liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Success and failure of conventional and laparoscopic fundoplication in gastro-oesophageal reflux disease
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
2003 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The outcome of antireflux surgery in a single institution during two decades is presented.

101 consecutive patients operated with open partial2 70° fundoplication and crural repair during 1982-1989 were prospectively analysed. All stages ofpreoperative oesophagitis were represented. Reflux competence, symptomatology, and postoperative side-effects were evaluated six months and ten years postoperatively. Recurrence (8%) was more common in patients who had severe oesophagitis before operation. The operative method is effective for long-term reflux control, it does not cause dysphagia, and it has few side-effect. Some months prior to the introduction oflaparoscopic fundoplication our unit had changed from partial to total fundoplication as a standard operation for gastro-oesophageal reflux disease (GORD). It was then convenient to perform the total Nissen fundoplication laparoscopically. All 50 patients operated with laparoscopic technique during a 30-months period 1992-1994 were prospectively compared with 21 patients operated with open technique. Nine patients were converted and then analysed in the open group. We tried to select patients with uncomplicated disease for laparoscopy but 7 patients in this group had severe disease diagnosed at preoperative endoscopy or/and at operation. In the open group 9 patients had severe disease. The patients were investigated six months, two years, and five years postoperatively. Early postoperative manometry was prognostic for recurrence. At long term follow-up the reflux control was similar, 10% of the patients operated with laparoscopy had recurrence and 8% of the patients operated with open technique.

Summer 1994 to spring 1998 we included 93 patients with uncomplicated GORD in a randomised clinical trial between laparoscopic and open 360° floppy Nissen fundoplication with crural repair. 45 patients were operated on laparoscopically and 48 patients underwent laparotomy. Only one patient was converted and then analysed in the laparotomy group. The patients were investigated before operation, half a year after and at long-term follow-up (33-79 months postoperatively). Long-term follow up also included endoscopy. Operation time was significantly longer for laparoscopy compared to laparotomy, 155.6 (±36.5) minutes and 104.3 (±30.7) minutes respectively (p<0.05). Laparoscopy patients had significantly shorter hospital stay, 3.6 (±1.9) days, compared to 5.8 (±1. 7) days for laparotomy patients. Sick leaves were 20.7 (±9.9) days for laparoscopy patients and 28.3 (14.7) for laparotomy patients. The difference was significant (p<0.05). Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. Early side-effects were more frequent after laparoscopy. Significantly less laparoscopy patients were satisfied at long-term follow-up; only 62% of the laparoscopy patients were satisfied compared to 91% of the laparotomy patients.

We have investigated the mechanisms and anatomical failures in twenty-one patients reoperated after laparoscopic total fundoplication. Recurrent heartburn occurs when wrong part of the stomach is used for the fundoplication. Dysphagia after failed laparoscopic total fundoplication is caused by hiatal fibrosis or other mechanical causes rather than a normal and tight fundoplication.

Also the reproducibility of an important diagnostic tool for GORD, the 24-hour pH monitoring, was evaluated. Twenty-two adult patients admitted to The Oesophageal Laboratory for 24-hour pH monitoring were investigated twice, six weeks apart, under identical conditions. The test was strictly standardised with the use of an antimony pH- probe and the patients hospitalised during 24 hours. We found that a normal 24-hour pH test should be assessed with caution because the biological variability of gastro-oesophageal reflux is not negligible from time to time.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2003. , 55 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 796
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-25644Local ID: 10019ISBN: 91-7373-554-X (print)OAI: oai:DiVA.org:liu-25644DiVA: diva2:246192
Public defence
2003-06-06, Berzeliussalen, Hälsouniversitet, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-10-10Bibliographically approved
List of papers
1. Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication
Open this publication in new window or tab >>Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication
1999 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 86, no 7, 956-960 p.Article in journal (Refereed) Published
Abstract [en]

Background:

This was a prospective study of symptoms, and short-term and long-term reflux competence after partial fundoplication.

Methods:

Some 101 patients were operated consecutively with posterior partial (270°) fundoplication. Indications for surgery were reflux disease without erosive oesophagitis in 25 patients, moderate oesophagitis in 43, severe oesophagitis in 25 and paraoesophageal hernia in eight. Symptom score, manometry and pH tests were performed before operation, 6 months after operation and after 6–14 years.

