Esophageal Manometry and Clinical Outcome After Laparoscopic Nissen Fundoplication

INTRODUCTION: The outcome after laparoscopic Nissen fundoplication can be assessed by either clinical symptoms or objective tests. Outcomes from objective tests are often held in higher regard than clinical data when determining the merits, or otherwise, of various antireflux surgery procedures. In this study, we sought to determine whether there is a relationship between postoperative symptoms and parameters measured by esophageal manometry to determine whether early postoperative esophageal manometry is a useful investigation for the routine assessment of post fundoplication outcome. METHODS: One hundred and forty-three patients who had undergone a laparoscopic Nissen fundoplication, clinical follow-up at 3 months and 5 years after surgery, and esophageal manometry at 3 months after fundoplication as part of routine follow-up in 1 of 5 clinical trials were studied. Nineteen of these patients also underwent manometry 5 years after fundoplication. Postoperative symptoms were prospectively determined by applying a standardized questionnaire, which assessed dysphagia, heartburn, bloat symptoms, and overall satisfaction using analog scales. Patients were classified into different groups according to the analog scores for clinical symptoms. Correlations between clinical and postoperative manometry outcomes were sought. RESULTS: No significant associations were found between parameters measured by esophageal manometry (lower esophageal sphincter resting and residual relaxation pressures, peristaltic amplitude and normal peristaltic propagation) and clinical parameters (dysphagia, heartburn, bloating, and overall satisfaction) for all time points -- 3 months postoperative manometry vs symptoms at 3 months and 5 years, 5 years postoperative manometry vs symptoms at 5 years, except for a weak (r = -0.17, p = 0.042) correlation between the percentage of successfully propagated swallows at 3 months and dysphagia for solids at 5 years. CONCLUSION: Postoperative esophageal manometry parameters at 3 months and 5 years after surgery were not associated with any clinically important differences in the postoperative symptoms of heartburn, dysphagia, bloat or with overall satisfaction with the surgical outcome. The routine use of esophageal manometry to assess the outcome after Nissen fundoplication does not predict clinical outcome.     

Effect of Preserving the Hepatic Vagal Nerve During Laparoscopic Nissen Fundoplication on Postoperative Biliary Functions

Background

Cutting the hepatic branch of the anterior vagus nerve (HB-AVn) technically facilitates the laparoscopic Nissen fundoplication. The aim of this study was to investigate the effects of preserving or sacrificing this branch on postoperative gallbladder functions.

Methods

The patients (n = 40) were prospectively randomized into two groups. The HB-AVn was preserved during the dissection of the lesser omentum in the first group. The nerve was cut in the second group. Postoperative fasting gallbladder volumes were calculated by ultrasonography. Postoperative gallbladder ejection fraction (GEF) and gallbladder emptying time (GET) were determined by calculating intestinal transit time scintigraphically.

Results

Fasting gallbladder volumes and GEF values were not different between the groups. On the other hand, in patients with HB-AVn preserved, GET measurements were found to be significantly shorter than those with HB-AVn sacrificed.

Conclusions

Sacrificing the hepatic branch causes prolongation in the GET. This change in the motor functions of the gallbladder does not cause any symptomatic effect during the early postoperative period. However, the delay in the GET may increase the risk of gallbladder stone formation in the long term.     

Distal Esophageal Erosion After Laparoscopic Adjustable Gastric Band Placement with Nissen Fundoplication Takedown

Although primary band placement is proven to be safe, gastric band placement after previous operations in the area of the gastroesophageal junction remains controversial. Erosion into the stomach has been described after failed vertical banded gastroplasty conversion to laparoscopic gastric banding (LAGB), but no reports in the English literature are available on erosion of an adjustable gastric band into the esophagus after conversion operations. To our knowledge, this is the first case report of distal esophageal erosion after LAGB placement with Nissen fundoplication takedown.     

Preoperative High-Resolution Manometry Criteria are Associated with Dysphagia After Nissen Fundoplication

World Journal of Surgery - Dysphagia after Nissen fundoplication is challenging for patients. High-resolution manometry (HRM) has rarely been studied preoperatively to determine whether manometry...     

