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Laparoscopic or conventional fundoplication for long-term management of gastroesophageal reflux disease?
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
(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: urn:nbn:se:liu:diva-84500OAI: oai:DiVA.org:liu-84500DiVA: diva2:559817
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2012-10-10Bibliographically approved
In thesis
1. Success and failure of conventional and laparoscopic fundoplication in gastro-oesophageal reflux disease
Open this publication in new window or tab >>Success and failure of conventional and laparoscopic fundoplication in gastro-oesophageal reflux disease
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:nbn:se:liu:diva-25644 (URN)10019 (Local ID)91-7373-554-X (ISBN)10019 (Archive number)10019 (OAI)
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

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Franzén, ThomasJohansson, Karl-Erik

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