Laparoscopic fundoplication for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.

Systematic review:Laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors

AIM: To assess laparoscopic fundoplication (LF) in partial responders to proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD).

Persistent severe hypomagnesemia caused by proton pump inhibitor resolved after laparoscopic fundoplication

Magnesium deficiency can cause a variety of symptoms, including potentially life-threatening complications such as seizures, cardiac arrhythmias and secondary electrolyte disturbances. Hypomagnesemia can be a serious adverse effect to proton pump inhibitor(PPI) therapy, which is worrying due to the widespread use of PPIs. Current evidence suggest that the mechanism of PPI induced hypomagnesemia is impaired intestinal magnesium absorption. In this report, we present the case of a long-term PPI user with persistent hypomagnesemia with severe symptoms at presentation. He was unable to stop PPI treatment because of severe reflux symptoms, and was dependent on weekly intravenous magnesium infusions, until his magnesium levels finally normalized without the need for supplementation after a successful laparoscopic fundoplication.

Laparoscopic fundoplication in the treatment of gastroesophageal reflux disease:analysis of 372 cases

Objective To investigate the feasibility and clinical value of laparoscopic surgery in treating patients with gastroesophageal reflux disease. Methods From September 2001 to August 2009,372 patients with gastroesophageal reflux disease undertwent laparoscopic fundoplication,including 146 cases of Nissen fundoplication,

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease. METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using metaanalysis. RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients' satisfaction, perioperative complications, postoperative heartburn, refluxrecurrence and reoperation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gasbloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Improved control of hypertension following laparoscopic fundoplication for gastroesophageal reflux disease

This study aims to determine whether successful laparoscopic fundoplication for gastroesophageal reflux disease （GERD） can improve the control of hypertension. We conducted an observational study of GERD patients with hypertension. The esophageal and gastroesophageal symptoms of these patients were successfully treated with laparoscopic fundoplication, as measured by the reduced GERD symptoms and proton pump inhibitor consumption. A hypertension control scale was used to classify the use of antihypertensive medications and the quality of blood pressure control before and after anti-reflux surgery. Wilcoxon signed-ranks test was used for the statistical analyses. Seventy GERD patients were included in the analysis and followed up for a mean period of 3.5± 1.4 years. Prior to surgery, all participating patients were taking at least one class of antihypertensive medication, and 56 patients （80%） had intermittently high blood pressure. After surgery, the mean number of antihypertensive medication classes per patient was significantly reduced from 1.61 ± 0.77 pre-procedure to 1.27 ± 0.88 post-procedure （P 〈 0.001）. The blood pressure of 48 of the 56 cases （86±） with preoperative intermittent high blood pressure returned to normal post procedure. A total of 50 patients （71%） recorded improvements on the hypertension control scale, with the overall mean score decreasing from 3.1 ± 1.0 pre- procedure to 1.4 ± 1.0 post-procedure （P 〈 0.001）. Therefore, successful laparoscopic fundoplication may result in better blood pressure control in some hypertensive GERD patients. This result suggests a possible connection between gastroesophageal reflux and hypertension.

Perioperative and late outcomes of laparoscopic fundoplication for neurologically impaired children with gastro-esophageal reflux disease

Background Persistent gastro-esophageal reflux （GER） due to various pathological factors often results in overt clinical symptoms and signs, which is termed as gastro-esophageal reflux disease （GERD）. Affected children usually present with failure to thrive, recurrent pneumonia or apnea. Many neurologically impaired children have symptoms related to GERD. Although laparoscopic fundoplication has been established to be an effective treatment modality for children with GERD, data on its role and long-term efficacy for neurologically impaired patients remain sparse. The aim of this study was to review the results of such patients who underwent laparoscopic fundoplication.

Effect of laparoscopic fundoplication treatment on gastroesophageal reflux disease-related respiratory symptoms

Gastroesophageal reflux disease(GERD)was diagnosed and fundoplication was performed,which relieved the symptoms.This paper explores the effect of fundoplication on GERD-related respiratory symptoms.From January 2007 to October 2008,64 patients with respiratory symptoms related to GERD were consecutively enrolled for laparoscopic fundoplication.Of these,60 patients had respiratory symptoms mainly combined with gastroesophageal reflux,while four had respiratory symptoms only.All patients had GERD confirmed,and medical treatment provided before surgery resulted in an insufficiently favorable effect or even producing further complications.All the patients were requested tofill a questionnaire form regarding the severity of symptoms and their medication so as to make an evaluation score for the follow-up.The outcome of respiratory symptoms after surgery was as follows:excellent in 23 cases(35.9%);good in 28(43.8%);fair in 5(7.8%);poor in 8(12.5%).The mean respiratory symptom score decreased from 6.3�2.65 to 2.33�2.37.Laparoscopic fundoplication can be an effective treatment for the majority of patients with GERD-related respiratory symptoms.

