Tanja Bammer

Five- to eight-year outcome of the first laparoscopic Nissen fundoplications.

The operative mortality and morbidity of laparoscopic fundoplication are lower than for the open procedure. Questions have been raised regarding its long-term durability. One hundred seventy-one patients who had undergone laparoscopic Nissen fundoplication at least 5 years previously answered a questionnaire. During this period, 291 patients underwent a laparoscopic Nissen fundoplication. Surveillance data were available for 171 patients at a mean of 6.4 years after surgery. Overall, 96.5% were satisfied and 3.5% were not satisfied with the result of the procedure. Persistent symptoms included abdominal bloating (20.5%), diarrhea (12.3%), regurgitation (6.4%), heartburn (5.8%) and chest pain (4.1%); 27.5% reported dysphagia, and 7% had required dilatation. Fourteen percent were on continuous proton pump inhibitor therapy, but 79% of these patients were treated for vague abdominal or chest symptoms unrelated to reflux, which calls into question the indications for this therapy. Ninety-three percent of all patients were satisfied with their decision to have surgery. The overall well-being score increased significantly from 2.2 ±1.6 before surgery to 8.8 ±2 (P >0.0001) at more than 5 years after surgery. Twenty-one percent had undergone additional diagnostic procedures after surgery such as endoscopy and/or barium swallow. Laparoscopic Nissen fundoplication is an excellent long-term treatment for gastroesophageal reflux disease with persistent success for more than 5 years. Some patients have continuing symptoms and remain on therapy, but more than 90% of all patients undergoing laparoscopic Nissen fundoplication remain satisfied with their decision to have surgery. These results are at least as good as those achieved with open fundoplication and prove the long-term worth of this procedure.

Predictability of dysphagia after laparoscopic nissen fundoplication.

OBJECTIVE:Dysphagia is the most common complication of antireflux surgery. Temporary dysphagia occurs in addition to persistent dysphagia because of technical or physiological problems. Temporary dysphagia may be due to the patients personal perception or faulty eating habits. The aim of this study was to investigate the impact of the patients personality as it relates to temporary dysphagia and individual impairment.METHODS:Several studies have used the construct of personality known as “health locus of control” to predict health-related behavior and convalescence after medical or surgical treatments. This study investigates the predictability of the subjective degree of dysphagia and its perceived degree of impairment in relation to the health locus of control after laparoscopic so-called “floppy” Nissen fundoplication in 90 patients. Several questionnaires and single-item questions were given to the patients preoperatively, and 1 wk, 6 wk, and 3 months after surgery. The answers to the questions provided the data for this study.RESULTS:Preoperatively, 92% of the patients had no dysphagia and 8% had a mild subjective degree of dysphagia. Temporary postoperative dysphagia was found in approximately 50% of the patients 1 wk after surgery. The intensity of the dysphagia ranged among mild (18%), moderate (15%), and severe (16%). Three months postoperatively about 80% had no dysphagia and only 2% severe dysphagia. Correlations between the construct of personality and the intensity of postoperative dysphagia and its impairment revealed a significant relationship at all times. Patients with high expectations for their own health-related abilities (internal control) had less dysphagia (r =−0.78 after 1 wk [p < 0.001], r =−0.71 after 6 wk [p < 0.001], and r =−0.64 after 3 months [p < 0.001]), compared with patients who believed that their convalescence depended more on luck, chance, or fate (external control) (r = 0.67 after 1 wk [p < 0.01], r = 0.72 after 6 wk [p < 0.001], and r = 0.63 after 3 months [p < 0.01]). These results are highly significant. The correlation between health locus of control and the degree of a subjective impairment from perceived dysphagia showed similar results (p < 0.01).CONCLUSIONS:The subjective degree of dysphagia and the perceived impairment as a result of laparoscopic antireflux surgery can be predicted according to the personality of the patient. Those patients with low expectations for their own abilities can be identified before surgery, thereby allowing adaptation techniques to be applied that could improve the results and well-being of patients after antireflux surgery.

Dysphagia and quality of life after laparoscopic Nissen fundoplication in patients with and without prostetic reinforcement of the hiatal crura

