Markku Luostarinen

The Long Term Results of Open Antireflux Surgery in a Community-Based Health Care Center

OBJECTIVES:There is no previous study concerning long term results of open Nissen fundoplication performed by general surgeons in a nonspecialized unit.METHODS:Of 45 consecutive patients in a general provincial center, 39 were available for follow-up after a mean period of 78 months. All patients were interviewed using a standard questionnaire, and 35 of them consented to undergo endoscopy.RESULTS:Of the patients, 85% had no or only mild reflux symptoms. The figures for dysphagia, flatulence, and bloating were 31%, 67%, and 46%, respectively. Endoscopy showed defective fundic wrap in 37% of the patients and erosive esophagitis in 29%. Five patients (13%) with recurrent esophagitis were referred for H2-blocker or omeprazole medication, and five others (13%) were scheduled for repeat antireflux surgery.CONCLUSIONS:The results were somewhat worse in regard to prevalence of defective fundic wrap and recurrent esophagitis than in other reports, which were from specialized units.

Long-term comparison of antireflux surgery versus conservative therapy for reflux esophagitis.

OBJECTIVE The purpose of the study was to evaluate the long-term symptomatic and endoscopic outcome in gastroesophageal reflux disease with erosive esophagitis, comparing conservative with operative management. METHODS The study comprised 105 of 120 patients consecutively referred for severe reflux symptoms to the gastroenterologic outpatient department of a teaching hospital, where erosive esophagitis was confirmed endoscopically. If conservative management (modified lifestyle and medication) failed to relieve symptoms and heal the esophagitis, antireflux surgery (Nissen fundoplication) was undertaken. Follow-up (median, 10.9 years) evaluation of all patients included comprehensive, standardized interviews; self-scoring of symptoms at the time of referral and currently; and observations at endoscopy. RESULTS Nissen fundoplication was performed on 37 of the 105 patients. At follow-up of these 37 patients, (31) 84% had no or only occasional mild heartburn, (33) 89% were free from erosive esophagitis, and (2) 5% were taking H2 antagonists or omeprazole. The corresponding figures in the 68 patients with only conservative treatment were (36) 53%, (31) 45%, and (14) 21%. The mean change in symptom score between referral time and follow-up was 5.7 in the surgically treated group and 1.7 in the nonsurgically treated group. Fifteen new cases of Barretts metaplasia were found at follow-up. CONCLUSIONS In gastroesophageal reflux disease with erosive esophagitis, surgical treatment gave results subjectively and objectively superior to those from conservative management.

Complications of open and laparoscopic antireflux surgery: 32-year audit at a teaching hospital

BACKGROUND Open or laparoscopic surgery for gastroesophageal reflux disease gives longterm freedom from symptoms in 83-100% of cases but has a certain percentage of complications. This study was undertaken to evaluate the early and late complication rates after primary or repeat antireflux operations. STUDY DESIGN The records of all patients who underwent surgery for gastroesophageal reflux disease during a 32-year period at a university teaching hospital were reviewed retrospectively. Records for 793 adults (448 men and 345 women) aged 16-85 years (mean, 51) were retrieved for calculation of complication rates and statistical analysis. RESULTS A total of 827 operations were performed: 793 primary and 41 for recurrent disease (2 patients were each reoperated on twice). There were 49 laparoscopic operations. Only two patients died (mortality, 0.3%), both after open operation. Morbidity was 24% after open surgery and 14% after laparoscopic operation. The total (early and late) complication rate was higher after reoperations than that after open or laparoscopic procedures. The overall complication rate in the open operations was similar in the first and the third decade of the study, namely, 24.6% and 26.1%, respectively. CONCLUSIONS Surgical treatment of gastroesophageal reflux disease carries very low mortality when performed in a specialized unit. The main causes of morbidity after open operation are infectious complications. The incidence of complications is substantially lower after laparoscopic surgery than after open operation. Reoperation is seldom required, but it carries higher morbidity than the primary operations.

Two Antireflux Operations: Floppy versus Standard Nissen Fundoplication

The effects of fundic mobilization in Nissen fundoplication on belching ability, abdominal gas volume, bloating and flatus were assessed in a prospective, randomized study of 25 patients with refractory gastro-oesophageal reflux disease. Reflux was cured regardless of fundic mobilization. Subjective ability to belch was restored to preoperative in 73% of the patients with fundic mobilization, compared to 50% without. About 10% in both groups totally lost their ability to belch. Disturbance from flatus increased postoperatively slightly in both groups, but from bloating it remained the same or even diminished. The residual intra-abdominal radioactivity (median (interquartile range)) after provoked belching was preoperatively 8.9% (4.4-12.0) with and 13.2% (6.8-15.2) without fundic mobilization, compared to 36.7% (31.1-40.9) of the controls (P < 0.05). After fundoplication this residual activity was normalized in both study groups. Disturbance from postoperative bloating or flatus were not related to the ability of belching. Preoperatively symptomatic patients tended to have more complaints postoperatively. In conclusion, fundic mobilization restored belching ability slightly more effectively without compromising antireflux efficacy, but there did not seem to be any advantage regarding flatus or bloating.

