J. Stratford

Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry

Laparoscopic fundoplication is an accepted treatment for symptomatic gastro‐oesophageal reflux disease. The aim of this study was to clarify whether total (Nissen) or partial (Toupet) fundoplication is preferable, and whether preoperative oesophageal manometry should be used to determine the degree of fundoplication performed.

A poor response to proton pump inhibition is not a contraindication for laparoscopic antireflux surgery for gastro esophageal reflux disease

BackgroundWe aimed to determine if a poor response to proton pump inhibitors (PPIs) can predict a poor outcome following laparoscopic antireflux surgery (LARS) in our surgically treated population.MethodsA total of 324 patients undergoing LARS were included in this study. Following standardized assessment, patients recorded the efficacy of their medication on visual analogue scales. Pre- and postoperative symptom scores were recorded, with outcomes measured by modified Visick scores.ResultsThere were 233 good responders (>50% relief) and 91 poor responders (<49% relief). Both groups demonstrated a significant decline in postoperative symptom scores. Ninety-four percent of good responders had an excellent or good outcome, compared to 87% of poor responders. Twenty-seven patients reported a fair or poor outcome, despite improved postoperative symptom scores. Fifteen of these patients reported continuing heartburn; five had positive pH tests.ConclusionOur results do not support the assumption that a poor response to PPIs equates to a poor outcome after LARS.

Does laparoscopic antireflux surgery improve quality of life in patients whose gastro-oesophageal reflux disease is well controlled with medical therapy?

Objective Both medical therapy and laparoscopic antireflux surgery have been shown to improve quality of life in gastro-oesophageal reflux disease. Although patients with poor symptom control or side effects on medical therapy might be expected to have improved quality of life after surgery, our aim was to determine, for the first time, whether patients whose symptoms are well controlled on medical therapy but who decide to undergo surgery (patient preference) would experience improved quality of life. Methods Retrospective analysis of our patient database (1998–2003, n=313) identified 60 patients who underwent laparoscopic antireflux surgery for the indication of patient preference. Two generic quality-of-life questionnaires (Short Form 36 and Psychological General Well-Being index) and a gastrointestinal symptom questionnaire (Gastrointestinal Symptom Rating Scale) were completed preoperatively, while on medical therapy, and 6 months after surgery. Results Thirty-eight patients completed all three questionnaires at both time intervals: 31 males, seven females; mean age 42 (15–66) years. Preoperative scores while on medical therapy were significantly improved after surgery: Short Form 36 median physical composite scores 52.0 and 54.0 (P=0.034) and mental composite scores 51.0 and 56.0 (P=0.020); Psychological General Well-Being median total scores 78.0 and 90.0 (P=0.0001); Gastrointestinal Symptom Rating Scale median total scores 2.13 and 1.73 (P=0.0007) and reflux scores 2.50 and 1.00 (P<0.0001). Conclusion Laparoscopic antireflux surgery significantly improved quality of life in reflux patients whose symptoms were well controlled on medical therapy. Although on the basis of a noncomparative trial with a relatively short follow-up period, we believe such patients should be considered for laparoscopic antireflux surgery.

Authors' reply: Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro‐oesophageal reflux disease based on preoperative oesophageal manometry (Br J Surg 2008; 95: 57–63)

Sir We read with interest the well constructed RCT by Booth et al., comparing Nissen and Toupet fundoplication in patients with or without oesophageal dysmotility. The inclusion criteria and definition of what constitutes abnormal motility is of paramount importance in a study of this nature. The majority of anti-reflux surgery studies1 describe a significantly lower incidence of preoperative dysphagia than this paper (40·9 per cent), suggesting that the method used to score dysphagia in this study differed, resulting in unusually high scores. Furthermore, the definition of abnormal motility was based on the threshold ratio of normal peristalsis on swallow initiation of 80 per cent. This is set at a lower level (70 per cent) in our unit in accordance with BSG guidelines2 and we would therefore have considered that many patients included in the study’s abnormal group as ‘normal’. There did not appear to be any stratification of the severity of this abnormal motility and it is unclear whether patients with an aperistaltic oesophagus were included in the study. Due to these discrepancies, we do not feel that this study has adequately answered the question of tailoring the fundoplication wrap with respect to preoperative manometry. A. G. N. Robertson, L. J. Dunn, J. Shenfine, D. Karat and S. M. Griffin Northern Oeosphago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK DOI: 10.1002/bjs.6281