Bariatric Surgery After Previous Antireflux Surgery Without Takedown of the Previous Fundoplication: a Prospective Study.

BACKGROUND: The increased prevalence of reflux disease in obese patients, combined with widespread availability of laparoscopic antireflux surgery, has increased the likelihood that more patients will seek bariatric surgery having previously undergone fundoplication. OBJECTIVES: This study examined our series of laparoscopic bariatric surgery after previous antireflux surgery without takedown of the previous fundoplication. We discuss our results, our technique and the tips and tricks to avoid complication after this procedure. SETTING: Private practice. METHODS: We operated on patients suffering from obesity who had already undergone laparoscopic Nissen. The patients were eligible for bariatric surgery according to the French National Institute of Health's criteria for bariatric surgery. The pre-operative assessment involved gastroscopy with biopsies looking for Helicobacter pylori, oesophago-gastroduodenoscopy, investigation for sleep apnoea syndrome and a full laboratory assessment. The patients took part in their choice of surgery. RESULTS: The patients' post-operative course was uncomplicated. No patients had symptoms of gastro-esophageal reflux late after surgery and good gastrointestinal comfort was achieved (no pain, no reflux). All of the patients were satisfied. Length of stay was 3 to 5 days. All patients exhibited significant weight loss. CONCLUSION: Bariatric surgery is possible after fundoplication without taking down the fundoplication. It appears to be a viable alternative in patients seeking weight loss surgery after fundoplication, which is currently assumed contraindicated.

Flatulence After Anti-reflux Treatment (FAART) Study.

BACKGROUND: Flatulence is known to be a common side effect of laparoscopic fundoplication, yet the true incidence is unclear and its impact on patients' quality of life not well understood. This study aimed to assess the long-term incidence of flatulence, and its effect on quality of life, following fundoplication. METHODS: All patients who underwent primary laparoscopic fundoplication between 1999 and 2009 were identified from a prospectively maintained institutional database. A cross-sectional analysis of post-operative gastrointestinal symptoms and quality of life was performed using a symptom-specific questionnaire. Statistical analysis of outcomes stratified by sex and type of fundoplication was performed. RESULTS: 462 eligible patients were identified from the database, with follow-up obtained in 265 (57%). Median age at surgery was 53 (22-78) years. 137 patients (52%) were female. 138 (52%) underwent a 360° fundoplication, the remainder a partial fundoplication. At median follow-up of 11 (8-15) years, excessive flatulence was reported by 85%. Only 12% reported an adverse impact on social life, and 11% an adverse impact on quality of life. Flatulence was worse following a total than partial fundoplication, women reported more gas-related symptoms than men, yet neither sex nor wrap type had a significant impact on social life or quality of life. CONCLUSIONS: The majority of patients report excessive flatulence at long-term follow-up after anti-reflux surgery, yet the impact on social life and quality life was small. There was no evidence to support tailoring of wrap type by sex to avoid gas-related symptoms. The authors advocate that all patients understand the inevitable side effects of fundoplication to help manage expectations from surgery.

Outcome of medical and surgical therapy of GERD: predictive role of quality of life scores and instrumental evaluation.

INTRODUCTION: Aim of this study is to determine whether quality of life (QoL) assessment in association with instrumental evaluation can help to identify factors predictive of outcome both in surgically and medically treated GERD patients. METHODS: Between January 2005 and June 2010, 301 patients affected with GERD were included in the study. QoL was evaluated by means of GERD-HRQL and SF-36 questionnaires administered before treatment, at 6 months, at 1 year follow-up and at the end of the study. The multivariate analysis was used to detect if variables such as sex, age, heartburn, acid regurgitation, dysphagia, presence of esophagitis, percentage of total time at pH < 4, symptom index score (SI), the SF-36 and HRQL scores before treatment, at 6 months and 1 year could affect the QoL questionnaires scores at the end of the study. RESULTS: One hundred forty-seven patients were included in the surgical group and 154 in the medical group. No differences with regard to gender, age, mean SF-36 and HRQL scores before treatment were documented. At the end of the study, quality of life was significantly improved for SF-36 and HRQL scores, either for surgical or medical group. The multivariate analysis showed no factors individually affected the SF-36 and the HRQL scores, but symptom index score (SI) and QoL questionnaires scores at 6 months and 1 year follow-up. CONCLUSIONS: The combined use of pHmetry with evaluation of SI and QoL questionnaires can predict the outcome of GERD patients managed either by medical or surgical therapy.