Normal Lower Esophageal Sphincter Pressure and Length Does Not Impact Outcome After Laparoscopic Nissen Fundoplication

Intuitively, a manometrically normal lower esophageal sphincter (LES) will promote dysphagia after laparoscopic Nissen fundoplication. This study was undertaken to compare outcomes after laparoscopic Nissen fundoplication for patients who had normal and manometrically inadequate LES preoperatively. Before fundoplication, the length and resting pressures of LES were determined manometrically in 59 patients with documented gastroesophageal reflux disease (GERD). Twenty-nine patients had a manometrically normal LES, with resting pressures >10 mm Hg and length >2 cm. Thirty patients had resting pressures of ≤10 mm Hg and length of ≤2 cm. Before and after fundoplication, patients graded the frequency and severity of symptoms of GERD utilizing a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). DeMeester scores and symptom scores before and after fundoplication were compared. Before fundoplication, the manometric character of the LES did not impact the elevation of DeMeester scores or the frequency/severity of reflux symptoms. All symptoms improved significantly with fundoplication independent of LES pressure/length. Prefundoplication, manometric character of the LES did not impact the frequency or severity of reflux symptoms after fundoplication. Preoperative manometric character of the LES does not impact the presentation of GERD or the outcome after fundoplication. Symptoms globally and significantly improve after fundoplication, independent of manometric LES character. Normal LES manometry does not impact outcome and, specifically, does not promote dysphagia, after laparoscopic Nissen fundoplication. Presented at the 47th Annual Meeting for the Society of Surgery of the Alimentary Tract, Los Angeles, CA May 20 to 24 2006     

腹腔镜Nissen胃底折叠术治疗老年胃食管反流病

目的:对比腹腔镜Nissen 胃底折叠术在老年组和非老年组胃食管反流病(GERD)的疗效,评价其在老年人应用的可行性.方法:回顾分析因GERD行腹腔镜Nissen胃底折叠术治疗的老年病人28例,随机选取同时期非老年GERD病人40例作为对照组,分析不同年龄组患者的治疗效果.结果:术后两组症状完全消失.食管下段压力由(8.8±2.6)mmHg(1mmHg =0.133 kPa)提高到(18.23±3.6)mmHg(P＜ 0.01),24 h pH值检测评分由105.4±3.7降低到8.12±2.1(P＜ 0.01),较术前明显改善,并达到正常范围.平均随访4.5年,非老年组症状复发2例,老年组1例.远期吞咽困难老年组发生8例,非老年组为1例,差异有统计学意义(P＜ 0.05).结论:在老年GERD病人中实施腹腔镜Nissen 胃底折叠术与在非老年病人中实施一样安全、有效,但远期吞咽困难发生率较非老年人为高.     

Laparoscopic Nissen Fundoplication Effectively Relieves Symptoms in Patients with Laryngopharyngeal Reflux

Introduction The utility of laparoscopic Nissen fundoplication in the treatment of laryngopharyngeal reflux symptoms remains controversial. We hypothesized that a carefully selected population with these symptoms would benefit from antireflux surgery. Materials and Methods Sixty-one consecutive patients have undergone antireflux surgery for laryngopharyngeal reflux at a single institution. Preoperative evaluation including upper endoscopy, laryngoscopy, and 24-h ambulatory pharyngeal pH probe monitoring confirmed the diagnosis. Patients completed two validated symptom assessment instruments preoperatively and at multiple time points postoperatively. Results Patients were followed for up to 3 years with a mean follow-up of 15.2 months. A significant improvement in reflux symptom index score (preoperative = 31.5 ± 7.4 vs 3 years = 12.4 ± 10.9, p < 0.01), laryngopharyngeal reflux health-related quality of life overall score (preoperative = 55.0 ± 26.0 vs 3 years = 11.3 ± 13.9, p < 0.01), and symptom domain scores (voice, cough, throat clearing, and swallowing) occured within 1 month of surgery and remained improved over the course ofthe study. Conclusion Laparoscopic Nissen fundoplication is effective in relieving the symptoms of laryngopharyngeal reflux in a carefully selected patient population. Benefits are seen within 1 month of surgery and persist for at least 3 years. Presented at the Digestive Disease Week 2007, May 22, 2007, Washington, DC.     

