Laparoscopic fundoplication is technically feasible in treating gastroesophageal reflux disease (GERD). Although medication is the primary treatment for GERD, not all patients respond completely or are able to adhere to a medical regimen. In the present series, 59 patients were laparoscopically treated for GERD at three centers using a standardized technique. All patients had been medically treated prior to referral, although 84 per cent had heartburn and 2 per cent had laryngitis despite 20 to 40 mg/day of omeprazole.

Fifteen per cent of patients were intolerant of or would no longer take omeprazole. Patients were evaluated by esophageal manometry (in 100%) and 24-hour pH studies (in 66%). Seventy-six per cent of patients had lower-esophageal sphincter pressure <15 mm Hg. Five patients had low esophageal body peristaltic pressures (<35 mm Hg). These patients underwent Toupet partial fundoplication, whereas 54 patients underwent Nissen fundoplication. Mean operative time was 158 +/- 7 minutes, and three patients (5%) were converted to an open procedure. Operative complications were minor and occurred in 13 per cent. In 45 patients evaluated 1 year after surgery, heartburn had resolved in 98 per cent. Thirty-nine of 56 patients (70%) had mild early (<1 month postoperatively) dysphagia, and 9 (19%) had severe early dysphagia, which improved in 7 after nonoperative dilatation.

Two of these had continued mild dysphagia. Two patients had severe dysphagia and were laparoscopically converted from Nissen to Toupet fundoplications, which resulted in marked improvement. Early gas bloat symptoms occurred in 45 per cent and dropped to 5 per cent at 1 year. Laparoscopic treatment of GERD is safe and effective in preventing reflux symptoms. Although mild dysphagia occurs after the procedure, this is transient in most patients. Patients with severe dysphagia can be treated with nonoperative dilatation or laparoscopic partial fundoplication and maintain the antireflux characteristics of the wrap.

THE SURGICAL TREATMENT of gastroesophageal reflux disease (GERD) entered the modern era in 1956 with Nissen's report of a 360 Celsius fundoplication preventing pathologic reflux. Because the nonsurgical treatment of this problem is usually effective, the Nissen procedure as well as other antireflux operations are generally reserved for patients with severe or complicated GERD. The development of laparoscopic gastrointestinal surgery has prompted a reexamination of the role of the surgeon in treating pathologic reflux by making the standard antireflux operation more acceptable to the patient and other care providers. The Nissen fundoplication continues to be the most widely performed antireflux procedure, open or laparoscopic. Consistently, the best results of open antireflux surgery have been obtained from single-institution studies, with symptomatic relief being obtained in more than 90 per cent of patients. When adherence to certain operative principles are stressed, similarly excellent results have been reported when the procedure is performed in a multi-institutional, multisurgeon setting. During the current series, laparoscopic Nissen fundoplication was performed using a standardized operative technique. Special emphasis was placed on ensuring "looseness" of the wrap in all patients to minimize the incidence of postfundoplication dysphagia and gas bloat symptoms. The results of laparoscopic treatment of GERD in 59 patients are reported.
Patients and Methods

Patient Selection

From January 1992 to May 1995, 59 patients (35 male, 23 female) were surgically treated for GERD at either Doctors Hospital (n = 41), the Veterans Affairs Medical Center (n = 10), or Parkland Memorial Hospital/University Hospital (n = 7) (all institutions in Dallas, TX). Mean age was 54 years. All of these patients had been evaluated and treated by a gastroenterologist prior to referral. Clinical complaints were strongly suggestive of GERD and consisted of heartburn (98%) and frequent daytime and nocturnal regurgitation (95%). Two patients (3%) had reflux laryngitis refractory to medical treatment. Eight patients (14%) reported dysphagia occurring at some time during the year prior to surgery, and seven patients (12%) had previously been treated for esophageal stricture by nonoperative dilatation. Fifty-four (93%) patients were on omeprazole ( 20-40mg/day) and although virtually all patients experienced some improvement in symptoms on this medication, 84 per cent reported residual heartburn ranging from occasional and mild to severe in nature. One patient had twice undergone a Belsey procedure, after which reflux symptoms had returned.

Patients were referred for a variety of reasons (Table 1). Nine patients would not continue to take omeprazole because of either intolerance or a desire to eliminate the need for medication. Most of the patients reported significant interference with their work, daily activities, and personal lives because of persistent regurgitation, laryngitis, or heartburn. Several patients, both male and female, were unable to complete sexual intercourse due to reflux symptoms.