Nissen fundoplication vs proton pump inhibitors for laryngopharyngeal reflux based on p H-monitoring and symptom-scale

AIM To compare the outcomes between laparoscopic Nissen fundoplication(LNF)and proton pump inhibitors(PPIs)therapy in patients with laryngopharyngeal reflux(LPR)and typeⅠhiatal hernia diagnosed by oropharyngeal p H-monitoring and symptom-scale assessment.METHODS From February 2014 to January 2015,70 patients who were diagnosed with LPR and type I hiatal hernia and referred for symptomatic assessment,oropharyngeal p H-monitoring,manometry,and gastrointestinal endoscopy were enrolled in this study.All of the patients met the inclusion criteria.All of the patients underwent LNF or PPIs administration,and completed a2-year follow-up.Patients’baseline characteristics and primary outcome measures,including comprehensive and single symptoms of LPR,PPIs independence,and satisfaction,and postoperative complications were assessed.The outcomes of LNF and PPIs therapy were analyzed and compared. RESULTS There were 31 patients in the LNF group and 39patients in the PPI group.Fifty-three patients(25 in the LNF group and 28 in the PPI group)completed reviews and follow-up.Oropharyngeal p H-monitoring parameters were all abnormal with high acid exposure,a large amount of reflux,and a high Ryan score,associated reflux symptom index(RSI)score.There was a significant improvement in the RSI and LPR symptom scores after the 2-year follow-up in both groups(P<0.05),as well as typical symptoms of gastroesophageal reflux disease.Improvement in the RSI(P<0.005)and symptom scores of cough(P=0.032),mucus(P=0.011),and throat clearing(P=0.022)was significantly superior in the LNF group to that in the PPI group.After LNF and PPIs therapy,13 and 53 patients achieved independence from PPIs therapy(LNF:44.0%vs PPI:7.14%,P<0.001)during follow-up,respectively.Patients in the LNF group were more satisfied with their quality of life than those in the PPI group(LNF:62.49±28.68 vs PPI:44.36±32.77,P=0.004).Body mass index was significantly lower in the LNF group than in the PPI group(LNF:22.2±3.1kg/m^2 vs PPI:25.1±2.9 kg/m^2,P=0.001).CONCLUSION Diagnosis of LPR should be assessed with oropharyngeal p H-monitoring,manometry,and the symptom-scale.LNF achieves better improvement than PPIs for LPR with type I hiatal hernia.

Is there a changing trend in surgical management of gastroesophageal reflux disease in children?

Gastroesophageal reflux disease (GORD) is a pathological process in infants manifesting as poor weight gain, signs of esophagitis, persistent respiratory symptoms and changes in neurobehaviour. It is currently estimated that approximately one in every 350 children will experience severe symptomatic gastroesophageal reflux necessitating surgical treatment. Surgery for GORD is currently one of the common major operations performed in infants and children. Most of the studies found favour laparoscopic approach which has surpassed open antireflux surgery as the gold standard of surgical management for GORD.However, it must be interpreted with caution due to the limitation of the studies, especially the small number of subject included in these studies. This review reports the changing trends in the surgical treatment of GORD inchildren.

Impact of minimally invasive surgery on the treatment of benign esophageal disorders

Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.

Is patient satisfaction sufficient to validate endoscopic anti-reflux treatments?

Endoscopic anti-reflux treatment is emerging as a new option for gastroesophageal reflux disease(GERD)treatment in patients with the same indications as for laparoscopic fundoplication.There are many techniques,the first of which are transoral incisionless fundoplication(TIF)and nonablative radio-frequency(STRETTA)that have been tested with comparative studies and randomized controlled trials,whereas the other more recent ones still require a deeper evaluation.The purpose of the latter is to verify whether reflux is abolished or significantly reduced after intervention,whether there is a valid high pressure zone at the gastroesophageal junction,and whether esophagitis,when present,has disappeared.Unfortunately in a certain number of cases,and especially in the more recently introduced ones,the evaluation has been based almost exclusively on subjective criteria,such as improvement in the quality of life,remission of heartburn and regurgitation,and reduction or suspension of antacid and antisecretory drug consumption.However,with the most studied techniques such as TIF and STRETTA,an improvement in symptoms better than that of laparoscopic fundoplication can often be observed,whereas the number of acid episodes and acid exposure time are similar or higher,as if the acid refluxes are better tolerated by these patients.The suspicion of a local hyposensitivity taking place after antireflux endoscopic intervention seems confirmed by a Bernstein test at least for STRETTA.This examination should be done for all the other techniques,both old and new,to identify the ones that reassure rather than cure.In conclusion,the evaluation of the effectiveness of the endoscopic anti-reflux techniques should not be based exclusively on subjective criteria,but should also be confirmed by objective examinations,because there might be a gap between the improvement in symptoms declared by the patient and the underlying pathophysiologic alterations of GERD.

Outcome of Stretta radiofrequency and fundoplication for GERD- related severe asthmatic symptoms

This study aimed to investigate the outcome of treatment with Stretta radiofrequency （SRF） or laparoscopic Nissen fundoplication （LNF）. A total of 137 gastroesophageal reflux disease （GERD） patients with severe asthmatic symptoms who responded inadequately to medical treatment for asthma were investigated. The patients were followed up 1 year and 5 years after SRF （n = 82） or LNF （n = 55） treatment. A questionnaire covering 29 related symptoms and medication use was employed. Digestive, respiratory, and ear-nose-throat （ENT） symptom scores significantly decreased after antireflux treatment. Symptom scores respectively changed from 17.2 ± 10.1, 31.9 ± 6.6, and 21.1± 11.8 to 5.0 ±6.2, 11.5 ±10.2, and 6.3± 6.8 at 1 year and to 5.6 ± 6.5, 13.1± 10.1, and 7.8 ± 7.2 at 5 years （P 〈 0.001）. The outcome of LNF was significantly better than that of SRF in terms of digestive （P 〈 0.001, P = 0.001）, respiratory （P = 0.006, P = 0.001）, and ENT symptoms （P = 0.006, P = 0.003） at both 1 year and 5 years. SRF and LNF were both effective against the digestive symptoms of GERD as well as GERD-related severe asthmatic and ENT symptoms, with better outcomes exhibited by the LNF group. Severe asthmatic symptoms and GERD were closely associated, and this finding warrants further study.