腹腔镜高选择性迷走神经切断术联合Nissen胃底折叠术:效果如何?——腹腔镜Nissen迷走神经切断术治疗胃食管返流

背景：Nissen胃底折叠术（Nissen fundoplication，NF）已不是治疗胃食管返流性疾病（gastroesophageal reflux disease，GERD）的唯一、有效的方法。对于能降低胃酸的手术方式来讲，如高选择性迷走神经切断术（highly selective vagotomy，HSV），也不仅仅是一种辅助治疗方法。对高选择性迷走神经切断术联合Nissen胃底折叠术（Nissen fundoplication with highly selective vagotomy，NFHSV）治疗GERD的作用目前尚无完整的评价。方法：2003年6月～2005年6月8例女性病人接受NFHSV，8例均有6个月GERD病史，经药物治疗症状无缓解，有餐前痛、消化性溃疡或严重的胃炎。平均随访时间12个月，术前、术后进行烧心严重程度评分测定（heart burn severity score，HSS）。结果：平均手术时间110min，无手术并发症。1例术后须用质子泵抑制剂，术后经戒烟5个月后停药。8例术后症状和烧心严重程度评分测定有明显改善。结论：NFHSV是有效的联合手术方式，尚需要进一步的研究证实这一联合术式的完全有效性和安全性。     

Preoperative Lower Esophageal Sphincter Manometry Data Neither Impact Manifestations of GERD nor Outcome After Laparoscopic Nissen Fundoplication

Background  Experience with laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) and manometrically intact lower esophageal sphincter (LES) is limited. The disease pattern may be different and LARS may fail to control reflux or result in higher rates of dysphagia. This is the first study investigating the impact of preoperative LES manometry data not only on manifestations of GERD and subjective outcome alone but also on objective outcomes 1 year after LARS. Methods  Three hundred fifty-one GERD patients underwent LARS and had subjective symptom and quality of life assessment, upper gastrointestinal endoscopy, barium swallow esophagogram, 24-h esophageal pH monitoring, and manometry pre- and 1 year postoperatively. Patients were divided into those with a preoperatively intact versus defective LES based on intraabdominal length and resting pressure. Baseline and 1-year postoperative follow-up data were compared. Results  Preoperative manifestations of GERD were similar in each group. Postoperatively, all symptoms except flatulence, quality of life scores, and objective manifestations improved significantly in each group. Conclusions  The preoperative manometric character of the LES neither impacts the manifestations of GERD nor subjective and objective outcomes after LARS. Patients with GERD and manometrically intact LES have no higher risk for postoperative dysphagia.     

Ineffective Esophageal Motility in Patients with GERD is no Contraindication for Nissen Fundoplication

Background

Patients with preoperative ineffective esophageal motility (IEM) are thought to be at increased risk for postoperative dysphagia leading to the recommendations for tailoring or avoiding anti-reflux surgery in these patients. The aim of this study was to evaluate if IEM has an influence on postoperative outcome after laparoscopic Nissen fundoplication (LNF).

Methods

Seventy-two consecutive patients with IEM underwent LNF and were case-matched with 72 patients without IEM based on sex, age, BMI, HH size, total pH percentage time, total number of reflux episodes and the presence of BE. Standardized interview assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake, GERD-health-related-quality-of-life (GERD-HRQL), alimentary satisfaction and patients’ overall satisfaction was evaluated.

Results

Although a higher rate of preoperative dysphagia was observed in patients with IEM (29% IEM vs. 11% no IEM, p = 0.007), there was no significant difference in rates of dysphagia postoperatively (2 IEM vs. 1 no IEM, p = 0.559). Furthermore, no distinction was found in the postoperative outcome regarding symptom relief, quality of life, gas bloating syndrome, ability to belch and/or vomit or revision surgery between the two groups.

Conclusion

Although preoperative IEM has an influence on GERD presentation, it has no effect on postoperative outcome after LNF. IEM should not be a cause for avoiding LNF, as is has been shown as the most effective and safe anti-reflux treatment.

     

Laparoscopic Fundoplication in Patients with a Hypertensive Lower Esophageal Sphincter

Background  A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. Material and Methods  Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP ≥30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0–10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. Results  Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30–55). Median follow-up after fundoplication was 99 (12–182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036). Conclusion  Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.     

Laparoscopic Nissen Fundoplication Plus Mid-gastric Plication for Treatment of Obese Patients with Gastroesophageal Reflux Disease

Background

Gastroesophageal reflux disease (GERD) is commonly associated with obesity, and its surgical management is debatable.

Objective

The objective of this study was to prove the safety and feasibility of laparoscopic Nissen’s fundoplication (LNF) combined with mid-gastric plication (MGP) for treatment of obese patients with GERD.