Results:

All patients (n = 101) were free from heartburn and regurgitation at early follow-up. There was evidence of clinical recurrence at late follow-up (n = 87) in two of 22 patients without oesophagitis before operation, two of 39 with moderate oesophagitis before operation and three of 19 patients with severe oesophagitis before operation; 92 per cent had good reflux control at late follow-up.

Conclusion

Posterior partial fundoplication shows excellent reflux control at early follow-up. Ten years later fewer than 10 per cent of patients have recurrence, which is more common in patients who had severe oesophagitis before operation.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25023 (URN)10.1046/j.1365-2168.1999.01183.x (DOI)9444 (Local ID)9444 (Archive number)9444 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
2. Prospective evaluation of laparoscopic and open 360o fundoplication in mild and severe gastro-oesophageal reflux disease
Open this publication in new window or tab >>Prospective evaluation of laparoscopic and open 360o fundoplication in mild and severe gastro-oesophageal reflux disease
2002 (English)In: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, no 10, 539-545 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

To investigate the relationship between five-year control of reflux and early postoperative oesophageal function after total fundoplication done either laparoscopically or through a laparotomy in severe and mild reflux disease.

DESIGN:

Prospective open study.

SETTING:

University hospital, Sweden.

PATIENTS:

In the group with severe disease 9 patients had a laparotomy and 7 laparoscopy. The corresponding figures for the group with mild disease were 21 and 34 respectively.

RESULTS:

The increase in lower oesophageal sphincter pressure 6 months after operation in patients with recurrent disease was significantly less than that for patients with good reflux control (p < 0.01). In patients who had laparotomy, including 30% (9/30) with severe reflux disease, good long-term reflux control was found in 93% (27/29). In patients operated on laparoscopically including 17% (7/41) with severe reflux disease good long-term reflux control was found in 90% (35/39).

CONCLUSION:

The mechanism of recurrence differed between patients with severe disease who had a laparotomy and patients with mild disease operated on laparoscopically. Early postoperative manometry was prognostic for recurrence. Long-term reflux control seems to be similar after laparotomy and laparoscopy. Further randomised studies are needed.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24845 (URN)12666693 (PubMedID)9243 (Local ID)9243 (Archive number)9243 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
3. Laparoscopic or conventional fundoplication for long-term management of gastroesophageal reflux disease?
Open this publication in new window or tab >>Laparoscopic or conventional fundoplication for long-term management of gastroesophageal reflux disease?
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: The study started in 1994 after over 50 laparoscopic 360o fundoplications had been performed by the surgeons involved. Complete mobilization of the fundus with posterior crural repair was used where a short floppy total fundoplication was constructed using three non-absorbable sutures, two of them including the esophageal wall. Initial experience in the first 50 consecutive patients operated laparoscopically in this center demonstrated 90% good reflux control.

Methods: Adult patients with uncomplicated reflux disease during the years 1994-1998 were included in this prospective ranomized clincal trial between laparoscopic and open total fundoplication. Patients with long segment Barrett's esophagus, strictures, unhealed severe esophagitis or paraesophageal hernia were excluded, as were patients with previous esophagus or stomach operations, those with weak peristalsis or suspected short esophagus. Two senior surgeons well trained in laparoscopic antireflux surgery performed the 45 laparoscopic operations. Forty-eight patients underwent open surgery performed and supervised by two other senior surgeons well trained in gastroesophageal surgery. One of the latter recruited all patients. Manometry and 24-h esophageal pH monitoring were performed before operation and half a year postoperatively. Manometry also included a short-term reflux test, an acid clearing test and an acid perfusion test. Symptom evaluation (modified DeMeester score) was performed before operation, half a year after and at long-term follow-up (33-79 months postoperatively). Long-term follow-up also included endoscopy.