Mechanisms of acid, weakly acidic and gas reflux after anti-reflux surgery.

BACKGROUND: Whereas it is well documented that fundoplication reduces acid reflux, the effects of the procedure on non-acid and gas reflux and the mechanisms through which this is achieved have not been fully elucidated. METHODS: In 14 patients, reflux was measured with impedance-pH monitoring during a postprandial 90 min stationary recording period before and 3 months after fundoplication. Concomitantly, the occurrence of transient lower oesophageal sphincter relaxations (TLOSRs) and morphology of the oesophagogastric junction were studied with high-resolution manometry. This was followed by 24 h ambulatory impedance-pH monitoring. RESULTS: Before fundoplication, two separate high-pressure zones (hernia profile) were detected during 24.9% of total time, during which there was a large increase in reflux rate. After fundoplication, the hernia profile did not occur. Fundoplication decreased the number of TLOSRs (from 10.5 (SEM 1.2) to 4.5 (0.7), p<0.01) and also the percentage of TLOSRs associated with acidic or weakly acidic reflux (from 72.7% to 4.1%, p<0.01). Nadir pressure during TLOSRs increased after surgery (from 0 (0-0) to 1.0 (1-2) kPa, p<0.05). In the ambulatory study, there was a large decrease in prevalence of both acid (-96%, from 47.0 (5.9) to 1.8 (0.5), p<0.01) and weakly acidic reflux (-92%, from 25.0 (9.7) to 2.3 (0.9), p<0.01). The decrease in gas reflux was less pronounced (-53%, from 24.2 (4.9) to 11.3 (3.0), p<0.01). CONCLUSIONS: Fundoplication greatly reduces both acid and weakly acidic liquid reflux; gas reflux is reduced to a lesser extent. Three mechanisms play a role: (1) abolition of the double high-pressure zone profile (hiatal hernia); (2) reduced incidence of TLOSRs; and (3) decreased percentage of TLOSRs associated with reflux.

Using quality-of-life instruments to measure outcome after laparoscopic fundoplication.

AIM: This article describe the symptomatic outcome of antireflux surgery in 56 consecutive patients in a single-centre, single-surgeon study--measured by previously validated, generic, and disease-specific quality-of-life instruments. METHODS: In this retrospective study, data was collected from the case records of patients and postal questionnaires. The quality-of-life instruments used were the global quality of life (GQOL) scale; gastroesophageal reflux disease health related quality of life (GERD-HRQL) scale; and the gastrointestinal symptom rating score (GSRS), self-administered version. Paired student t test and Wilcoxon signed rank test were used to analyse the data. RESULTS: The response rate to our postal questionnaire was 100%. The male:female ratio was 1:1.4 and the age range was from 19 to 71 years. The operative technique was either a 'total 360 degree wrap' (47 patients) or a partial posterior fundoplication (270 degree wrap) based on the DeMeester technique. The median follow-up time was 36 months. The mean hospital stay post procedure was 2.3 days. Our results showed good satisfaction rates (80%) and recommendation rates (93%). Best results were achieved in the subgroup of older (over 50 years of age) males. The side-effect profile was comparable to that reported in literature.

Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease.

BACKGROUND: The aim of this study was to compare laparoscopic and open Nissen fundoplication for gastro-oesophageal reflux disease in a randomized clinical trial. METHODS: Ninety-nine patients were randomized to either laparoscopic (52) or open (47) Nissen fundoplication. Patients with oesophageal dysmotility, those requiring a concurrent abdominal procedure and those who had undergone previous antireflux surgery were excluded. Independent assessment of dysphagia, heartburn and patients' satisfaction 1, 3, 6 and 12 months after surgery was performed using multiple standardized clinical grading systems. Objective measurement of oesophageal acid exposure and lower oesophageal sphincter pressure before and after surgery, and endoscopic assessment of postoperative anatomy, were performed. RESULTS: Operating time was longer in the laparoscopic group (median 82 versus 46 min). Postoperative pain, analgesic requirement, time to solid food intake, hospital stay and recovery time were reduced in the laparoscopic group. Perioperative outcomes, postoperative dysphagia, relief of heartburn and overall satisfaction were equally good at all follow-up intervals. Reduction in oesophageal acid exposure, increase in lower oesophageal sphincter tone and improvement in endoscopic appearances were the same for the two groups. CONCLUSION: The laparoscopic approach to Nissen fundoplication improved early postoperative recovery, with an equally good outcome up to 12 months.