The effect of obesity on the outcome of laparoscopic antireflux surgery.

BACKGROUND: Obesity has long been considered to be a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery. This study examined the effect of body mass index (BMI) on clinical outcomes following laparoscopic antireflux surgery. METHODS: Patients were included if they had undergone a laparoscopic fundoplication, their presurgical BMI was known, and they had been followed for at least 12 months after surgery. The clinical outcome was determined using a structured questionnaire, and this was applied yearly after surgery. Patients were divided into four groups according to BMI: normal weight (BMI < 25), overweight (BMI 25-29.9), obese (BMI 30-34.9), and morbidly obese (BMI > or = 35). The most recent clinical outcome data was analyzed for each BMI group. RESULTS: Patients, 481, were studied. One hundred three (21%) had a normal BMI, 208 (43%) were overweight, 115 (24%) were obese, and 55 (12%) were morbidly obese. Mean follow-up was 7.5 years. Conversion to an open operation and requirement for revision surgery were not influenced by preoperative weight. Operating time was longer in obese patients (mean 86 vs 75 min). Clinical outcomes improved following surgery regardless of BMI. CONCLUSIONS: Preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery. Obesity is not a contraindication for laparoscopic fundoplication.

Prevalence of symptoms and use of medication for gastroesophageal reflux in an Australian community.

INTRODUCTION: Gastroesophageal reflux disease is common in Western societies, although the prevalence of reflux symptoms in the community is not well described. In this study we determined the prevalence of symptoms of gastroesophageal reflux and other "esophageal" symptoms, and the consumption of medication for reflux in an Australian community. PATIENTS AND METHODS: A population sample designed to accurately reflect the characteristics of the population aged 15 years or older in the State of South Australia was studied. Demographic data; symptoms specific to reflux, dysphagia, and abdominal bloating; and the consumption of antireflux medication were determined in a face-to-face interview. The frequency and severity of heartburn and dysphagia were assessed with analog scales. RESULTS: A total of 2,973 people (age range: 15-95 years) were interviewed between September and December 2006. Approximately half experienced the symptom of heartburn; 21.2% experienced heartburn at least once a month, and 12.4% described frequent symptoms of heartburn (at least a few times each week). Of those with heartburn, 25.0% graded it as moderate or severe, 10.9% reported some dysphagia for solid foods, and 6.9% reported dysphagia for liquids. 3.7% described dysphagia for solids at least once a month. Abdominal bloating was reported by 48.2%. 16.9% were taking medications for reflux symptoms (10.1% proton pump inhibitors, 1.2% H2-receptor antagonists, 2.1% simple antacids, 3.4% alternative medications). Heartburn was more common in individuals who consumed medication. There were significant associations between heartburn and bloating, and between heartburn and dysphagia. CONCLUSIONS: Symptoms of gastroesophageal reflux and the use of medications to treat such symptoms are very common in the community of South Australia. Nearly 1 in 7 people over the age of 15 consume medication for the treatment of symptoms of reflux.

Laparoscopic anterior 90 degree fundoplication for reflux or large hiatus hernia.

Anterior 90 degree partial fundoplication has been proposed as technique to minimize the risk of side-effects following surgery for gastro-oesophageal reflux. We have applied this approach for the treatment of gastro-oesophageal reflux and/or large hiatus hernias. Previous studies have shown that this type of procedure can achieve good control of reflux, with fewer side-effects. However, only short-term follow up has been reported. In this study, we determined later clinical outcomes in patients who have undergone this procedure. All patients who underwent a laparoscopic anterior 90 degree partial fundoplication surgery were identified from a database, which collected prospective clinical data. Patients completed a standardized questionnaire 3 months after surgery and then yearly to assess clinical symptoms of reflux and postoperative side-effects. Between February 1999 and January 2006, 246 patients underwent surgery--74 in conjunction with repair of a large hiatus hernia and 172 for reflux. Three patients underwent further surgery within 2 days of the original procedure (one for repair of a perforated oesophagus) and four underwent later surgical revision (reflux 3, dysphagia 1). Clinical follow-up data were available for 98% at 3-84 months (median 36). Most patients had effective relief of reflux symptoms at up to 3 years follow up. Dysphagia scores improved following surgery. The magnitude of this improvement was greater in patients with large hiatus hernias. More than 80% of the patients were able to belch normally at all time points after surgery and most were highly satisfied with the overall outcome. Satisfaction scores were higher following repair of a large hiatus hernia. The clinical results of laparoscopic anterior 90 degree fundoplication for either reflux or as part of repair of a large hiatus hernia are encouraging, although longer-term follow up is required to confirm durability of reflux control.

Randomized trial of division versus nondivision of the short gastric vessels during laparoscopic Nissen fundoplication: 10-year outcomes.