Preoperative workup consisted of 24-hour pH monitoring (66% of patients) and esophageal manometry (100%). Patients with dysphagia symptoms had barium esophograms in addition to other studies. All patients had gastroesophageal endoscopy within the previous 1 year with assessment of esophagitis and identification of other abnormalities. Thirty patients (52%) were determined to have moderate to severe esophagitis (Savary-Miller grade II-III), the remainder being mild or completely healed, although patients had received varying durations of medical treatment at the time of study. Barrett's esophagus was determined to be present by biopsy in eight patients (14%). Abnormal lower esophageal sphincter pressures (<15 mm Hg) were documented in 76 per cent of patients. Five patients were selected to undergo primary partial fundoplication (Toupet procedure) based on low amplitude esophageal body pressures (<35 mm Hg) with wet swallowing.

Results after surgery were determined either by direct interview and examination (65%) or telephone interview (35%). Heartburn, dysphagia, and gas bloat symptoms were characterized as mild, moderate, or severe and described as early (within 1 month of surgery) or late (after 1 month).

Operative Technique

All patients received general anesthesia and were placed in a modified lithotomy position with steep reverse Trendelenberg. The procedure was performed via five 11-mm ports with the operator between the patient's legs and the first and second assistants to the patient's left and right, respectively. After abdominal insufflation to 15 mm Hg, the left lobe of the liver was elevated with a fan retractor. The stomach was retracted inferiorly, reducing any sliding hiatal hernia present, and permitting identification of the esophageal hiatus. After incising the peritoneum overlying the esophagus, the hiatus was exposed by sharp and blunt peri- and retroesophageal dissection. The hepatic branch of the vagus nerve was identified and preserved. The esophagus was encircled with a Penrose drain, which permitted extensive mobilization of the gastric cardia. The gastric fundus was mobilized as completely as possible, particularly posteriorly and along the highest portion of the greater curvature of the stomach to the level of the short gastric vessels. Short gastric vessels were initially divided selectively if the fundus could not be positioned easily for the wrap. Later in the series, short gastric vessels were divided routinely to help minimize the risk of dysphagia. A disposable, articulating right-angled "rasper (Autosuture Roticulating Endograsp; U.S. Surgical, Norwalk, CT) was used to pull a tongue of gastric fundus behind the esophagus to the patient's right side. A 54-60-F Maloney bougie was passed into the stomach. The wrap was deemed satisfactorily loose at this point if the two opposing segments of stomach comprising the wrap overlapped easily without traction being placed on the greater curvature or spleen. The fundoplication was secured with three interrupted sutures. The two upper sutures incorporated esophagus while avoiding the anterior vagus nerve. Wrap length was approximately 2 cm. Most knots were tied extracorporeally. The hiatus required closure in 84 per cent of patients. The repair was done either anterior (12%) or posterior (88%) to the esophagus.

The nasogastric tube and the Foley catheter were removed on discharge from the recovery room. On postoperative day 1 patients were placed on oral liquids and rapidly advanced to a soft diet and then discharged on postoperative day 2. A soft diet was continued until the 7th postoperative day, when patients resumed a regular diet with adjustments to suit individual needs.
Results

Three patients (5%) required conversion to open procedures. Two occurred during the initial 10 cases, the first because the liver could not be retracted adequately, and the second because of excessive distance between the ports and the esophagogastric junction. One patient was converted to an open procedure to repair an esophageal perforation. Mean operative time was 158 +/- 7 minutes and ranged from 75 to 350 minutes. Times were significantly longer during the first 30 cases than during the remainder (168 +/- 11 versus 148 +/- 7; P < 0.05, Student's unpaired t-test).

Operative complications included four supraumbilical wound infections not requiring drainage and two port-site hernias. During the last 30 cases, upper abdominal port sites were routinely closed at the level of the fascia. One patient sustained an esophageal perforation during passage of the bougie, which was repaired primarily and patched by open Nissen fundoplication. One patient with underlying lung disease required immediate postoperative reintubation and intensive case unit admission for mechanical ventilation but was discharged home on the 5th postoperative day. There were no splenic injuries incurred during the series.

