P. A. Game

Five‐year follow‐up of a randomized clinical trial of laparoscopic total versus anterior 180° fundoplication

Total fundoplication for gastro‐oesophageal reflux disease may be followed by unwanted side‐effects. A randomized trial demonstrated that an anterior 180° partial fundoplication achieved effective reflux control and was associated with fewer side‐effects in the short term than total fundoplication. This paper reports longer‐term (5 year) outcomes from that trial.

Ten‐year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180° partial fundoplication

A randomized trial of laparoscopic Nissen fundoplication and anterior 180° partial fundoplication was undertaken to determine whether the anterior procedure might reduce the incidence of dysphagia and other adverse outcomes following surgery for gastro‐oesophageal reflux disease. This study evaluated clinical outcomes after 10 years.

Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations

From September 1991 to January 1995 we performed 230 Nissen fundoplications by a laparoscopic technique. Whilst a loose 360° fundoplication secured by 3 or 4 sutures was performed in all instances, there was variation between surgeons regarding the performance of hiatal repair and division of short gastric vessels; 207 operations were completed laparoscopically and 23 were converted to an open operation when a satisfactory wrap could not be achieved. Operating time ranged from 30 to 260 min (median 95) and the median postoperative stay was 3 days (1–19).Twenty-three patients (10%) underwent a subsequent operation (14 within 3 months of the original surgery), 2 for recurrent reflux, 10 for para-esophageal herniation, 2 for a misplaced fundoplication resulting in gastric obstruction, 7 for persistent dysphagia (4 due to stenosis of the esophageal hiatus), 1 for bleeding, and 1 for mesenteric thrombosis. (This patient died.) Five other patients were readmitted to hospital subsequent to their discharge—four because of pulmonary emboli and one because of gastric obstruction. Some 226 patients (98%) are free of reflux symptoms with follow-up ranging up to 40 months (median 16). Absence of reflux and the integrity of the fundoplication has been confirmed by postoperative esophageal manometry and pH monitoring in 90 patients, and by barium meal in 126.Postoperative recovery has been quick and wound-related morbidity minimal. Although the rate of surgical revision was significant in this series, the likelihood of complications or further surgery, as well as incidence of conversion to open surgery, decreased in the second half of the experience. Strategies developed to improve the outcome now include routine posterior closure of the hiatus, early postoperative barium-meal examination, and minimization of diathermy dissection. A loose fundoplication is always constructed over a large bougie. The need for division of the short gastric vessels in laparoscopic fundoplication remains controversial and awaits the outcome of a randomized trial.

Laparoscopic resection of benign tumors of the posterior gastric wall

Laparoscopic wedge excision of benign gastric tumors using stapling instruments alone is not feasible for distal lesions and some tumors arising from the posterior gastric wall. An alternative transgastric approach to distal posterior wall lesions utilizing an anterior gastrotomy for access has been successfully applied in two reported cases.

Early reoperation following laparoscopic antireflux surgery.

PURPOSE To assess the outcome for patients undergoing early reoperation following laparoscopic antireflux surgery. METHODS The outcome was prospectively determined for 28 patients who underwent 30 reoperative procedures within 4 weeks of their initial laparoscopic fundoplication between 1992 and 1998. Follow-up ranged from 3 months to 4 years (median 2 years). Before mid 1994, patients were assessed and managed based on clinical findings (first 192 patients in overall series), whereas subsequently (for the most recent 530 patients) all patients underwent routine early postoperative barium swallow radiography, and laparoscopic exploration during the first postoperative week if problems were suspected. RESULTS The reoperations were performed for acute paraoesophageal hiatus hernia (8 patients), tight oesophageal hiatus (7), postoperative haemorrhage (3), tight Nissen fundoplication (8), early recurrent reflux (1), and coeliac/superior mesenteric artery thrombosis (1). Two patients required a second operation for persistent dysphagia due to a tight hiatus. Both patients initially underwent loosening of their fundoplication. Before mid 1994, reoperations were usually undertaken by an open approach, whereas subsequently a laparoscopic approach has usually been successful. Laparoscopic reintervention was easily achieved within 7 days of the first procedure whereas subsequent surgery was more difficult and often required open surgery. The change in protocol was associated with an improvement in overall patient satisfaction and dysphagia in the latter part of this experience. CONCLUSIONS Routine early contrast radiology following laparoscopic fundoplication and a low threshold for laparoscopic reexploration facilitates early identification of postoperative problems at a time when laparoscopic correction is easily achieved. This may result in an improved overall outcome for patients requiring early reintervention following laparoscopic antireflux surgery.

Hand-assisted laparoscopic vertical banded gastroplasty. Initial report.

Abstract. Laparoscopic approaches to surgery for morbid obesity offer to reduce the morbidity associated with conventional weight reduction surgery. This paper describes a hand-assisted laparoscopic technique for vertical banded gastroplasty, a method which shortens and simplifies the laparoscopic approach to this established open surgical procedure.