BACKGROUND: Although laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastroesophageal reflux, in some patients it is followed by troublesome side effects, such as dysphagia, abdominal bloating, and inability to belch. It has been claimed that dividing the short gastric blood vessels during laparoscopic Nissen fundoplication minimizes the risk of these problems. We have previously reported the 6-month and 5-year outcomes from a randomized trial, which have shown no advantages after division of these vessels. In this study, we determined the longer-term (10 years) outcomes from this trial. METHODS: From May 1994 to October 1995, 102 patients with gastroesophageal reflux disease who underwent a laparoscopic Nissen fundoplication were entered into this randomized trial (vessels divided in 50, not divided in 52). At 10-year follow-up, 88 patients provided clinical follow-up information. Follow-up was obtained by telephone interview conducted by an independent and blinded investigator who applied a standardized questionnaire. RESULTS: At 10-year follow-up no significant differences between the 2 groups could be identified. Heartburn, dysphagia, and overall satisfaction were similar for both study groups. CONCLUSIONS: The 10-year clinical outcomes from this trial have shown no benefit for division of the short gastric vessels during laparoscopic Nissen fundoplication.

Use of antireflux medication after antireflux surgery.

INTRODUCTION: It is claimed that a substantial number of patients who undergo antireflux surgery use antireflux medication postoperatively. This study was aimed to determine the prevalence and underlying reasons for antireflux medication usage in patients after surgery. MATERIALS AND METHODS: A questionnaire on the usage of antireflux medication was sent to 1,008 patients identified from a prospective database of patients who had undergone a laparoscopic antireflux procedure. RESULTS: A total of 844 patients (84%) returned the questionnaire. Mean follow-up was 5.9 years after surgery. A single or combination of medications was being taken by 312 patients (37%): 82% proton pump inhibitors, 9% H2-blockers and 34% antacids. Fifty-two patients (17%) had never stopped taking medication, whereas 260 patients (83%) restarted medication at a mean of 2.5 years after surgery. Return of the same (31%) or different (49%) symptoms were the commonest reasons for taking medication, whereas 20% were asymptomatic or had other reasons for medication use. Postoperative 24-hour pH studies were abnormal in 16/61 patients (26%) on medication and in 5/78 patients (6%) not taking medication. CONCLUSIONS: Antireflux medication is frequently taken by many patients for various symptoms after antireflux surgery. Symptomatic patients should be properly investigated before antireflux medications are prescribed.

Esophageal manometry and clinical outcome after laparoscopic Nissen fundoplication.

INTRODUCTION: The outcome after laparoscopic Nissen fundoplication can be assessed by either clinical symptoms or objective tests. Outcomes from objective tests are often held in higher regard than clinical data when determining the merits, or otherwise, of various antireflux surgery procedures. In this study, we sought to determine whether there is a relationship between postoperative symptoms and parameters measured by esophageal manometry to determine whether early postoperative esophageal manometry is a useful investigation for the routine assessment of post fundoplication outcome. METHODS: One hundred and forty-three patients who had undergone a laparoscopic Nissen fundoplication, clinical follow-up at 3 months and 5 years after surgery, and esophageal manometry at 3 months after fundoplication as part of routine follow-up in 1 of 5 clinical trials were studied. Nineteen of these patients also underwent manometry 5 years after fundoplication. Postoperative symptoms were prospectively determined by applying a standardized questionnaire, which assessed dysphagia, heartburn, bloat symptoms, and overall satisfaction using analog scales. Patients were classified into different groups according to the analog scores for clinical symptoms. Correlations between clinical and postoperative manometry outcomes were sought. RESULTS: No significant associations were found between parameters measured by esophageal manometry (lower esophageal sphincter resting and residual relaxation pressures, peristaltic amplitude and normal peristaltic propagation) and clinical parameters (dysphagia, heartburn, bloating, and overall satisfaction) for all time points -- 3 months postoperative manometry vs symptoms at 3 months and 5 years, 5 years postoperative manometry vs symptoms at 5 years, except for a weak (r = -0.17, p = 0.042) correlation between the percentage of successfully propagated swallows at 3 months and dysphagia for solids at 5 years. CONCLUSION: Postoperative esophageal manometry parameters at 3 months and 5 years after surgery were not associated with any clinically important differences in the postoperative symptoms of heartburn, dysphagia, bloat or with overall satisfaction with the surgical outcome. The routine use of esophageal manometry to assess the outcome after Nissen fundoplication does not predict clinical outcome.

Laparoscopic cardiomyotomy for achalasia: long-term outcomes.

