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The topic of “when and what” for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the “when”) and on the right antireflux operation to perform once the ideal candidate is identified (the “what”). The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.

A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD). Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis. This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.

Background: This study was designed to analyze the outcomes of Nissen fundoplication (NF) versus Toupet fundoplication (TF) in patients undergoing laparoscopic antireflux surgery (LARS). Methods: All perioperative data, operative/postoperative complications, and follow-up data were prospectively recorded. All patients were seen on the 2nd month postoperatively and by yearly intervals thereafter. All patients have at least 12-month follow-up. Using SPSS software, groups were compared by t-test and chi-square tests as appropriate. Results: One thousand consecutive patients underwent primary LARS from May 2004 to August 2009. Six hundred eighty-four patients had NF and 316 had TF fundoplication. The mean follow-up of the NF (51.26 months) group was slightly longer than the TF group (43.53 months) (P=.018). There was no mortality and conversion. Esophageal perforation, jejunal perforation, and pulmonary emboli were the sole three major complications in separate patients. Dysphagia occurred in 15.4% and 9.9% in NF and TF, respectively (P=.001). Corresponding numbers for bloating were 19.6% and 10.8% in NF and TF, respectively (P=.001). Seventeen patients underwent reinterventions such as dilatation and re-do surgery and all 17 were in the NF group (P

Endoscopic techniques for the treatment of reflux disease were first introduced in 2000 as an alternative to laparoscopic antireflux operations. Because of reports of long-term treatment failure with laparoscopic fundoplication and the fact that surgery is increasingly being reserved for the relatively small proportion of patients with complicated reflux disease, attempts to develop safe, effective, and durable endoscopic approaches to antireflux surgery continue. Techniques include radiofrequency ablation, injection therapy, and suturing/stapling techniques. Of these, the suturing/stapling techniques are most similar to the anatomic restructuring of the gastroesophageal junction provided by fundoplication. While early attempts at endoscopic suturing have been disappointing, significant advances in endoscopic instrumentation, a more complete understanding of the gastroesophageal junction anatomy, and improvements in the technical skills of the endoscopic surgeon have been realized. As a result, techniques now being tested, such as the endoluminal fundoplication, may prove more effective and durable than previous endoscopic antireflux procedures.

Background Total fundoplication is the most common antireflux operation and can be performed with or without division of the short gastric vessels. There seems to be no difference in short-term outcomes with either approach. The aim of the study was to determine whether there were the long-term differences (after 10 years). Methods Ninety-nine patients were enrolled in the study. Short gastric vessels were divided in 52 patients (group 1) and left intact in 47 (group 2). Ten patients were lost to follow-up and seven patients died, leaving 42 patients for analysis in group 1 and 40 in group 2. All patients were evaluated by standardized quality of life questionnaires. Results Three patients underwent reoperation within 5 years. Thirty-eight of 42 patients with a completely mobilized fundus reported no reflux symptoms, compared with 31 of 40 patients with intact vessels. There were no differences between the groups in other symptoms reflecting postfundoplication complaints and quality of life outcomes. Conclusion When total fundoplication is performed it makes no difference whether the fundus is mobilized or not. Both types of repair provide lasting control of reflux.

For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently, the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50-61). Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7-86). Average LES pressure before the operation was 50.5 mmHg (range 35.6-81.3). Six weeks after operation, all patients were symptom free. DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure (24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure may be an etiologic factor in the development of hypertensive lower esophageal sphincter.

OBJECTIVE. Gastroesophageal reflux disease is extremely common in the pediatric population, and antireflux procedures are performed with increasing frequency. The objective of this study was to determine whether pediatric antireflux procedures are associated with a decreased rate of reflux-related hospitalizations.METHODS. A study was conducted of pediatric patients who were undergoing antireflux procedures using data that were derived from the Washington State Comprehensive Hospital Abstract Reporting System and Vital Records. Patients were identified by a search of all records (1987–2001) for procedure codes that pertained to antireflux procedures in patients who were younger than 19 years. The number of hospitalizations for and rates of reflux-related events per patient-year before and after an antireflux procedure was calculated, and factors that were associated with higher antireflux procedure rates were examined.RESULTS. A total of 1142 patients underwent antireflux procedures. The rate of reflux-related events declined sharply with age both before and after an antireflux procedure. The cohort was divided into 3 groups on the basis of age at first antireflux procedure (CONCLUSIONS. The rate of reflux-related events was lower after an antireflux operation for children who underwent an antireflux procedure before age 4. Older children, however, were hospitalized at equal rates before and after an antireflux procedure, and older children with developmental delay were hospitalized at greater rates after an antireflux procedure. These findings highlight the need to clarify the subjective and objective indications for antireflux procedures in infants and children.

