Acceptable outcomes after fundoplication-different views are held by patients, GPs, and surgeons.

Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.

Impact of gender and age on the long-term outcome of laparoscopic fundoplication.

BACKGROUND: It has been suggested that gender and age could be factors that influence the likelihood of success following antireflux surgery, and our anecdotal impression has been that the outcome following Nissen fundoplication in older women is often disappointing. If correct, characterization of the extent of any differences in outcome might help patient selection and, hence, surgical outcomes. Therefore, in this study we investigated the impact of gender and age on longer-term clinical outcomes following laparoscopic fundoplication. METHODS: Perioperative and follow-up data from patients undergoing laparoscopic fundoplication in our departments have been collected prospectively and stored in a database. From the database, patients who had undergone either an anterior 180 degrees partial or 360 degrees total laparoscopic fundoplication for gastroesophageal reflux and completed 5 years clinical follow-up were identified. Patients were classified according to gender and age, and outcome data were analyzed to determine differences. Analog scales of 0-10 were used to determine symptoms of heartburn and dysphagia and overall satisfaction. RESULTS: Seven hundred three patients were studied (58% males). Females were less satisfied with the outcome (score = 7.8 +/- 2.8 vs. 8.4 +/- 2.5, P = 0.0036), and had higher scores for heartburn (2.0 +/- 2.7 vs. 1.2 +/- 2.2; P = 0.0001) and dysphagia for solid food (2.7 +/- 2.9 vs. 2.0 +/- 2.5, P = 0.0049) compared to males. Revisional procedures were undertaken more frequently in females (15.5% vs. 8.4%, P = 0.0038). Age had no impact on any clinical outcome. CONCLUSIONS: While the outcome for laparoscopic fundoplication is not influenced by age, the outcome for women is poorer than in males.

Laparoscopic stapled cardioplasty for end-stage achalasia.

INTRODUCTION: The standard of care for achalasia is laparoscopic Heller's cardiomyotomy. This procedure achieves satisfactory and long-standing results in over 85 % of patients. However, in 10-15 % of patients, esophageal function will progressively deteriorate, and up to 5 % will develop end-stage achalasia. Options in these difficult patients are limited, and include redo cardiomyotomy, repeat dilatation, and in severe cases, esophagectomy. METHODS: In this report, we describe an alternate approach, a cardioplasty, which was originally described by Heyrovsky in 1913. RESULTS: The development of an angulated stapling device now makes this operation feasible by a laparoscopic approach. CONCLUSION: This report highlights our technique for laparoscopic cardioplasty in patients with end-stage achalasia.

Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome--how I do it.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a well-described condition involving mechanical compression of the third part of the duodenum by the SMA and the aorta, resulting in proximal obstruction. DISCUSSION: Although there are a handful of case reports describing various techniques of laparoscopic duodenojejunostomy, a technique that involves creating the anastomosis in the infracolic compartment provides a more dependent stoma for the patient. CONCLUSION: This is a safe, effective, and relatively simple procedure for the experienced minimally invasive surgeon.

Laparoscopic Nissen fundoplication with anterior versus posterior hiatal repair: long-term results of a randomized trial.

BACKGROUND: Postoperative dysphagia in patients after Nissen fundoplication might be related to the technique used for the closure of the esophageal hiatus. METHODS: A total of 102 patients with gastroesophageal reflux were randomized to undergo laparoscopic Nissen fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. RESULTS: Clinical data at 5 years after surgery were available for 96% of patients enrolled in the trial. There was no significant difference between the 2 techniques for symptoms of dysphagia at the 5-year follow-up evaluation, although more patients who underwent posterior hiatal repair underwent further surgery for dysphagia-related symptoms (8 vs 2). Better control of heartburn was achieved in patients in the anterior hiatal repair group. Patients from both groups were equally satisfied with the overall outcome after surgery. CONCLUSIONS: At the 5-year follow-up evaluation, there was no significant difference in dysphagia between anterior closure and posterior hiatal repair.

Laparoscopic Nissen fundoplication: clinical outcomes at 10 years.

BACKGROUND: Laparoscopic Nissen fundoplication is now the most common operative procedure for treatment of gastroesophageal reflux disease, although longterm clinical outcomes after this procedure remain uncertain. STUDY DESIGN: Outcomes for 250 patients who underwent Nissen (total) fundoplication at least 10 years ago (September 1991 to August 1995) were determined prospectively using a structured questionnaire that evaluated clinical symptom scores for heartburn, dysphagia, and satisfaction with clinical outcomes. RESULTS: Clinical followup data for at least 10 years (120 to 167 months) after operation were available for 226 patients, an additional 21 patients had died, making outcomes for 247 patients (99%). Of the three (1%) remaining patients, one was lost to followup and dementia developed in two. One hundred eighty-seven (83%) patients were highly satisfied with the clinical outcomes. One hundred eighty-nine (84%) had good or excellent control of heartburn. Symptom scores for heartburn, dysphagia, and overall satisfaction were unchanged from 5-year followup data. Forty-two (17%) patients underwent revision operations, 28 (22%) were in the first 125 patients and 14 (11%) in the subsequent 125 patients. Antireflux medication use increased gradually, resulting in 47 (21%) patients using medication at 10 years. Of 21 deaths, 1 was postoperative and the remaining 20 were similar to that predicted for a matched population. A high preoperative heartburn score correlated with high patient satisfaction and lower dysphagia score at 10 or more years (p = 0.038 and p = 0.041, respectively). CONCLUSIONS: Laparoscopic Nissen fundoplication is an effective longterm treatment for gastroesophageal reflux disease.