Initial Experience of the Feasibility of Single-Incision Laparoscopic Appendectomy in Different Clinical Conditions

Introduction. Single-incision laparoscopic surgery (SILS) is a new technique developed for performing operations without a visible scar. Preliminary studies have reported the use of the technique mainly in cholecystectomy and appendectomy. We evaluated the feasibility of the technique in various appendicitis conditions including children, fertile women and obese patients. Materials and Methods. SILS technique was used in a random sample of patients hospitalised for suspected appendicitis. The ordinary diagnostic laparoscopy was performed and the appendix was removed if needed. The ligation of appendix was performed by thread loop, absorbable clip or endoscopic stapler. The details regarding the recovery of patients were collected prospectively. Results. Ten SILS procedures were performed without conversions or complications. The patient series included uncomplicated and complicated appendicitis patients. The mean age of the patients was 37 years (range 13–63), mean BMI was 26 (range 18–31), mean operative time was 40 minutes (range 18–31), and mean postoperative stay was 2 days (range 1–5). Conclusions. SILS technique is feasible for obese patients, uncomplicated and complicated appendicitis as well as for exploratory laparoscopy. Most common methods to ligate appendix are feasible with SILS technique. The true benefit of the technique should be assessed by randomised controlled trials.

Histological improvement of oesophagitis after Nissen fundoplication

Nissen fundoplication gives lasting relief from symptoms of gastro-oesophageal reflux and cures endoscopic oesophagitis effectively. The histological effect on the oesophageal mucosa is less clear. We studied the long-term histological effect of Nissen fundoplication on refractory gastro-oesophageal disease with erosive oesophagitis or Barretts metaplasia in 33 patients with biopsy both before and after antireflux surgery. The median postoperative interval to re-examination was 80 (range 37-110) months. Symptoms of reflux were greatly relieved; 31 (94%) of the 33 patients had none or, at the most, mild symptoms. Endoscopic oesophagitis was healed in 26 (79%) of the cases. The histological appearance of the oesophageal mucosa had been abnormal in all the patients preoperatively, but at follow-up it was normal in 22 cases (67%): in 89% of the patients without objectively observed recurrent reflux and in 45% of those with recurrence. Both the pre- and postoperative severity of the histological changes correlated significantly with the endoscopic grade of oesophagitis (r=0.42, P=0.017 and r=0.837, P=0.0001, respectively), but not with the clinical reflux score. In conclusion, Nissen fundoplication resulted in histological healing in the great majority of patients with oesophagitis.

SURGICAL AND MEDICAL THERAPIES FOR GERD-CAN WE SEE INTO THE FUTURE?

Isolauri J, Luostarinen M, Viljakka M, et al. Long-Term Comparison of Antireflux Surgery Versus Conservative Therapy for Reflux Esophagitis Ann Surg 1997;225:295–9ABSTRACTThe authors studied the symptomatic and endoscopic outcome of patients who were treated for gastroesophageal reflux disease (GERD) with erosive esophagitis. The aim was to clarify the course of erosive esophagitis in GERD treated with an antireflux procedure or conservatively and furthermore to assess possible predictive factors of the long-term outcome. Included in this study were 105 of 120 patients who were consecutively referred for reflux symptoms to a gastroenterological department of a teaching hospital. The diagnosis was made symptomatically and endoscopically. Patients who were not relieved of symptoms or who had continued esophagitis underwent antireflux surgery. Conservative treatment included a modified lifestyle (elevated bedhead, avoidance of drugs or food, which reduced lower esophageal sphincter pressure, no smoking, no late evening meals) and medication (antacids, alginates, H2 antagonists). Thirty-seven patients underwent surgical treatment and 68 patients were treated conservatively. The median follow-up time was 10.9 yr (range 9–13.4) for all patients. The evaluation included a detailed, standardized interview, and an endoscopy with biopsy done by an investigator who was not involved previously. After the initial questionnaire, the patients assessed their symptoms with a self-scoring test. Compared to the conservatively treated group, the surgical patients initially had more severe disease. This was represented by a symptom score for heartburn and regurgitation and an endoscopic grade of esophagitis according to the Savary-Miller esophageal grading, which was mainly between 1 and 2 in the medical group and between 2 and 3 among the surgical patients, respectively. There was no mortality or morbidity in the group who underwent surgery. The follow-up evaluation showed that 84% of the surgery group were symptom-free or had only occasional heartburn, and 89% had healing of the esophagitis. For the conservatively treated group, the figures were 53% and 45%, respectively. In total, 57% of the conservative group had some objective sign of ongoing GERD, and 21% were still taking H2 antagonists or omeprazole regularly. Fifty-five percent had erosive esophagitis at follow-up endoscopy and eight new cases of Barretts metaplasia were found. Within the surgical group, 12 patients were found to have Barretts esophagus, five at referral time and seven new cases at follow-up. The authors conclude that in terms of symptoms and signs of erosive esophagitis in GERD, surgery was superior to conservative therapy and more cost-effective. No factors were found to predict the course of the disease.