The purpose of this trial was to measure the health-related quality of life (HRQL) of gastroesophageal reflux disease (GERD) patients waiting for an antireflux operation.A total of 120 patients waiting for a laparoscopic fundoplication were sent questionnaires measuring their symptoms and quality of life.Ninety-five of the patients still needing an operation returned the questionaires and were included in the analysis. Thirty-one of 84 patients (37%) felt that the symptoms had worsened, and 51/90 (57%) were unsatisfied. Thirty percent suffered from throat or airway infections, 25% from swallowing difficulties, 48% from retrosternal pain, and 18% had asthma. The mean GERD HRQL score (0-45) was 21.7 (95% confidence interval, 19.7-23.7). Short Form-36 scores of this population were significantly worse when compared to patients with inguinal hernia or moderate asthma.Patients waiting for a fundoplication seem to have a significantly decreased health-related quality of life due to poor symptom control regardless of continuous medical treatment.

In most patients who have Barrett's esophagus and who are undergoing open or laparoscopic antireflux surgery, there is a significant improvement in symptom control that is equivalent to that in patients who have uncomplicated gastroesophageal reflux disease. The requirement for reoperation in patients with Barrett's esophagus may be slightly higher, although in the two laparoscopic series published to date, the rate is still only approximately 6%. How much this will increase with longer follow-up, time alone will tell, but given the good results in approximately 95% of patients operated to date, the authors do not believe that the diagnosis of Barrett's esophagus should be considered a blanket contraindication for laparoscopic antireflux surgery. Clearly, in most patients with Barrett's esophagus, an antireflux operation will not result in regression of Barrett's mucosa. It is still unclear whether antireflux surgery provides any protection against subsequent development of esophageal adenocarcinoma. What is clear, however, is that after antireflux surgery, patients who have Barrett's esophagus are still at risk for developing adenocarcinoma and should remain in surveillance programs. The authors believe that laparoscopic antireflux surgery is a safe and effective approach for the cure of reflux-related symptoms in patients who have Barrett's esophagus.

The impetus to identify and counsel patients with progressive disease regarding the need for surgical therapy is critical. This goes largely unheeded by gastroenterologists due to their lack of confidence in the durability of a fundoplication and concern over the side effects of the operation. Consequently, early referral of a patient with symptoms and signs of progressive disease for surgical therapy is resisted. Further, there is widespread concern that not all surgeons are sufficiently experienced in evaluating esophageal patients, many are not knowledgeable enough to select the proper antireflux procedure, and some are not sufficiently trained to properly perform the procedure. 4,5 Over the last 5 decades, 5 principles of the surgical treatment of GERD have emerged and when followed, lead to a successful outcome in nearly all patients. These principles are: documentation of the diagnosis of GERD; determination of the status of the lower esophageal sphincter (LES) and esophageal body; identification of the patient who is a proper candidate for surgical therapy; selection of the proper surgical procedure; and surgeon awareness of the technical nuances of the procedure. Application of these principles requires surgeons to hone their cognitive, diagnostic, clinical, and surgical skills regarding reflux disease. Errors can lead to surgical failure and the need for repetitive reoperations with the inherent risk of vagal injury and ischemic damage to esophageal and gastric tissues. The last 5 decades of experience have taught that a successful therapeutic outcome is unlikely after 3 failed antireflux operations. 6-8 Consequently, it is imperative that the first operation be performed for the right diagnosis, on the right patient, and by a knowledgeable and capable surgeon. The objective of this review is to describe the current state of surgical treatment for GERD, to expand on how new knowledge about disease progression and LES function has improved our ability to select the appropriate patient for surgical therapy, and to offer a more personalized surgical approach to these patients.

Eighty-eight consecutive patients with antireflux fundoplication had manometry and pH recording pre- and post-operatively at 6 months and 1, 3 and 5 years for a mean follow-up of 30.6 months. Failure occurred in nine patients (11.4%). For the whole group of patients, surgery produced a significant increase in the lower esophageal sphincter (LES) pressure gradient from 9.5 +/- 6.3 to 14.6 +/- 6.7 mmHg and a significant decrease in acid exposure from 20.6% +/- 17.6% to 5.5% +/- 8.8% at 6 months. There was a similar change in pressure (p < 0.0005) and pH (p < 0.002) in the successful but not in the failure group. Over time, the values remained stable in both groups. Post-operative LES pressure was significantly correlated with the outcome at 6 months (p < 0.02), and the pH was inversely correlated at 5 years (p < 0.039). This study confirms the early predictive value of the post-operative LES pressure. Esophageal acid exposure remains a reliable marker of the outcome. However, recurrences remain unexplained by LES pressure measurement and long-term follow-up using manometry and pH recording does not bring additional valuable data.

