Edgar J.B. Furnée

Five-year subjective and objective results of laparoscopic and conventional nissen fundoplication : A randomized trial

Objective:The purpose of this prospective study was to compare the subjective and objective outcome of laparoscopic (LNF) and conventional Nissen fundoplication (CNF) up to 5 years after surgery as obtained in a multicenter randomized controlled trial. Summary of Background Data:LNF is regarded as surgical treatment of first choice for refractory gastroesophageal reflux disease by many surgeons based on several short- and mid-term studies. The long-term efficacy of Nissen fundoplication, however, is still questioned as objective data gathered from prospective studies are lacking. Methods:From 1997 to 1999, 177 patients were randomized to undergo LNF or CNF. Five years after surgery, all patients were requested to fill in questionnaires and to undergo esophageal manometry and 24-hour pH-metry. Results:A total of 148 patients agreed to participate in the follow-up study: 79 patients after LNF and 69 after CNF. Of these, 97 patients (48 LNF, 49 CNF) consented to undergo esophageal manometry and 24-hour pH-metry. At 5 years follow-up, 20 patients had undergone reoperation: 12 after LNF (15%) and 8 after CNF (12%). There was no difference in subjective outcome, with overall satisfaction rates of 88% and 90%, respectively. Total esophageal acid exposure times (pH < 4) were 2.1% ± 0.5% and 2.0% ± 0.6%, respectively (P = 0.21). Antisecretory medication was taken daily in 14% and 16%, respectively (P = 0.29). There was no correlation between medication use and acid exposure and indices of symptom-reflux association (symptom index and symptom association probability). No significant differences between subjective and objective results at 3 to 6 months and results obtained at 5 years after surgery were found. Conclusions:The effects of LNF and CNF on general state of health and objective reflux control are sustained up to 5 years after surgery and the long-term results of LNF and CNF are comparable. A substantial minority of patients in both groups had a second antireflux operation or took antisecretory drugs, although the use of those medications did not appear to be related to abnormal esophageal acid exposure.

EAES recommendations for the management of gastroesophageal reflux disease

BackgroundGastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett’s esophagus, and enteroesophageal and duodenogastroesophageal reflux.MethodsThe European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.ResultsRecommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.ConclusionsSince the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Surgical Reintervention After Antireflux Surgery for Gastroesophageal Reflux Disease: A Prospective Cohort Study in 130 Patients

HYPOTHESIS Surgical reintervention after antireflux surgery for gastroesophageal reflux disease is required in 3% to 6% of patients. The subjective outcome after reintervention has been reported in several studies, but objective results after these subsequent operations have rarely been published. The purpose of this study was to assess the symptomatic and objective outcomes in patients who underwent subsequent operation because of recurrent reflux symptoms or troublesome dysphagia after primary antireflux surgery. DESIGN Prospective cohort study. SETTING University medical center. PATIENTS Between January 1, 1994, and March 31, 2005, 130 patients (mean [SD] age, 48.4 [14.1] years) undergoing surgical reintervention after antireflux surgery for gastroesophageal reflux disease were prospectively studied. MAIN OUTCOME MEASURES Symptomatic outcome was determined by questionnaires. Esophageal manometry and 24-hour pH monitoring were performed to assess the objective outcome. RESULTS A total of 144 reinterventions were performed in 130 patients, for recurrent reflux in 94 patients (65.3%) and for troublesome dysphagia in 50 patients (34.7%). Belsey Mark IV fundoplication through a left-sided thoracotomy was performed in 78 (54.2%) and a subsequent Nissen or partial fundoplication during 66 reinterventions (45.8%), including 16 laparoscopic procedures. After a mean (SD) follow-up of 60.1 (37.2) months, symptoms were absent or significantly improved in 70.3% of patients and esophageal acid exposure was normalized in 70.2% of patients after surgery. Postoperative complications occurred after 14 subsequent operations (9.7%). CONCLUSIONS Surgical reintervention after antireflux surgery for gastroesophageal reflux disease yielded good symptomatic and objective results in 70% of patients in this prospective cohort study. Since the morbidity of this type of surgery is far from negligible, the expectations should be discussed in detail before additional operation.

Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair

BACKGROUND The long-term durability of laparoscopic repair of paraesophageal hiatal herniation is uncertain. This study focuses on the long-term symptomatic and radiologic outcome of laparoscopic paraesophageal herniation repair. METHODS Between 2000 and 2007, 70 patients (49 females, mean age +/- standard deviation 60.6 +/- 10.9 years) undergoing laparoscopic repair of paraesophageal herniation were studied prospectively. After a mean follow-up of 45.6 +/- 23.8 months, symptomatic (65 patients, 93%) and radiologic follow-up (60 patients, 86%) was performed by standardized questionnaires and esophagograms. RESULTS The symptomatic outcome was successful in 58 patients (89%), and gastroesophageal anatomy was intact in 42 patients (70%). The addition of a fundoplication was the only significant predictor of an unfavorable radiologic outcome in the univariate analysis (odds ratio .413; 95% confidence interval, .130 to 1.308; P = .125). CONCLUSIONS The long-term symptomatic outcome of laparoscopic repair of paraesophageal hiatal herniation was favorable in 89% of patients, and 70% had successful anatomic repair. The addition of a fundoplication did not prevent anatomic herniation.