Postoperative Results

Relief of symptoms. Of the 56 patients undergoing laparoscopic fundoplication, 98 per cent reported freedom from heartburn and marked improvement in regurgitation 1 month postoperatively. Forty-five patients evaluated 1 year after fundoplication continue to have excellent relief of these symptoms. One patient with severe preoperative reflux laryngitis continues to require medical treatment for chronic cough attributed to bronchitis after laryngoscopic determination of healed laryngitis.

Early dysphagia. Results for both early and late dysphasia are shown in Table 2. Thirty-nine patients (70%) had mild dysphagia within 1 month after surgery. In most cases, this manifested itself as a perception of food passing slowly through the esophagus, which the patient did not find distressing, but which sometimes required slower ingestion of food. None of these patients lost weight as a result of these symptoms. Nine patients (17%) had severe dysphagia and underwent nonoperative dilatation. Two of these had had preoperative dysphagia secondary to stricture and had been periodically dilated prior to surgery. Seven of these patients improved markedly with one or two dilatations. Two experienced worsening dysphagia and underwent a second laparoscopic procedure 2 weeks and 2 months, respectively, after the first. In both patients, the Nissen fundoplication was taken down and a Toupet fundoplication was performed. Dysphagia resolved in these patients postoperatively. The seven patients undergoing dilatation continued to have excellent relief of reflux after these interventions.

Late dysphagia. Forty-five patients were evaluated 1 year after fundoplication. Two patients, both of whom had severe early postoperative dysphagia, continued to have dysphagia, albeit improving. One of these has required a-total of six dilatations.

Gas bloat. Symptoms of bloating and difficulty belching were reported by 25 patients (45%) during the 1st month after surgery. Three patients (5%) continue to have moderate gas bloat symptoms at 1 year. Only one patient reported a significant increase in flatulence since fundoplication.

Toupet procedure. Of the seven patients undergoing partial fundoplication, six (86%) had excellent relief of reflux symptoms. One patient reported occasional heartburn, which was treated with ranitidine as needed. One patient had early postoperative dysphagia, which responded satisfactorily to a single dilatation procedure.
Discussion

Since its description by Dallemagne and Weerts in 1991, the technical feasibility of laparoscopic antireflux surgery has been demonstrated in several centers, where it has supplanted. the open procedures as the first-line surgical treatment for GERD. The precise role of laparoscopically performed antireflux surgery is evolving and may very well be different in 1 or 2 years. Medical treatment in conjunction with behavior modification relieves heartburn and milder regurgitation symptoms in the majority of patients. If heartburn alone is examined, proton pump inhibition with 20 to 40 mg/day of omeprazole provides complete or partial relief in 85 to 95 per cent of patients examined.( Indications for surgical treatment of GERD are frequently cited,3 but reluctance to refer patients for open Nissen fundoplication has largely been due to 1) the perceived, magnitude of the surgery, 2) concerns regarding post-wrap dysphagia and gas bloat, 3) uncertain durability of the wrap, and 4) fear of incomplete symptom relief. Several of the patients selected for surgery by the authors were satisfied with the degree of symptom relief provided by omeprazole and had opted for surgery because of a reluctance to continue to take this medication for an indefinite period, especially when severe symptoms occurred after very brief periods (24-48hours) of noncompliance. This subgroup of patients tended to be young (<50 years old) and expressed concerns regarding long-term achlorhydria as well as the inconvenience of a possible lifetime medical regimen. Expense of medication was cited by only two patients as a factor in deciding to undergo operation, but the current cost of omeprazole might be a significant influence to patients who pay all or part of their medication costs and are offered the option of surgical treatment. In patients such as these, the surgeon is faced with the challenge of equaling or exceeding the results of proton pump inhibition in order for surgery to be perceived as successful by the patient. Prospective comparisons of laparoscopic and long-term medical treatment are required to more precisely assess the results of the two patient options.

In the current series, all patients were satisfied with the relief of reflux provided by operation at up to 2 years' follow-up. The major difficulty encountered, as in most reports of antireflux surgery, was postoperative dysphagia, the incidence of which was similar to that experienced in other series. Early and late postoperative dysphagia was mild in most patients. Severe late dysphagia occurred in only 3 per cent. Results of observation and/or dilation in patients with dysphagia have been satisfactory, and no patient has lost the antireflux characteristics of the wrap after nonoperative dilatation. No specific comment can be made regarding late wrap failure, but none of the postoperative findings are suggestive of either wrap slippage or disruption.

