A Physiologic Approach to Laparoscopic Fundoplication for Gastroesophageal Reflux Disease

Abstract

ObjectiveThe authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. Summary of Background DataLaparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. MethodsOver a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. ResultsThe most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51 % of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). lntraoperative technical difficulties occurred in 19 (6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91 % of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%.673

Axial force measurement for esophageal function testing

“…In future studies, combined axial force recordings and manometry may provide more useful information on esophageal muscle function in basic and clinical studies, especial protocols where a challenge test of the esophagus is incorporated will be of major interest in basic and clinical studies. It has been suggested that manometry could subgroup gastroesophageal reflux disease patients into those requiring partial or total fundoplication treatment [29][30][31] . However, studies have not been able to prove that preoperative manometry could predict postoperative outcome in terms of dysphagia [32][33][34] .…”

Two-year results of a feasibility study on antireflux transoral incisionless fundoplication using EsophyX

“…Patients (n = 14, 50% female) available at 2 years had a median age of 34 (range, 23-55) years and a median BMI of 22 (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31) kg/m 2 . Patients had suffered from GERD for a median of 10 (range, 3-15) years and were on continuous daily PPI therapy for a median of 6 (range, 2-13) years before undergoing TIF.…”

Gastroesophageal Reflux and Asthma: Can the Paradox Be Explained?

“…Hunter and colleagues (103) reported symptomatic improvement in 25 of 30 asthma patients following fundoplication. Unfortunately, neither the effects on asthma medication requirements nor pulmonary function were reported.…”