Laparoscopic partial fundoplication vs laparoscopic Nissen-Rosetti fundoplication. Short-term results of 231 cases.

BACKGROUND: Since 1992, all patients at our institution who have met standard accepted criteria for surgical intervention for complicated gastroesophageal reflux disease have been entered into a prospective sequential clinical study to evaluate outcomes of the laparoscopic approach to the Nissen-Rosetti procedure and a modified Toupet procedure. METHODS: A standardized workup with upper GI series, esophagography, and endoscopy was used in all patients. Manometry, pH testing, and other special tests were used selectively. A measuring technique was used to determine wrap size without the use of dilators. The short gastric vessels were left intact in all patients. A cosurgeon approach was used, with technical factors described herein. RESULTS: Some 226 of 231 cases were completed laparoscopically (98%)-125 patients in the Nissen-Rosetti group and 101 in the partial fundoplication group. There were no clinical failures in either group. The partial fundoplication group performed better than the Nissen-Rosetti group in all categories of comparison. Return to normal eating habits was much earlier in the partial wrap group (p < 0.0001). Postop distal esophageal sphincter pressures in the two groups were equal at 15 mmHg. Eight patients suffered significant dysphagia requiring endoscopy and dilatation, all in the Nissen-Rosetti group (p < 0.01). Minor complications occurred in 12% of the total group. There was a total surgical revision rate of 3%. There were no gastric or esophageal perforations. Average operative time was 30 min. Average hospital stay was 1.4 days. Hospital charges for the laparoscopic approach averaged $6,000 dollars compared to $12,000 for the open approach. CONCLUSION: Laparoscopic partial fundoplication is as effective as laparoscopic Nissen-Rosetti fundoplication, with a higher satisfaction rate and fewer side effects. Measuring for wrap and hiatus size eliminates the need for and risk of using stiff dilators. By utilizing cosurgeons and currently available technology, cost, operative time, hospital time, and complications can be reduced to a finite minimum.

Laparoscopic Nissen fundoplication--a curative, safe, and cost-effective procedure for complicated gastroesophageal reflux disease.

We prospectively evaluated the cases of 52 patients who underwent laparoscopic Nissen fundoplication from October 1992 to January 1994 for patient outcome, satisfaction, hospital stay, hospital cost, and disability. All cases were evaluated with historical findings, routine chemistry studies, upper gastrointestinal series, fluoroesophagography for esophageal motor function, gallbladder ultrasonography, and esophagogastroduodenoscopy. Six patients required esophageal manometry for diagnosis. All patients had refractory esophageal reflux disease or complications of chronic esophageal reflux. Forty-nine (94%) of the 52 cases were completed laparoscopically. Ninety percent of those were cured of their symptoms and returned to a normal life-style. The percent had significant improvement, with rare episodes of reflux or dysphagia, and received antacids only occasionally. Hospital stay was reduced to 2.3 days, compared to 8.3 days for the open technique. Hospital cost was reduced to $6,870, compared to $11,990 for the open technique. Mean time until return to work was 15 days in the laparoscopic group, compared to 42 days in the open Nissen group. There were two major complications (4%) and 12 minor complications (24%). There were no deaths. Fifty-one of 52 patients stated that they would recommend the procedure for others with the same problem. Laparoscopic Nissen fundoplication is a safe and effective treatment for refractory esophageal reflux and its complications and has the extra benefit of reduced hospital cost and stay and a more rapid return to work. Preoperative esophageal manometry and 24-h esophageal pH testing may be used selectively with excellent results.