Symptomatic and objective results of laparoscopic Nissen fundoplication after failed EndoCinch gastroplication for gastro-oesophageal reflux disease

Background Several endoscopic techniques have been introduced to treat gastro-oesophageal reflux disease, but their effectiveness varies. Subsequent laparoscopic Nissen fundoplication (LNF) might be required because of persistence or recurrence of symptoms. The aim of this study was to evaluate the outcome of LNF after previous EndoCinch gastroplication. Methods Eleven consecutive patients who underwent LNF after failed EndoCinch were included. Data were prospectively collected. Symptomatic outcome was obtained by validated questionnaires, and objective outcome by endoscopy, oesophageal manometry and pH monitoring. Results LNF was performed without major complications. After a median (range) follow-up of 31 (6–61) months, preoperative symptoms were resolved or improved in nine patients (81.8%), and general quality of life was significantly improved. None of the patients experienced daily complaints of heartburn postoperatively, and the median Gastro-Esophageal Reflux Disease Health Related Quality of Life score was 4 (0–9). Three patients (27.3%) had troublesome daily dysphagia. Oesophageal acid exposure was normalised after surgery in all but one patient, and another patient (9.1%) had persisting grade A oesophagitis. One patient (9.1%) underwent revisional LNF because of reflux and dysphagia caused by an intrathoracic migrated wrap. Conclusion This study has shown that quality of life and reflux control were satisfactory after LNF for failed EndoCinch gastroplication. Troublesome dysphagia was more frequently present after surgery in comparison with primary LNF.

Dyspeptic Symptoms after Laparoscopic Large Hiatal Hernia Repair and Primary Antireflux Surgery for Gastroesophageal Reflux Disease: A Comparative Study

Background: Several patients with gastroesophageal reflux disease suffer from functional dyspepsia. After laparoscopic Nissen fundoplication, these symptoms persist in a substantial number of patients. We hypothesized that, due to a higher chance of vagal nerve impairment during extensive hernia sac resection and esophageal mobilization, dyspeptic symptoms are more frequent after laparoscopic large hiatal hernia (types II–IV) repair than after primary antireflux surgery. Methods: From January 2003 to December 2007, 60 consecutive patients who primarily underwent an antireflux fundoplication for gastroesophageal reflux disease and 22 consecutive patients who had large hiatal hernia repair with fundoplication for concomitant gastroesophageal reflux disease were included. According to a system combining frequency and severity, patients scored 8 dyspeptic symptoms. Additionally, symptoms presenting preoperatively were scored according to the Visick grading system. Results: In 43 of the 49 available patients (87.8%) who primarily underwent antireflux surgery and in all 20 available patients who had hiatal hernia repair, preoperative symptoms resolved or improved. Mean symptom scores of all dyspeptic symptoms after surgery were comparable between both cohorts. General quality of life was equal in both cohorts. Conclusion: After laparoscopic large hiatal hernia repair, dyspeptic symptoms were present in similar frequencies as after primary antireflux surgery.

Combined surgery for primary colorectal cancer and synchronous pulmonary metastasis: a pilot experience in two patients.

Background Pulmonary metastasectomy in patients with pulmonary metastases from primary colorectal cancer seems to improve survival in properly selected patients. Therefore, pulmonary metastasectomy has been incorporated widely into the management of colorectal pulmonary metastases. Generally, in patients presenting with primary colorectal cancer and synchronous pulmonary metastases, the primary colorectal cancer is resected first, followed by pulmonary metastasectomy during a second-stage procedure. In the current paper we describe our pilot experience with laparoscopic resection of primary colorectal cancer and thoracoscopic pulmonary metastasectomy during the same operative session. Patients and methods The results of two patients who underwent laparoscopic resection of primary colorectal cancer and thoracoscopic pulmonary metastasectomy during the same operative session are described. Results Both patients were healthy women, 60 and 81 years old, respectively, and without severe comorbidities. In both patients, the colorectal resection was performed first by a laparoscopic approach. Subsequently, thoracoscopic resection of a single pulmonary metastasis followed in both patients. The operative procedure and postoperative course were uneventful and the patients could be discharged within 1 week after surgery. Both the primary colorectal cancer and the pulmonary metastasis were radically removed in both patients. Current follow-up, 14 and 8 months after surgery, respectively, showed no signs of disease recurrence on computed tomographic scan of the abdomen and chest in both patients. Conclusion The outcome in these two patients suggests that simultaneous resection of primary colorectal cancer and pulmonary metastasectomy using minimal invasive surgery is safe and might lead to both a decrease in costs and benefit to patients. This simultaneous approach could therefore be considered as an alternative for a two-stage approach in properly selected patients. However, these results should be validated in a larger series.

Identification of prognostic factors in early stage low rectal cancer to optimize surgical treatment; local excision or abdominoperineal resection.

I read the article ‘Analysis of the prognostic factors for low rectal cancer with the pT1-2NxM0 stage after abdominoperineal resection’ with great interest. In this paper, the authors analyzed a lot of prognostics factors in a large cohort of patients who underwent abdominoperineal resection for low rectal cancer after a median follow-up of 52 months [1]. In 54 of the included patients, the diseasestage of the rectal cancer was T1. All of these patients were surgically treated by abdominoperineal resection. However, local excision is increasingly being applied in patients with T1 rectal cancer, and current evidence shows that this approach is safe [2,3]. Unfortunately, the authors do not comment on this or on the fact that these 54 patients underwent quite extensive surgical treatment for their stage of disease. This is, in my opinion, extremely important, as local excision prevents significant problems associated with abdominoperineal excision by avoiding a definitive end colostomy, long-lasting hospital stay and sick leave, and delayed perineal wound healing [4]. In addition, there is a subgroup of patients with T1 rectal cancer with a high risk for local recurrence and decreased disease-free survival after local excision [5]. The identification of risk factors for an unfavorable oncologic outcome could help categorize these patients into ‘low risk’ and ‘high risk’ groups and identify those who are eligible for local excision. This might help clinicians during clinical decision-making and counseling of patients with T1 rectal cancer. Because of the relatively large group of patients with T1 rectal cancer, I would encourage the authors to carry out an analysis in this subgroup to identify risk factors for an unfavorable oncologic outcome.