Peptic esophageal stricture with dysphagia is a late manifestation of severe gastroesophageal reflux disease (GERD). Although laparoscopic fundoplication is an effective antireflux operation, its efficacy for persons with peptic esophageal stricture and dysphagia has not been well defined. The aim of this study was to evaluate outcomes after fundoplication in this subgroup of GERD patients. Forty GERD patients with moderate, severe, or incapacitating dysphagia and peptic esophageal stricture were compared to a control group of 121 GERD patients without significant dysphagia or stricture. Reflux symptom severity was scored by each patient preoperatively and at most recent follow-up postoperatively (mean 1.5 years) using a scale ranging from 0 to 4 (0 = symptoms absent; 4 = symptoms incapacitating). Symptom scores were compared by the Wilcoxon rank-sum test. Postoperative redilation and fundoplication failure rates were also determined. At a mean follow-up of 1.5 years after fundoplication, the median dysphagia score had improved from 3 to 0 (P

Background: Primary antireflux surgery provides excellent symptom relief in most patients. Unfortunately, the results of redo surgery are less predictable. In these patients, esophageal injury from long-standing reflux of gastric contents and operative trauma from previous failed antireflux procedures results in progressive deterioration in esophageal propulsion, poor clearance of reflux episodes, mucosal damage, and, in some cases, stricture formation. For the past 16 years, we have selectively used esophageal resection and replacement instead of another reoperation in these challenging patients. Methods: Seventeen patients with end-stage esophageal body dysfunction and one or more previously unsuccessful antireflux procedures underwent esophagectomy and reconstruction by colon interposition in 15 patients and jejunum interposition in 2 patients. The indications for esophagectomy rather than a redo antireflux procedure were a global loss of effective esophageal motility in 13 and a nondilatable stricture in four. Their outcome was compared with that of 32 patients with adequate motility and 18 with a similar global loss of motility who had a redo antireflux procedure. Perioperative complications after esophagectomy were recorded, and long-term outcome was assessed by means of a standardized questionnaire at a median of 7 years after the operation. Results: Patients with profound esophageal body dysfunction who underwent esophageal resection had outcomes similar to those with normal motility who underwent a redo antireflux procedure. Those with profound esophageal motility dysfunction who underwent a redo antireflux procedure had a worse outcome than those who underwent resection. Esophageal resection and replacement was performed without mortality or graft failure. All patients who underwent resection stated that their preoperative symptoms were relieved completely ( n = 6) or improved ( n = 10). Thirteen patients (81%) were able to eat three meals a day, and 12 patients (75%) enjoyed an unrestricted diet. Two thirds of the patients were at or above their ideal body weight, and 88% were fully satisfied with the outcome of the procedure. Conclusion: Patients with end-stage esophageal body dysfunction who have had a previous unsuccessful antireflux procedure can be treated by esophageal resection with a high expectation of success. (J Thorac Cardiovasc Surg 1998;115:296-302)

Background Minimally invasive procedures have become common, and more reoperations for failed antireflux procedures are performed laparoscopically. We wanted to study the outcomes of laparoscopic reoperations for reflux. Methods Medical records of all patients who underwent reoperation without esophageal resection after previous antireflux procedures between January 2000 and October 2012 were reviewed. Results Seventy-five patients were included in this report: 56 (77%) women and 19 (23%) men. Median age was 58 years. The previous operation was laparoscopic antireflux procedures in 65 (87%) patients. The median interval between the last antireflux procedure and laparoscopic reoperation was 42 months. The median body mass index (BMI) was 28.7. All patients were symptomatic. Intraoperative findings included recurrent hiatal hernia in 47 (63%) patients, incompetent fundoplication in 14 (19%) patients, tight fundoplication in 8 (11%) patients, and tight crura in 2 (3%) patients. Laparoscopic Nissen fundoplication was performed in 57 (76%) patients, partial posterior fundoplication was performed in 12 (16%) patients, partial anterior fundoplication was performed in 3 (4%) patients, removal of crural stitches was performed in 2 patients, and a combination of partial posterior fundoplication and removal of crural stiches was performed in 1 patient. Complications occurred in 13 (15%) patients. Improvement in symptoms was observed in 70 (93%) patients in early postoperative follow-up and in 59 (78%) patients in long-term follow-up. Functional results were classified as excellent in 59 (78%) patients, good in 6 (7%) patients, fair in 7 (8%) patients, and poor in 3 (4%) patients. Conclusions Laparoscopic reoperation for failed antireflux operations is a complex procedure, but it is safe and effective in selected patients. Reoperation after a failed antireflux repair results in excellent or good functional status in a majority of patients, but these results may deteriorate over time.