BackgroundRecurrent hiatal hernia with or without intrathoracic wrap migration (“slipping Nissen”) is one of the most common complications after laparoscopic Nissen fundoplication (LNF). Therefore, we decided to reinforce the hiatal crura using a prostetic mesh prothesis in an attempt to reduce recurrent hiatal hernia.MethodsThe current nonrandomized study compares the surgical outcome, including quality of life data [Gastrointestinal Quality of Life Index (GIQLI)] and subjective degree of dysphagia, in a total of 200 patients with (n=100) or without (n=100) mesh prothesis for a follow-up for at least 1 year.ResultsThere are no significant differences between groups in postoperative DeMeester score or lower esophageal sphincter pressure. In the group without mesh prothesis, in 6 cases laparoscopic redo surgery was necessary due to severe and persistent dysphagia (n=2) or a slipping Nissen (n=4). Additionally, in 5 patients we found recurrent hiatal hernia, but patients have been without symptoms for at least 1 year. In the group with mesh prothesis, laparoscopic refundoplication was performed in only 1 patient due to a slipping Nissen. In this group, recurrent hiatal hernia was not found in endoscopy. After laparoscopic antireflux surgery, GIQLI showed an equal improvement in both groups with an outcome comparable to that for healthy individuals. Postoperative dysphagia was significantly higher in the group with mesh prothesis within the 3 first months after surgery. One year after surgery no differences could be found.ConclusionsOur findings suggest that LNF with reinforcement of the hiatal crura reduces the risk of recurrent hiatal hernia with or without wrap migration. In addition, LNF with mesh prothesis improves patient’s quality of life significantly to the same level as that in patients without mesh prothesis. Postoperative dysphagia is higher in the early period after surgery, but this is only temporary. Long-term results of a randomized tiral must be obtained before a general standardization can be discussed.

ANTIREFLUX SURGERY: Indications, Preoperative Evaluation, and Outcome

Gastroesophageal reflux disease (GERD) is an extremely common disorder. Many patients require lifelong medical therapy for symptom control. In patients being considered for antireflux surgery, thorough evaluation is required. Laparoscopic antireflux surgery is a safe and effective method of treating patients who have severe, refractory, or complicated GERD. Excellent long-term results are obtained with minimal morbidity, freeing the patient from the burden of chronic medical therapy.

Redo laparoscopic surgery for achalasia

BackgroundOperative treatment of achalasia can fail in 10% to 15% of patients. No information is available on the outcome of laparoscopic reoperation for achalasia.MethodsData from patients undergoing redo surgery for achalasia were prospectively collected. The data were analyzed, and a questionnaire was sent to all the patients.ResultsEight patients underwent redo procedures at our institution between 1994 and 1998. The reasons for failure of the initial operations were incomplete myotomy (n=5), incorrect diagnosis (n=2), and new onset of reflux symptoms (n=1). All the redo procedures were performed laparoscopically. All the patients except one had excellent or good results. The average symptom severity score for dysphagia, regurgitation, chest pain, cough, and heartburn all improved after redo procedures. The average quality of life score improved from poor to good.ConclusionsLaparoscopic reoperation for achalasia is safe and feasible. It results in symptom improvement for most patients. Surgeon experience and recognition of the cause for failure of the original operation are most important in predicting the outcome.

LEBENSQUALITAT NACH LAPAROSKOPISCHER ANTIREFLUXCHIRURGIE : NISSEN-FUNDOPLICATIO

Summary.Purpose: During the last few years there has been an increasing interest in evaluating quality of life (QOL) data regarding surgical treatment. Methods: The present study comments the efficacy of laparoscopic antireflux surgery after required Nissen fundoplication of 70 patients. Therefore, the German Gastrointestinal Quality of Life Index (GIQLI) was used to query the patients preoperatively and three times after surgery up to 1 year. Results: Preoperatively, we found a low general GIQLI score (mean 92.7 points), which increased 6 weeks postoperatively (116.8 points), 3 months (124.8) and 1 year (mean 123.9 points) significantly and is now comparable to the healthy population (122.6 points). Conclusion: It is our opinion that the efficacy of the treatment of gastroesophageal reflux disease with required Nissen fundoplication can also be documented and discussed by using QOL.Zusammenfassung.Ziel: Innerhalb der letzten Jahre ist das Interesse an der Erfassung von Lebensqualitätsdaten zur Beurteilung chirurgischer Behandlungen gestiegen. Methode: Die vorliegende Studie beschreibt die Wirksamkeit der laparoskopischen Antirefluxchirurgie nach durchgeführter Floppy-Nissen-Fundoplicatio bei 70 Patienten mittels Lebensqualitätsdaten. Zur Erhebung der Lebensqualität wurde der Gastrointestinale Lebensqualitätsindex (GLQI) verwendet und präoperativ sowie zu drei postoperativen Meßzeitpunkten den Patienten vorgelegt. Ergebnisse: Präoperativ wurde ein geringer Lebensqualitätsindex erhoben (92,7 Punkte), welcher postoperativ nach sechs Wochen (116,8 Punkte), drei Monaten (124,8 Punkte) und nach einem Jahr (123,9 Punkte) signifikant anstieg und nunmehr vergleichbar zur Normalpopulation (122,6 Punkte) ist. Schlußfolgerung: Unserer Meinung nach kann die mittels Nissen-Fundoplicatio durchgeführte chirurgische Therapie der gastrooesophagealen Refluxerkrankung auch anhand von Lebensqualitätsdaten zum Nachweis der Effizienz dokumentiert und diskutiert werden.