Laparoscopic treatment of GERD is effective and safe. It is the authors' impression that patients with severe positional or exertional regurgitation will improve dramatically when surgically treated, and assume a more normal lifestyle postoperatively in spite of already having had complete or partial relief of heartburn with preoperative medical treatment. These patients, as well as those for whom lifetime medical treatment is an unsatisfactory option, are appropriate candidates for laparoscopic fundoplication. Patients can be discharged on the 2nd postoperative day and return to work as early as 1 week after the procedure. Although no formal comparisons have been made, preliminary information suggests that these short-term results are superior to those expected after open Nissen fundoplication, which requires hospitalization of 5 to 10 days and 6 weeks of activity restriction. A splenic injury rate of as high as 10 per cent has been reported for the open procedure,3 4 whereas recently reported results of the laparoscopic Nissen suggest that splenic injury rates are negligible.

Questions regarding the long-term effectiveness of antireflux surgery have generally focused on the durability of the wrap. High rates of wrap slippage and disruption with very long periods of follow-up have been reported. The significance of these data are uncertain. Many of these wraps had failed relatively early (during the first 5 years) after the procedure and may reflect difficulties with wrap construction. Furthermore, a large proportion of patients with endoscopically diagnosed wrap failure were free of reflux symptoms. Carefully compiled 5-10-year data reported by others are far more optimistic in quantifying wrap integrity and freedom from recurrent symptoms.

The various modifications of the Nissen fundoplication differ in length of wrap, degree of mobilization of the proximal stomach and suture material, as well as the method of fixation of the wrapped portion of stomach. These differences may impact on patient outcomes but are difficult to control for when analyzing published data. For example, the Rossetti-Hell modification of the Nissen fundoplication calls for minimal fundic mobilization, preservation of short gastric vessels and a long wrap that is not necessarily fixed to the esophagus. Results of this procedure may not be directly comparable to those reported by investigators who emphasize a short, loose wrap that is fixed to the anterior esophageal wall. Because the description of the floppy Nissen fundoplication by Donahue et al. and the wide acceptance of the principle that a very loose 360 Degree wrap is less likely to produce dysphagia than a more tightly constructed one, efforts have been made to perform the laparoscopic procedure in a short and loose fashion. No laparoscopic reports emphasize all of the technical points underscored by Donahue et a.,( n2) although complete mobilization of the fundus, division of the short gastric vessels, and dissection of the cardioesophageal fat pad were cardinal points of the operation as performed by the authors of the current series.

The Toupet partial fundoplication was employed selectively by the authors to correct or prevent postoperative dysphagia. Although it appeared to be effective when used in this manner, even in the two patients with unacceptable dysphagia after a 360 Degree wrap, convincing data demonstrating long-term decreased dysphagia compared with a loosely-performed Nissen fundoplications are lacking. Thor and Lundell compared Rossetti-Hell and Toupet fundoplications in randomized groups of patients and reported less dysphagia after the partial wrap, although this difference was far less marked with time. Protection from reflux symptoms was comparable in the two groups, but in the current series the only patient to complain of continued heartburn symptoms did so after a Toupet. It is not uncommon to offer Toupet fundoplication to patients with diminished esophageal body peristaltic pressures identified preoperatively. Although there are no specific data to indicate that this group of patients is better served by partial fundoplication, it has been widely presumed that the Toupet procedure is less likely to further impede esophageal clearance than a 360 Degree wrap.

The surgical options in treating GERD continue to grow. Although the precise choice of operation cannot yet be dictated by a clear superiority of one technique versus another, the Nissen fundoplication remains the standard surgical approach to pathologic reflux. Recent reports of thoracoscopically performed Belsey-Mark IV procedures indicate that antireflux surgery through the chest is technically feasible without left thoracotomy. This partial fundoplication has also been reported to minimize the likelihood of postoperative dysphagia and may gain in acceptance if patient outcomes prove comparable to those after laparoscopic Nissen. As more information becomes available regarding the long-term fate of laparoscopically performed antireflux surgery and the outcomes of patients receiving long-term proton pump inhibition, further changes in the operative approach to GERD can be expected.

Last updated Jan 4/07