Modern upper GI function studies allow for the detection of several pathophysiological factors that contribute to gastroesophageal reflux disease. The information obtained can lead to therapeutic consequences in patients with an indication for a surgical intervention, i.e., an individualized choice of antireflux procedure according to the existing pathophysiologic defect.In an experimental study on mini-pigs the mechanical effect of four standardized antireflux operations (anterior and posterior 180 degrees hemifundoplication, Nissen-DeMeester and Nissen-Rossetti 360 degrees fundoplication) on the lower esophageal sphincter (LES) was investigated. It was the aim of the study to objectively determine the extent of changes in pressure and length parameters at the LES according to the performed antireflux procedure.It could be demonstrated that different degrees of fundic wrap formation lead to a proportional mechanical effect at the LES according to the size of this wrap.Choosing a distinct type of fundoplication will allow for a tailored augmentation of the LES according to the individual functional defect.

A further operation is required in a small proportion of patients who have had prior antireflux surgery. This has a surprisingly good chance for success in appropriately evaluated patients. The surgeon must make very specific decisions regarding the surgical approach. The use of laparoscopy for redo surgery is being defined.

Background: Nissen fundoplication reduces gastro-oesophageal reflux effectively, but the mechanisms through which this effect is brought about have remained rather obscure. Methods: In this study the effect of fundoplication on oesophageal acid exposure, oesophageal body motility, and lower oesophageal sphincter pressure (LOSP) was assessed prospectively. Eleven patients were studied before and 3 months after a floppy Nissen fundoplication. A Dent sleeve was used to measure LOSP, and ambulatory pH and pressure monitoring were used to evaluate oesophageal motor function. Results: Gastro-oesophageal reflux was significantly decreased after fundoplication without an increase in LOSP. The motor function of the oesophageal body was not affected by the antireflux procedure. Conclusions: Nissen fundoplication is an effective antireflux operation, even though the procedure does not increase LOSP, and the motility pattern of the oesophageal body is not affected by the construction of a floppy fundic wrap.

Introduction: With improved outcomes demonstrated at high volume centers, many complex surgical procedures have migrated to large, specialized hospitals. The purpose of this study is to examine the extent of regionalization and outcomes in anti-reflux surgery. Methods: The Nationwide Inpatient Sample (NIS) data were analyzed from 1998-99 (T1) and 200809 (T2) for all antireflux operations in patients with gastroesophageal reflux symptoms using ICD-9-CM codes. Hospitals were stratified into high-, mid-, and low-volume centers (HVC, MVC, LVC) based on annual antireflux surgery volume. Complications and outcomes were also compared. Socio-demographic factors were examined as effectors of surgery location. Results: A total of 11804 cases were performed in T1 and 8856 in T2. In T1, 41.0% of procedures were performed in a HVC vs 35.4% in T2. LVC rates increased with time: 20.53% vs. 26.87% (p

A retrospective review of gastroesophageal leaks complicating antireflux operations was conducted to determine the incidence, predisposing factors, optimal treatment, and outcome in such patients. Twelve postoperative gastroesophageal leaks occurred in a series of 1,005 antireflux procedures (1.2%). Four of the 12 patients had undergone a previous hiatal operation, and this was a significant risk factor for postoperative leak (p0.001). Ten of the 12 patients had undergone "incomplete" wraps that involved suturing of the gastric fundus to the esophagus, and this was a significant risk factor for postoperative leak (p0.04). Five patients had peritoneal contamination and 7 had mediastinal or pleural soilage. Patients with peritoneal perforations were less likely to require intensive care unit admission than were patients with thoracic perforations (p0.05). Six of the 12 perforations were either well contained or well drained at the time of the diagnostic contrast study. All 6 of these patients responded to conservative treatment. The remaining 6 perforations were not contained at the time of diagnosis. Two of the affected patients initially received conservative treatment (1 death and 1 late empyema) and 4 were treated by operation (1 death). The mortality associated with gastroesophageal perforation was 17%. Contained perforations can be treated conservatively but noncontained perforations require early and aggressive surgical intervention.

Reoperative antireflux procedures are traditionally approached through an open technique. However, with increasing experience in minimally invasive antireflux procedures, more reoperative procedures are being performed laparoscopically. The success rate for reoperative surgery, either open or laparoscopic, does not equal that of primary antireflux operations. Redo antireflux surgery is a complex operation and a thorough evaluation prior to treatment is essential. There are several options for failed primary antireflux surgery including reconstructive options, such as redo fundoplication and Roux-en Y near esophagojejunostomy. In some cases of anatomic disruption, esophagectomy is required. In this article, we discuss the following: clinical presentation; the evaluation of patients; causes of failure; and choice of operation with a focus on reconstructive options, and technical aspects of minimally invasive redo antireflux surgery. We describe our experience and summarize the lessons learned.

The most commonly employed antireflux operation is the Nissen fundoplication. However, its origin and subsequent modifications are rarely defined. These aspects of the operation are reviewed in this article as are the results currently obtainable with the modern version of the operative procedure.