BACKGROUND: Although the laparoscopic approach to oesophageal myotomy for achalasia is associated with reduced early postoperative morbidity compared with the open approach, most published reports describe relatively short-term follow up. For this reason, in a prospective cohort study, we determined the longer-term outcome for patients with uncomplicated achalasia who underwent a laparoscopic myotomy. In addition, we sought to identify preoperative factors predicting a good postoperative outcome. METHODS: The outcome for 167 patients who underwent a laparoscopic cardiomyotomy and anterior partial fundoplication at one of two teaching hospitals was determined. All patients underwent preoperative assessment with a contrast swallow radiology, gastroscopy and oesophageal manometry. Patients also underwent objective symptom evaluation before and after surgery using various outcome scales to determine dysphagia, reflux symptoms, side-effects and overall satisfaction with the clinical outcomes. Patients were followed prospectively at yearly time points and data were managed on a computerized database. Postoperative objective investigations were undertaken if clinically indicated. RESULTS: Median operating time was 78 min (range, 30-210 min). Most patients left the hospital within 72 h of surgery. Surgery was associated with a 5% complication rate and a 4% rate of conversion to open surgery. Five per cent of patients required a subsequent intervention during follow up. Over longer-term follow up (5 years or longer), 77% of patients had either no or minimal symptoms. At 1, 3 and 5 years, 96, 93 and 97% of patients indicated that they thought that they had made the correct decision to undergo surgery, although men consistently fared worse on their reported dysphagia outcome across a range of measures. CONCLUSION: Laparoscopic myotomy with anterior partial fundoplication achieves a good outcome for patients undergoing treatment of achalasia. Male patients do not perceive their outcome to be optimal in comparison with females but in the long term, they do not regret proceeding.

Single center prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees fundoplication.

Although Nissen fundoplication is a very effective treatment for gastroesophageal reflux, it is associated with a small incidence of troublesome postoperative side effects. To prevent this, progressive modification of surgical techniques has led to the development of an anterior 90 degrees fundoplication. We undertook a prospective randomized trial to compare this procedure with Nissen fundoplication to determine whether it would achieve a better clinical outcome. Patients presenting to a single center for primary laparoscopic antireflux surgery were randomized to undergo either an anterior 90 degrees fundoplication (n = 40) or a Nissen fundoplication without division of the short gastric vessels (n = 39). Clinical questionnaires were used to assess outcome at 1 month, 3-6 months, and 12 months. Both patients and the clinical interviewer were masked as to which procedure was performed. Follow-up with endoscopy, esophageal manometry, and pH monitoring was also undertaken. Operating time was similar for the two procedures (60 minutes for anterior vs. 55 minutes for Nissen fundoplication). Early postoperative complications were more common after Nissen fundoplication (18% vs. 5%). Two patients underwent laparoscopic reoperation for recurrent reflux after anterior 90 degrees fundoplication, and four underwent laparoscopic reoperation after Nissen fundoplication (dysphagia, 3 patients; acute hiatus hernia, 1 patient). One year after surgery, dysphagia and other wind-related side effects were less common after anterior 90 degrees fundoplication. Control of reflux symptoms and satisfaction with the overall outcome was similar for the two procedures. Anterior 90 degrees fundoplication is followed by fewer side effects than Nissen fundoplication. This advantage is offset by a greater likelihood of reflux recurrence. However, this does not diminish patient satisfaction.

Laparoscopic anterior 180 degrees partial fundoplication: five-year results and beyond.

HYPOTHESIS: Laparoscopic anterior 180 degrees partial fundoplication provides good long-term relief for symptoms of gastroesophageal reflux disease and is associated with few adverse effects. DESIGN: Prospectively evaluated case series. SETTING: University teaching hospital. PATIENTS: The late clinical outcome was determined for all patients who had undergone a laparoscopic anterior 180 degrees partial fundoplication by us between August 1, 1993, and November 30, 1999. INTERVENTIONS: Long-term (>/=5 years') follow-up after laparoscopic anterior 180 degrees partial fundoplication was obtained using a structured questionnaire. MAIN OUTCOME MEASURES: Overall satisfaction and the symptoms of heartburn and dysphagia were assessed using analog scales, and the presence or absence of other adverse outcomes was also determined. RESULTS: One hundred seventeen procedures were performed. The outcome at 5 to 11 years' (mean, 6.4 years') follow-up was determined for 113 patients (97%). Twelve patients (11%) died of unrelated causes during follow-up, and 1 patient underwent esophagectomy. Further surgery was undertaken in 12 patients (11%): 8 for recurrent reflux, 3 for a symptomatic hiatal hernia, and 1 for dysphagia. For 100 patients with clinical outcome data at late follow-up, gastroesophageal reflux symptoms were significantly improved following surgery and were well controlled in 80 patients. The incidence and severity of dysphagia were reduced after surgery. Normal belching was preserved in 91 patients, and almost all patients were able to eat normally. The overall outcome of surgery was rated as satisfactory, with 95 patients reporting that they considered their original decision to undergo surgery correct. CONCLUSIONS: Laparoscopic anterior 180 degrees partial fundoplication is an effective procedure for the surgical treatment of gastroesophageal reflux and is associated with a high rate of patient satisfaction at late follow-up. Compared with Nissen fundoplication, however, it is likely to be associated with a higher risk of recurrent reflux, although this is balanced by a lower rate of adverse effects.