Methods

LNF combined with MGP was done for 18 patients. All interventions were performed under general anesthesia. The follow-up protocol included body mass index (BMI), percentage of excess weight loss (%EWL), percentage of excess BMI loss (%EBMIL), and clinical assessment using the Gastro-esophageal Reflux Health-Related Quality-of-Life (GERD-HRQOL) scale at 6 and 12 months.

Results

The period of follow-up ranged from 12 to 33 months with a mean of 17.74 ± 3.73 months. The operation time was 1.40 ± 0.27 h. No serious procedure-related complications occurred. GERD-related symptoms resolved in all patients (p < 0.001). There was a significant improvment in endoscopic findings at 6 months compared to properatively (p = 0.001). There was a significant patient satisfaction score using GERD-HRQOL at 6 and 12 months (p = 0.000). The 1-year follow-up excess weight was significantly less than the baseline excess weight (p < 0.001). The average BMI decreased from 37.59 ± 1.89 kg/m² at baseline to 30.61 ± 1.57 kg/m² at 1 year (p < 0.001).

Conclusions

LNF combined with MGP for treatment of obese patients with GERD is technically safe, feasible, and promising with no serious procedure-related complications. The technique is effective in terms of weight loss and cure of GERD. However, future larger studies are required to demonstrate the safety, effectiveness, and long-term durability of the procedure.

     

Assessment of Quality of Life after Laparoscopic Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease

Background In this study two different quality of life items are compared, and correlation of patient satisfaction with preoperative and postoperative symptoms after laparoscopic Nissen fundoplication (LNF) for chronic gastroesophageal reflux disease is evaluated. Materials and Methods Between December 2002 and December 2004, 60 patients with a diagnosis of chronic gastroesophageal reflux disease scheduled for laparoscopic Nissen fundoplication were recruited prospectively and volunteered to participate in this study. Patients underwent endoscopy, and their disease-specific symptoms were scored on a scale. Quality of life was measured preoperatively and in the first and sixth postoperative months with two questionnaires: Short Form-36 (SF 36) (preoperatively) and the Gastroesophageal Reflux Disease—Health-Related Quality of Life (GERD-HRQL) (postoperatively). Results In more than 90% of the patients, typical symptoms (regurgitation and pyrozis) were controlled postoperatively (p < 0.001). In the first postoperative month, however, dysphagia (early dysphagia) was seen in 46 (76%) patients, whereas in the sixth postoperative month (late dysphagia) its incidence decreased to only 2 (3.3%) patients. Similarly, in the first postoperative month 42 (70%) patients had gas bloating, but the incidence of this symptom decreased to 26 (43.3%) patients by the sixth month (p = 0.01). The quality-of-life measurements obtained from both SF 36 and GERD-HRQL showed that quality of life of the patients improved significantly in the related domain of each item after surgery (p < 0.001). Conclusions Laparoscopic Nissen fundoplication is an effective operation that controls the typical symptoms and improves the quality of life of patients, but new-onset symptoms affect postoperative well-being. For closer evaluation of the benefits of the operation, we need new questionnaires that comprehensively evaluate the symptom spectrum of GERD both preoperatively and postoperatively.     

Effect of Laparoscopic Fundoplication on Hypertensive Lower Esophageal Sphincter Associated with Gastroesophageal Reflux

For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently, the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50–61). Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7–86). Average LES pressure before the operation was 50.5 mmHg (range 35.6–81.3). Six weeks after operation, all patients were symptom free. DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure (24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure may be an etiologic factor in the development of hypertensive lower esophageal sphincter.     

Laparoscopic Long Esophagomyotomy with Dor's Fundoplication Using a Transhiatal Approach for an Epiphrenic Esophageal Diverticulum

The conventional treatment for an epiphrenic diverticulum consists of diverticulectomy with or without myotomy via a left thoracic approach. We describe the resection of an epiphrenic esophageal diverticulum using a laparoscopic transhiatal approach after observing its rate of enlargement on routine chest X-rays done over a number of years. This approach eliminates the need for thoracotomy and pleural drainage, and permits a complete laparoscopic procedure, including diverticulectomy, myotomy, and antireflex surgery.     

Laparoscopic Nissen Fundoplication with Gastric Plication as a Potential Treatment of Morbidly Obese Patients with GERD,First Experience and Results

Background

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD). However, there is no consensus for the surgical treatment of GERD in morbidly obese patients.