An understanding of gastroesophageal reflux disease in infants and children by the clinician requires a working knowledge of 18- to 24-hour esophageal pH monitoring and the motility disorders of the esophagus and stomach that may be associated with gastroesophageal reflux disease. The results of surgical therapy for childhood gastroesophageal reflux disease cannot be assessed accurately without this knowledge. Antireflux operations can be tailored to the child's situation, which includes a combination of clinical symptoms and findings on objective tests for reflux and associated alimentary-tract motility disorders. The presence of severe complications from gastroesophageal reflux disease in "asymptomatic" infants and children is a troublesome and not yet fully defined problem. Special areas include the documentation of gastroesophageal reflux disease as a cause of SIDS, the increased reporting of Barrett's esophagus and adenocarcinoma of the esophagus in childhood, and the effect of associated alimentary-tract motility disorders in children with CNS disease who have gastroesophageal reflux disease requiring surgical intervention.

Between 1976 and 1989 an antireflux operation (193 Nissen; 5 Thal) was performed in 198 children with profound neurological impairment (NI). Etiology of the NI was a syndrome in 24%, congenital in 30%, and acquired in 46%. The most frequent symptoms of gastroesophageal reflux (GER), vomiting and pneumonia, were significantly reduced (P less than .05) after the antireflux operation. Postoperatively, 141 children (71%) developed return of one or more symptoms that had been preoperatively associated with GER, whereas 57 patients (29%) remained asymptomatic. Of the children with symptoms, 86 (61%) underwent diagnostic testing to exclude recurrent GER and 55 (39%) had no diagnostic evaluation. Recurrent GER was documented in 31 patients and a mechanical problem with the fundoplication in 18 children, an operative failure rate of 25%. The symptom-free interval following the antireflux operation averaged 11 months postoperatively; return of symptoms showed no statistical relationship to the etiology of NI, presence of seizures, or degree of muscle tone. The majority of children required multiple outpatient or emergency department visits for evaluation of these symptoms or assessment of gastrostomy tube problems. Survival of all children was 71% at an average postoperative follow-up of 3.5 years.

The Nissen fundoplication is the most frequently applied antireflux operation worldwide. The aim of this review was to compare laparoscopic Nissen with partial fundoplication.Nine randomized trials comparing several types of wraps were analyzed, four for the comparison Nissen vs. Toupet and five for the comparison Toupet or Nissen vs. anterior fundoplication. Similar comparisons in nonrandomized studies were also included.Dysphagia rates and reflux recurrence were not related to preoperative esophageal persistalsis independent of the selected procedure. Overall, Nissen fundoplication revealed slightly better reflux control, but was associated with more side effects, such as early dysphagia and gas bloat. Advantages of an anterior approach were only reported by one group. A significantly higher reflux recurrence rate for anterior fundoplication was observed in all other comparisons.Tailoring antireflux surgery according to esophageal motility is not indicated. At present, the relevant factor for selection of a Nissen or Toupet fundoplication is personal experience. Anterior fundoplication offers less effective long-term reflux control.

SUMMARY Hiatoplasty is generally considered an essential part of antireflux operations. Posterior closure of an enlarged hiatus may lead to anterior displacement of the esophagus and it may be contributory to postoperative dysphagia. The aims of this study were to (i) measure the normal esophageal anteroposterior angulation, (ii) evaluate the variation of the angulation after laparoscopic hiatoplasty and fundoplication, and (iii) correlate the angulation with postoperative dysphagia. Normal esophageal anteroposterior angle determined by barium preoperative barium esophagram was evaluated based on the study of 100 patients. Postoperative angulation was evaluated based on the study of 32 patients who underwent barium esophagram after laparoscopic hiatoplasty and fundoplication. The results showed that the normal esophageal anteroposterior angle was 150.4 ± 10.7 (range 119–169) degrees. There was no correlation between the angle and gender (P = 0.6) or age (P = 0.1). Postoperative angle averaged 146.6 ± 11.7 (range 122–170) degrees. Normal and post-operative angle were not different (P = 0.1). The difference between post- and preoperative angle averaged 0.7 ± 8.9 (range –15–14). There was no statistically significant difference when pre- and post-operative angles were compared (P = 0.6). De novo dysphagia was present in 31% of the 32 postoperative patients. There was no statistically significant difference when the angles in patients with and without de novo dysphagia were compared (P = 0.2). We concluded that (i) laparoscopic hiatoplasty and fundoplication does not significantly change the esophageal anteroposterior angle; and (ii) de novo dysphagia is not with the esophageal anteroposterior angle.