Results: Half a year after laparoscopy four patients had disabling dysphagia. No patient had disabling dysphagia after laparotomy. Four patients had mild heartburn six mouths after laparoscopy and two patients after laparotomy. Between six months follow-up and long-term follow up six patients were reoperated in the laparoscopy group and two patients in the laparotomy group. Three patients operated with laparotomy had died in intercurrent diseases. After laparoscopy, at long-term follow-up, 62% (28/45) were satisfied compared to 91% ( 41145) after laparotomy. The difference was significant (p<0.01).

Conclusions: Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. At long-term follow-up significantly more patients were satisfied after laparotomy than after laparoscopy.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84500 (URN)
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2012-10-10Bibliographically approved
4. Symptoms and reflux competence in relation to anatomical findings at reoperation after laparoscopic total fundoplication
Open this publication in new window or tab >>Symptoms and reflux competence in relation to anatomical findings at reoperation after laparoscopic total fundoplication
2002 (English)In: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, no 12, 701-706 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

To investigate the mechanisms and anatomical failures after total laparoscopic fundoplication using the symptoms and findings at reoperation.

DESIGN:

Prospective open study.

SETTING:

University hospital, Sweden.

PATIENTS:

Twenty-one patients who were reoperated on a median of 33 (0.5-102) months after laparoscopic fundoplication.

INTERVENTIONS:

The patients were divided into three groups according to the mode of presentation. The first group presented with dysphagia and no gastro-oesophageal reflux (GOR) (n = 6). The second group (n = 11) had recurrent GOR and the third group (n = 4) complained of a sense of excessive fullness.

RESULTS:

In the dysphagia group the reason for it in 4 patients was severe fibrosis in the hiatal region including the right part of the fundoplication. One patient had correctly located fundoplication but it was too tight. In the last patient the part of the stomach used was too low down. All patients in the GOR group had a slippage and rupture of the fundoplication. Ten patients also had a recurrent hernia. In 6/11 patients the fundal mobilisation was incomplete. In the last group (excessive fullness) one patient had a postoperative leak from the fundal part, one patient a para-oesophageal hernia, and one patient an intact but herniated repair. One further patient had an intact abdominal oesophagus and crural repair, but a large portion of the stomach had herniated through the left part of the fundoplication and acted as a volvulus.

CONCLUSIONS:

Dysphagia was caused by hiatal fibrosis or other technical failures rather than a normal tight fundoplication. Using the wrong part of the stomach causes recurrent heartburn. The laparoscopic suturing technique must be improved.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25025 (URN)15362579 (PubMedID)9446 (Local ID)9446 (Archive number)9446 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
5. Reliability of 24-hour oesophageal pH monitoring under standardized conditions
Open this publication in new window or tab >>Reliability of 24-hour oesophageal pH monitoring under standardized conditions
2002 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 37, no 1, 6-8 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Twenty-four-hour pH monitoring is an investigation technique that can give both false-positive and false-negative results, depending on patient factors such as diet and different activities. The aim was to study the reproducibility of 24-h oesophageal pH monitoring under as standardized conditions as possible in patients with symptoms of gastro-oesophageal reflux disease.

METHODS:

Antimony pH electrodes were used in 22 adult patients who were investigated twice, 6 weeks apart, under identical conditions. They were hospitalized and were served a standardized diet which had been tested to contain no lower than pH 5.0. Neither coffee nor smoking was allowed. The patients had to refrain from proton-pump inhibitors for 10 days and H2 blockers for 2 days prior to the investigation. The paired t test was used.

RESULTS:

There was no significant difference in total reflux time, upright or supine reflux time, or longest reflux periods between the two test occasions. However, there were discordant results in six patients who had normal total reflux time on one test occasion but pathological results on the other.

CONCLUSION:

Since the biological variability of gastro-oesophageal reflux is not negligible from time to time, a normal 24-h oesophageal pH test should be assessed with caution.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25024 (URN)10.1080/003655202753387275 (DOI)11843037 (PubMedID)9445 (Local ID)9445 (Archive number)9445 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved

Open Access in DiVA

No full text

Authority records BETA

Franzén, Thomas

Search in DiVA

By author/editor
Franzén, Thomas
By organisation
SurgeryFaculty of Health Sciences
Medical and Health Sciences

Search outside of DiVA

GoogleGoogle Scholar

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 77 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf