Any differences in the symptomatic outcome of laparoscopic Nissen and Toupet fundoplication appear minimal. There is no reason to tailor the degree of fundoplication to preoperative oesophageal manometry.

Laparoscopic floppy Nissen fundoplication is an effective and durable treatment for gastro-oesophageal reflux disease. Longer-term follow-up of patients operated on beyond the learning curve can be expected to show further improvements in surgical outcome.

The Bravo capsule significantly reduces the patient discomfort and interference with normal daily activities during pH monitoring associated with a naso-oesophageal catheter. Moreover, 48-h Bravo studies offer an advantage over conventional 24-h studies in diagnosing gastro-oesophageal reflux disease.

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years. The patients were grouped consecutively into cohorts of 50 patients. The operating time, the length of postoperative hospital stay, the conversion rate to open operation, the postoperative dilatation rate, and the reoperation rate were analyzed. Results showed that the mean length of operative time decreased from 143 min in the first 50 patients to 86 min in the last 50 patients. The mean postoperative length of hospital stay decreased from 3.7 days initially to 1.2 days latterly. There was a 14% conversion to open operation rate in the first cohort compared with a 2% rate in the last cohort. Fourteen percent of patients required reoperation in the first cohort and 6% in the last cohort. Sixteen percent required postoperative dilatation in the first cohort. None of the last 150 patients required dilatation. In conclusion, laparoscopic fundoplication is a safe and effective operation for patients with gastroesophageal reflux disease. New techniques and better instrumentation were introduced in the early era of LNF. The learning curve, however, continues well beyond the first 20 patients.

INTRODUCTION Obesity has long been regarded as a risk factor for the development of gastro-oesophageal reflux disease (GORD). It has been claimed that surgical efficacy of laparoscopic anti-reflux operations is decreased in obese patients. The aim of this study was to assess whether laparoscopic anti-reflux surgery is effective in obese patients with GORD compared to non-obese patients. PATIENT AND METHODS A total of 366 patients (mean age 44 years; range, 12–86 years) underwent laparoscopic anti-reflux surgery between 1997–2003. Of these, 74 patients were considered obese; 58 patients had a body mass index (BMI) of 30–34 kg/m2 and 16 were classified as morbidly obese with a BMI ≥ 35 kg/m2. Pre-operative symptomatic scoring, indications for surgery, pH studies, operative times and complications were compared between obese and non-obese patients. Symptomatic outcome and Visick score between the two groups were assessed at 6 weeks, 6 months and 1 year following surgery. RESULTS Failure of medical treatment was the main reason for surgery in all groups. Operative time was longer in obese patients (mean time 93 min compared to 81 min; P = 0.0007), the main difficulty being gaining access because of their body habitus. All groups found the procedure to be effective in symptomatic outcome, 91% of obese patients compared to 92% of non-obese patients scored Visick I or II at 6 weeks' postoperatively. Similar Visick scoring was shown between the two groups at 6 months and 1 year, and in the morbidly obese group. CONCLUSIONS The outcome of laparoscopic anti-reflux surgery is similar between obese and non-obese patients with no trend towards a worse outcome in the obese or morbidly obese. Obesity should not be seen as a contra-indication, although it may be more technically challenging in this group of patients. Good results can be achieved in obese patients.