Antireflux surgery has not gained wide acceptance in The Netherlands in the past two decades. The introduction of laparoscopic fundoplication seems to have had no impact on the number of antireflux operations performed per year.The SIG data were consulted in order to compile an inventory on the number of antireflux operations performed in The Netherlands between 1977 and 1995. The data were compared with those kindly supplied by the Laparoscopic Societies of the Scandinavian countries.The number of antireflux operations per year in The Netherlands, 1.7/100,000 per year, is far less than reported in the four Scandinavian countries, 15/100,000 per year, and also far below the 10/100,000 per year needed for antireflux surgery on a yearly basis.In The Netherlands, 1.7/100,000 inhabitants per year undergo antireflux surgery. This figure has remained virtually stable in the past two decades, i.e. it has not changed even since the introduction of H2-receptor antagonists, proton-pump inhibitors and laparoscopic antireflux surgery. The success of medical treatment and personal, anecdotal, experience of gastroenterologists with patients they have referred for surgery explain the low number of antireflux operations performed. Currently, a randomized trial is being conducted in The Netherlands comparing the effectivity, costs and quality of life after conventional Nissen fundoplication with the laparoscopic approach. All operations are performed or supervised by a limited number of experienced surgeons who have gone through the learning curve of both the open and conventional technique.

Gastroesophageal reflux disease is a common disorder, and patients diagnosed with GERD face a lifelong treatment requirement. A surgical antireflux procedure may be offered as an alternative to lifelong treatment with proton-pump inhibitors. Many investigations have been performed to help discover the best surgical alternative to medical management. An ideal antireflux procedure should be safe, effective, durable, and result in minimal complications. Total fundoplication in the form of Nissen fundoplication is the most widely used antireflux operation worldwide. Although its efficacy is well documented, the clinical success rate in terms of reflux control is occasionally compromised by troublesome mechanical side effects. Because of these unsatisfactory symptoms and continued hindered quality of life, the Nissen fundoplication has undergone many modifications. The current standard appears to be the 2 cm floppy Nissen; however, the alternative approach has been the use of a partial fundoplication, most frequently the Toupet procedure. Both the Nissen and Toupet fundoplications have proven to provide relief in the majority of patients, but each has its own drawback. Patients undergoing Nissen fundoplication have a higher incidence of dysphagia early after operation, although this appears to resolve in most. The Toupet, on the other hand, may not be as durable, and may lead to the early re-emergence of symptoms. The problem of post-Nissen dysphagia led many surgeons to believe that the Nissen night be contraindicated in patients who have dysmotility,because it would cause even greater dysphagia; however, recent articles have not demonstrated this to be the case. It seems that the floppy Nissen performed over a large bougie (56-60 Fr) with division of short gastrics and crural closure is an acceptable operation for reflux in both those who have normal motility and those who have mild to moderate dysmotility. Thus, for most patients who have GERD and normal motility, either procedure appears effective in the majority of patients; however, those patients who have severe dysmotilty disorders and who require an antireflux procedure(ie, scleroderma, postmyotomy achalasia) are likely best served with a partial fundoplication.

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.

Objective: To report the feasibility and efficacy of posterior partial fundoplication for patients with recurrent reflux after previous antireflux operations. Design: Prospective non-randomised single hospital study. Setting: University hospital, Sweden. Patients: 32 consecutive patients who required reoperation after failure of previous operations for gastro-oesophageal reflux disease. Main outcome measures: Control of symptoms, oesophageal acid reflux. Results: Most patients were referred for reoperation because of recurrent reflux, but six patients had a symptomatic intrahoracic herniation of the wrap with a life-threatening perforation in one patient. Three patients had recurrent reflux within 6 months of the operation and another two were classified as failures. The remaining 27 (84%) were classified as having a successful outcome during a mean follow-up period of 20 months. Conclusion: A posterior partial fundoplication can be done safely in a repeat operation for patients whose antireflux operation...

We determine the feasibility of laparoscopic revision surgery in children following previous open and laparoscopic antireflux operations. To give an objective overview about this topic, we analyzed the outcome of 15 children (8 girls and 7 boys) who had undergone attempted laparoscopic revision between 4 and 72 months (median 16 months) after a previous antireflux operation. Seven patients had previously undergone an open antireflux procedure (4 Nissen fundoplication; 3 Thal procedure) and 8 a laparoscopic procedure (5 Nissen; 3 Toupet's procedure). Two of these children were mentally handicapped. The indications for revision were: recurrent reflux, 5; valve migration, 5; valve dismount, 5. Eight procedures comprised construction of a new Nissen fundoplication and in 7 cases a Toupet's procedure was performed. Revision was successfully completed laparoscopically in 10 cases, 7 of 8 patients following a previous laparoscopic procedure and in 3 of 7 following a previous open operation. Operating time ranged between 70 and 140 minutes (median 90 minutes). No perioperative complications occurred in either group. All patients were discharged within 3 to 4 days after the redo procedure. Follow-up time varied between 6 months and 7 yrs. Preoperative symptoms were relieved in all patients and all antireflux medication has been discontinued, except in two cases that still had rare symptoms. Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with good results, in the hands of experienced endoscopic surgeons. Reoperation is likely to be more difficult following failure of an open procedure than after failure of a laparoscopic one. Concerning the type of procedure, redo surgery is more difficult to perform after Nissen's than after Toupet's or Thal's procedure.