Rationale for Surgical Therapy of Barrett Esophagus

Barrett esophagus has malignant potential and seems to be an acquired abnormality. It is associated with chronic gastroesophageal reflux disease and represents its severest form. The literature comparing medical treatment with antireflux surgery was reviewed. Questions regarding the advantages of surgery, who should undergo surgery, whether surgery can change the course of Barrett esophagus, the change in cancer risk, who needs surveillance, and cost-effectiveness were addressed. The incidence of developing Barrett cancer was 1 in 145 patient-years in reviewing 2032 patient-years of medical therapy compared with 1 in 294 patient-years in reviewing 4122 patient-years after surgery. Median follow-up time in the 2 groups was 2.7 years in the medically treated patients and 4.0 years in the surgically treated patients. Surveillance of Barrett esophagus is required irrespective of treatment. Laparoscopic antireflux surgery was found to be cost-effective after 7 years. Although these data do not prove that surgery is superior to medical treatment in the prevention of cancer related to Barrett esophagus, we found a tendency for surgery to be better than medical therapy to prevent the development and progression of Barrett carcinoma.

Use of Acid Suppressive Medications After Laparoscopic Antireflux Surgery: Prevalence and Clinical Indications

Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients. Despite this high success rate, some patients continue to consume acid suppressive medications after surgical intervention. In this study we evaluate the prevalence, clinical indications, and cause of use of acid reducing drugs in patients after LARS. Consecutive patients undergoing LARS for GERD were surveyed 2–3 years after surgery regarding use of acid suppressive medications, surgical outcome, and GERD specific symptoms. During the study period, 119 patients underwent LARS at our center. Ninety-eight (82%) were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 94 individuals are the subject of this report. Ninety-four percent were satisfied with the outcome of surgery. Despite this high satisfaction rate, 37 of 94 (39%) were on antireflux medication (ARM; 62% proton pump inhibitors, 22% H2-receptor antagonists, and 16% others), with 70% using continuous medication. Of these patients, 54% took ARM after surgery for GERD-related symptoms, 95% of these patients responded to medical therapy, and yet again, 85% remained satisfied with the surgical outcome. Forty-six percent of patients on ARM after surgery had no GERD symptoms and took ARM for nonappropriate indications such as bloating. Only 47% of these responded to ARM; 82% of this group was satisfied with the surgical outcome. In conclusion, the use of ARM after LARS is a common occurrence despite a high satisfaction rate with this operation. Nearly half of patients consuming ARS after LARS are taking these medications for symptoms not necessarily related to GER. These findings underscore the importance of patient education in the use of these agents.

Safety and long-term outcome of laparoscopic antireflux surgery in patients in their eighties and older

BACKGROUND The elderly have more severe reflux disease and paraesophageal hernias than younger patients, leading to a high failure rate of medical therapy. Laparoscopic antireflux surgery has an overall mortality of 0.1% and a low morbidity, making it a safe and beneficial procedure for the elderly. METHODS We performed a retrospective study of octo- and nonogenerians with a mean follow-up of 3.1 years after laparoscopic fundoplication. Thirty (3.5%) patients who were in their eighties or older are reported. Preoperative symptoms, esophageal testing, postoperative symptoms, and satisfaction rate were analyzed. RESULTS Fifty-seven percent of patients had paraesophageal hernias. Mean duration of procedures was 146 +/- 49 min, blood loss was 76 +/- 101 ml, and hospitalization was 2.2 +/- 1.0 days. There was one conversion to laparotomy, two intraoperative complications, and no deaths. Follow-up data were available in 93% of patients. Mean follow-up time was 3.1 years. Two died of unrelated causes. At follow-up 96% stated that their surgical outcome was satisfactory. Two patients were suffering from severe symptoms. Overall well-being at follow-up was 7.5 (range 3-10) on a 10-point scale in comparison to 2.2 (range 1-5) before surgery (p = 0.03). CONCLUSION Laparoscopic surgery is a good option for the treatment of severe gastroesophageal reflux disease in octo- and nonagenarians.

Treatment of achalasia: recent advances in surgery.

Achalasia is an uncommon motility disorder of the esophagus with an uncertain etiology. Considerable debate exists regarding the most effective treatment for long-term relief of symptoms. For decades, pneumatic dilatation has been the primary treatment option, and surgery was reserved for patients who required repeated dilations or for those who were not willing to undergo the risk of perforation associated with dilatation. Recently botulinum toxin injection of the lower esophageal sphincter has been shown to provide substantial short-term relief from dysphagia; however, its effect only lasts for a short period of time. Recently, minimally invasive surgical techniques have been developed to perform a Heller myotomy effectively with an antireflux procedure. This has become a primary treatment option for many patients. We present a review of the outcome of different therapeutic options of achalasia with a special focus on laparoscopic procedures.