Inoperable adenocarcinoma of the oesophagogastric junction: a comparative clinical study of laser coagulation versus self-expanding metallic stents with special reference to cost analysis.

AIMS: Neither clinical nor financial comparisons yet exist between self-expanding metallic stents (SEMS) and laser therapy, concentrating on the treatment of obstructive adenocarcinomas of the oesophagogastric junction. The aim of our study was to compare the relative lifetime costs and clinical results of the Nd:YAG laser to those of SEMS as alternative forms of primary palliation of dysphagia for adenocarcinoma near the oesophagogastric junction. METHODS: Fifty-two patients with distal oesophageal or oesophagogastric adenocarcinomas underwent palliative treatment for dysphagia: 32 treated with laser therapy and 20 with SEMS in this retrospective study. The clinical outcome and real cumulative costs as physical units and in financial terms were analysed for these study groups. RESULTS: Although patients palliated with SEMS underwent fewer procedures (1.9+/-1.6 vs 3.4+/-4.0, P=0.0048) and spent less time in endoscopic theatre (38+/-25min vs 118+/-152min, P=0.0048), they spent as many days in hospital (12.9 vs 15.1, P=0.370) and required as high overall costs for therapy (5360 EUR vs 5450 EUR, P=0.679) as those treated with laser therapy. In addition, they had higher morbidity rates (30 vs 6.3%, P=0.043), hospital mortality (20 vs 3.1%, P=0.066), and 30-day mortality (40 vs 3.1%, P=0.0011) than did patients with laser therapy, with no evidence of SEMS being the more effective treatment modality. CONCLUSIONS: In patients with adenocarcinoma at the distal oesophagus or at the oesophagogastric junction, laser therapy palliates dysphagia effectively with lower morbidity and mortality rates and without increased costs or hospital stays than does use of self-expanding metallic stents.

The long term results of open antireflux surgery in a community-based health care center.

OBJECTIVE: 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.

Randomized trial to study the effect of fundic mobilization on long-term results of Nissen fundoplication.

BACKGROUND: It has been suggested that fundic mobilization in Nissen fundoplication decreases adverse postoperative symptoms and increases the durability of the fundic wrap. There are no previous randomized, prospection long-term studies assessing this. This study addresses the question. METHODS: Fifty consecutive patients were randomized to undergo open Nissen-Rossetti fundoplication with total fundic mobilization (n == 26) or an identical procedure without mobilization (n == 24). After a median of 36 (range 6-53) months 49 had endoscopy and a personal interview. RESULTS: Oesophagitis was cured in 20 of 21 patients who had fundic mobilization and 18 of 19 who did not. a defective fundic wrap was observed in five and recurrent reflux symptoms in six of those who had fundic mobilization compared with two and one respectively of those who did not (P not significant). Recurrent sliding hiatal hernia was observed in nine of those with a mobilized fundus and one of those without (P == 0.02). There was no significant difference in incidence of new-onset long-term dysphagia, subjective belching ability, amount of flatus or bloating between the study groups. CONCLUSION: Fundic mobilization did not give any apparent advantage regarding postoperative adverse effects. Instead, it was associated with a higher rate of recurrent hiatal hernia.

Surgical experience improves the long-term results of Nissen fundoplication.

BACKGROUND: Nissen fundoplication relieves symptoms of gastro-oesophageal reflux and effectively heals oesophagitis. During long-term follow-up some cases of recurrent reflux are seen. We investigated the possibility that long-term cure of gastro-oesophageal reflux after fundoplication is influenced by the surgeon's experience and focused interest, in line with results of surgery for rectal, gastric, and breast cancer. METHODS: One hundred and five consecutive patients were evaluated a median of 77 months after open Nissen-Rossetti fundoplication for erosive oesophagitis. Follow-up included personal interviews and upper gastrointestinal endoscopy by an investigator not previously involved in the patients' treatment. The surgeons were classified as experienced (>10 of the operations in the series), less experienced (<10 operations), or trainees. RESULTS: Of the most experienced surgeons' patients, 97% had no or at most mild reflux symptoms at follow-up, compared with 88% of the of less experienced surgeons' patients (P = 0.04). Healing of erosive oesophagitis was commoner when the operations were performed by experienced specialist surgeons (88% versus 72%; P = 0.04). The reoperation rate fell as the surgeons' experience increased, from 12% to 4%. CONCLUSIONS: Surgery for gastro-oesophageal reflux should be centralized to units specializing in the techniques and with sufficient annual numbers of operations to optimize results. This policy becomes especially advisable as laparoscopic surgery increases the numbers of treated patients.

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 Barrett's 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.

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.

Effect of fundal mobilisation in Nissen-Rossetti fundoplication on oesophageal transit and dysphagia. A prospective, randomised trial.

OBJECTIVE: To assess the effect on postoperative dysphagia and oesophageal transit of fundal mobilisation during Nissen-Rossetti fundoplication. DESIGN: Prospective, randomised study. SETTING: University Hospital, Finland. SUBJECTS: 20 consecutive patients with confirmed gastro-oesophageal reflux who were referred for antireflux surgery. INTERVENTIONS: Fundoplication with either conventional Nissen-Rossetti procedure or an otherwise identical technique incorporating total fundal mobilisation (n = 10 in each group). MAIN OUTCOME MEASURES: Recurrent or persistent symptoms of dysphagia, and the oesophageal transit time of a liquid bolus labelled with radioactive nuclide. RESULTS: In both groups excellent relief of heartburn and regurgitation was achieved (only 2 patients in each group reported occasional symptoms), one patient had oesophagitis, and the pH returned to the normal range. The incidence of dysphagia was similar in both groups by 6 months postoperatively, but there was significant, though transient, impairment of oesophageal transit after findal mobilisation (p = 0.03). CONCLUSIONS: Fundal mobilisation did not seem to confer any advantage as fas as the incidence of postoperative dysphagia was concerned. On the contrary, it was associated with transient disturbance in the oesophageal transit time of a liquid bolus. Longer follow up is needed to show if this impairment is of any clinical relevance.

Refundoplication for recurrent gastroesophageal reflux.

Reoperation after a failed antireflux procedure is a surgical challenge. Many operative techniques have been proposed, but reports on systematic follow-up with endoscopy and esophageal function tests are few. The purpose of the present study was to evaluate the results of repeated fundoplication in cases of recurrent reflux, including assessment of esophageal function. Of the 18 cases of repeat fundoplication performed for recurrent reflux during 1970-1991 at Tampere University Hospital, 15 were evaluated a median of 18 (range 5-152) months after reoperation. Follow-up studies included endoscopy in all and esophageal function tests (esophageal 24-hour pH recording, manometry, and radionuclide transit) in 14 cases. All the patients had defective fundic wrap before reoperation, whereas at follow-up 12 of the 15 wraps were intact. Reflux symptoms were diminished in all 15. Six patients (40%), however, had objective recurrence of reflux (esophagitis or pathologic pH recording). Three of the recurrences were due to slipped fundic wrap, but the others were probably caused by impaired esophageal function. By repeat fundoplication the wrap could be repaired as reliably as in primary operation. Symptomatic outcome and objective results were reasonable. The results were, however, not as good as after primary operation, which was due to more impaired esophageal motility caused by prolonged reflux or repeated surgery (or both).