The number of antireflux procedures performed for gastroesophageal reflux disease in the United States has increased in the past decade. In a sampling of US hospitals by the National Center for Health Statistics, the number of patients discharged with the International Classification of Disease (ICD-9-CM) classification 44.66 (“Other procedures for creation of esophagogastric sphincteric competence,” ie, fundoplication) in the years 1988, 1993, and 1998 was 13,000, 22,000, and 40,000, respectively. It would be safe to say that the majority of these antireflux procedures are now minimally invasive. The trend for more laparoscopic antireflux procedures also has been seen in Europe. The current approach of choice for surgical treatment of gastroesophageal reflux disease is a minimally invasive transabdominal antireflux procedure. During this evolution of operational approach there have been untoward events associated with the minimally invasive antireflux operation. There is a growing need to audit the results of minimally invasive antireflux procedures because there has been (in the medical literature) a question of its efficacy, and also because of the development of novel endoscopic procedures to reproduce a sphincter mechanism in the lower esophagus, which potentially could compete with laparoscopic antireflux surgery. In this review the results of primary laparoscopic antireflux procedures will be examined (international experience, English-language literature) with an emphasis placed on the description of perioperative complications and primary procedure failures. Data on redo procedures also will be analyzed to determine the causes for failure of primary minimally invasive procedures. Recommendations for avoiding the complications and failure of the primary minimally invasive antireflux procedure will be described.

In Sweden laparoscopic antireflux surgery started in 1991, and within four years replaced the open procedure as the method of choice. It is, however, not yet settled which of the two techniques is most cost effective. To compare these two operations in economic terms we studied all reports up to September 1997 as well as the register in the epidemiological unit of the National Board of Health and Welfare (EpC). We found numerous reports on consecutive series of laparoscopic procedures, several non-randomised studies, and only one randomised prospective study comparing open and laparoscopic antireflux surgery. The few studies about the economics of antireflux surgery indicated that hospital costs were equal or less for the laparoscopic procedure. If one adds the costs from loss of production (sick leave) it will be an even more favourable outcome for the laparoscopic treatment. The figures from EpC showed that antireflux surgery is done infrequently in many surgical departments. This may have a substantial influence on the economic outcome as well as the effectiveness of antireflux surgery in Sweden. Few studies have compared open and laparoscopic methods from an economic perspective. As a tool for cost benefit analysis these reports are incomplete.

O objetivo do presente estudo é apresentar as complicações que ocorreram em seiscentos pacientes consecutivos com doença do refluxo gastroesofágico submetidos à fundoplicatura laparoscópica. O procedimento de Nissen-Rosetti (fundoplicatura de 360°) foi realizado em 587 pacientes (97,8%) e o de Toupet (fundoplicatura de 270°) em 13 (2,2%). Oitenta e um pacientes também foram submetidos à colecistectomia no mesmo ato operatório, e um a diverticulectomia faringoesofágica cervical com miotomia cricofaringeana. Trinta e nove pacientes tinham operação prévia no abdome superior. O período de internação hospitalar variou de 12 horas a 23 dias, com média de 1,2 dias. A via de acesso foi convertida em laparotomia em dez pacientes (1,7%). A principal causa de conversão foi a presença de aderências. A complicação intra- operatória mais freqüente foi pneumotórax, que foi observado em oito pacientes. Todos os pneumotóraces ocorreram nos cem primeiros casos. Cinco pacientes apresentaram hemorragia significante, sendo que dois deles necessitaram laparotomia para controle do sangramento. Úlcera gástrica foi diagnosticada em sete pacientes. Um paciente etilista morreu de pancreatite aguda e outro de síndrome de disfunção de múltiplos órgãos e sistemas conseqüente à perfuração gástrica. Outras complicações importantes foram: dois abscessos intra-abdominais, uma perfuração esofágica, uma sepse secundária à perfuração gástrica, um choque hemorrágico e uma obstrução gástrica secundária à herniação da fundoplicatura. Concluímos que a taxa de complicações da fundoplicatura laparoscópica é baixa e diminui significativamente com a experiência do cirurgião. The objective of the present study is to present the complications that occurred in 600 consecutive patients with gastroesophageal reflux disease who underwent laparoscopic fundoplication. A Nissen-Rosetti procedure (360° fundoplication) was performed in 587 patients (97.8%) and a Toupet procedure (270(0) fundoplication) in 13 (2.2%). Eighty- one patients were also subjected to a concurrent cholecystectomy and one patient a concurrent cervical pharyngoesophageal diverticulectomy with cricopharyngeal myotomy. Thirty-nine patients had a previous upper abdominal operation. The period of hospitalization varied from 12 hours to 23 days, with an average of 1.2 days. The operation was converted to an open procedure in 10 patients (1,7%). The main cause of conversion was the presence of adhesions. The most frequent intraoperative complication was pneumothorax, that was observed in eight patients. All pneumothoraces occurred in the first 100 cases. Five patients had significant operative bleeding; two of them required laparotomy for bleeding control. Gastric ulcer was diagnosed in seven patients. One alcoholic patient died of acute pancreatitis and other with gastric perforation of multiple organ failure syndrome. Other major complications were two intrabdominal abscesses, one esophageal perforation, one sepsis due to gastric perforation, one hemorrhagic shock, and one gastric obstruction due to fundoplication herniation. It is concluded that complications of laparoscopic fundoplication are low and decrease significantly with the surgeon's experience.