Methods

Twenty-five morbidly obese patients with GERD underwent our novel procedure, laparoscopic Nissen fundoplication with gastric plication (LNFGP), and were monitored for 6 to 18 months. Operative complication, weight loss, and GERD symptoms were monitored.

Results

The study subjects consisted seven males and 18 females. The average age was 38.2 years (from 18 to 58), and the mean BMI was 37.9 kg/m² (from 31.5 to 56.4). The mean operative time was 145.6 min (from 105 to 190). All procedures were performed via laparoscopic surgery. Two patients (8 %) displayed a major 30-day perioperative complication. The first patient had an acute leak on the second postoperative day. The patient received a laparoscopic revision sleeve gastrectomy and was discharged 5 days later after an uneventful recovery. Another patient developed an intra-abdominal abscess 3 weeks after surgery and received laparoscopic drainage and a revision sleeve gastrectomy. Upon follow-up, only four (16 %) patients experienced occasional acid regurgitation symptoms; however, no anti-acid medication was required. A significant decrease in the prevalence of erosive esophagitis (80 vs. 17 %) after LNFGP was observed. The mean weight loss was 9.7, 14.1, 17.9, and 18.1 % at 1, 3, 6 and 12 months, respectively. The mean BMI decreased to 30.8 kg/m² 1 year post surgery with a mean body weight loss of 25 kg.

Conclusions

LNFGP appears to be an acceptable treatment option for treating GERD in morbidly obese patients who refuse Roux-en-Y gastric bypass. However, further study is indicated to verify this novel procedure.     

Reflux Symptoms and Side Effects Among Patients with Gastroesophageal Reflux Disease at Baseline, During Treatment with PPIs, and After Nissen Fundoplication

Background

There are no prospective studies available on the behavior of extraesophageal and esophageal symptoms and treatment-related side effects in patients without effective antireflux medication, receiving the most effective antireflux medication, and after laparoscopic fundoplication.

Methods

Extraesophageal and esophageal reflux symptoms and treatment-related side effects were assessed in 60 patients while they were on no effective antireflux medication (three-week washout period), after three month of treatment with double-dose esomeprazole, and 3 months after laparoscopic Nissen fundoplication. Esophageal and extraesophageal reflux symptoms, rectal flatulence, and bloating were analyzed with the visual analog scale. In addition, dysphagia, rectal flatulence, and bloating were recorded as none, mild, moderate, or severe.

Results

Both extraesophageal and esophageal reflux symptoms decreased after treatment with esomeprazole and were further reduced after fundoplication. Dysphagia and flatulence did not increase from baseline after surgery. Bloating decreased both after treatment with esomeprazole and after fundoplication. In contrast, dysphagia and increased flatus were found more often after surgery than during treatment with esomeprazole. Dysphagia and rectal flatulence were less common during treatment with esomeprazole than at baseline or after surgery.

Conclusions

Both extraesophageal and esophageal reflux symptoms decreased after treatment with esomeprazole and were reduced further after fundoplication. Any treatment-related side effect was not increased after surgery when compared to baseline. However, compared to esomeprazole there was more dysphagia and flatulence after fundoplication.     

Prognostic Significance of Skeletal Muscle Loss During Early Postoperative Period in Elderly Patients with Esophageal Cancer

Annals of Surgical Oncology -     

Prognostic Significance of Skeletal Muscle Loss During Early Postoperative Period in Elderly Patients with Esophageal Cancer

Annals of Surgical Oncology - Skeletal muscle loss during the early postoperative period frequently occurs during post-esophagectomy. Preoperative sarcopenia is a known prognostic factor. However,...     

210例腹腔镜手术中钛夹固定引流管的疗效评价

目的探讨腹腔镜腹部手术中钛夹内固定腹腔引流管的疗效。方法回顾性分析我院1997～2009年期间210例腹腔镜腹部手术中应用钛夹固定腹腔引流管的临床资料。结果210例引流管放置5～20d,平均8.5d,无引流管漂移、挪位和引流不畅发生,且拔管顺利,未出现腹腔积液、腹腔脓肿、腹膜炎等并发症。结论腹腔镜腹部手术中,用钛夹内固定腹腔引流管的放置方法简单,引流效果可靠,疗效安全肯定,可明显减少手术并发症,值得临床推广使用。