENTIONS: Conventional Nissen fundoplication, LNFI, and LNFII. MAIN OUTCOME MEASURES: Intraoperative and in-hospital characteristics, objective reflux control, and clinical outcome. RESULTS: In LNFII, operating time (110 vs 165 minutes; P < .001), dysphagia (2.5% vs 12.3%; P = .008), dilatations for dysphagia (0.8% vs 7.0%; P = .02), and conversions (3.5% vs 7.7%; P = .19) were reduced compared with LNFI. Moreover, in LNFII, hospitalization (4.2 vs 5.6 days; P = .07 and 4.2 vs 7.6 days; P < .001) and in-hospital complications (5.1% vs 13.5%; P = .046 and 5.1% vs 19.3%; P = .005) were reduced compared with LNFI and CNF, respectively. In LNFII, the 6-month reintervention rate was reduced compared with LNFI (0.8% vs 10.1%; P = .002). Esophagitis and esophageal acid exposure at 3 months and reflux symptoms, proton-pump inhibitor use, and quality of life at 5 years improved similarly. CONCLUSIONS: Operating time, complications, hospitalization, early dysphagia, dilatations for dysphagia, and reintervention rate after LNF improve significantly when surgeon experience increases from more than 5 to more than 30 LNFs. In contrast, short-term objective reflux control and 5-year clinical outcome do not improve with experience. In experienced hands, LNF reduces in-hospital complications and hospitalization compared with CNF, with similar 5-year effectiveness and reoperation rate

The preoperative reflux pattern as prognostic indicator for long-term outcome after Nissen fundoplication.

Item does not contain fulltex

Ten-year outcome of laparoscopic and conventional nissen fundoplication: randomized clinical trial.

Item does not contain fulltex

Oesophageal acid hypersensitivity is not a contraindication to Nissen fundoplication.

Item does not contain fulltex