Num período de 12 anos, de julho de 1984 a junho de 1996, 120 pacientes portadores de doença do refluxo gastroesofágico foram submetidos à cirurgia anti-refluxo pela técnica de Toupet. A média de idade foi 52,4 anos e 72 (60%) eram do sexo feminino. Do total de doentes, 74 (61,7%) apresentavam doença clínica associada e/ou vício. Oito pacientes já haviam realizado cirurgia prévia para correção de doença do refluxo gastroesofágico, com recidiva dos sintomas. Os acidentes operatórios foram lesão esplênica (seis casos), lesão de esôfago, pleura, fígado e veia porta, que ocorreram, isoladamente, em quatro pacientes. A letalidade hospitalar foi 6,6% porém, não houve óbito intra-operatório. Complicações pós-operatórias imediatas ocorreram em 27 (22,5%) dos doentes. A análise univariada mostrou que foram significantes para o aparecimento de complicações as variáveis: idade, tabagismo, alcoolismo, lesão de baço e reoperação. Para letalidade foram significantes apenas: idade e reoperação. A análise multivariada confirmou a significância apenas da variável reoperação no aparecimento de complicações pós-operatórias e na letalidade. In a 12 years period, from july 1984 to june 1996, 120 patients were submitted to antireflux surgery using the modified Toupet procedure. The medium age was 52.4 years and 72 (60%) patients has association with other diseases or were smokers or heavy drunkers. Eight patients have had previous surgery for gastric reflux, with recurrent symptoms. Opera tive accidental injuries were splenic lesions (six patients), esophagus lesion (one), pleura (one), liver(one) and portal vein(one). Mortality rate was 6.6% but no intraoperative death was observed. Early post-operative complications were significant for the following parameters: age, smocking, alchoolism, splenic lesion, and reoperation regarding complication and for morbility were age and reoperation. The multifactory analysis confirmed significance only to reoperation for complications and morbility.

Although the pediatric surgical literature is replete with reports of the success of operations for gastroesophageal reflux, postoperative complications are being reported with increasing frequency for the neurologically impaired subpopulation. Because a large portion of a care-giver's life is involved in attending to a neurologically impaired child, parental satisfaction with the outcome of these operations should be an important consideration when the use of such procedures is contemplated. The purpose of the present study was to assess the impact of antireflux operations with respect to care-giver opinions regarding the procedure. The authors retrospectively reviewed 25 charts (of 13 girls and 12 boys; age range, 3 months to 18 years) and documented (through survey results) perceived child well-being, objective care requirements, and overall care-giver satisfaction with the procedure. Results indicate there was significant improvement in feeding indexes, care-giver perception of the child's comfort, and quality of life postoperatively. Moreover, there was significant improvement in the care-givers' attitudes regarding their child, including the level of frustration in caring for the child, and the parents' overall quality of life. Care-givers also believed that the operation's result was about or better than what they had expected. In conclusion, the study documents care-giver satisfaction with antireflux procedures. Postoperatively, child care is easier and the quality of time spent with the child is better. The impression of better quality of life postoperatively for a neurologically impaired child may be the greatest success in this sometimes frustrating endeavor.

Fourteen patients with scleroderma underwent antireflux operations (10 short Nissen, 2 Collis-Nissen, 1 Collis-Belsey, and 1 vagotomy and antrectomy with Roux-en-Y). Esophageal function was assessed preoperatively and postoperatively with a follow-up range of 8 to 181 months (mean, 65 months). Reflux symptoms were relieved in 10 of the 14 patients (p0.01), as shown by a decrease in their 24-hour acid exposure of from 15% to 7.5% (p0.05). However, the lower esophageal sphincter pressure gradient created by the operations did not increase significantly (3.7 +/- 3.4 mm Hg to 5.5 +/- 3.5 mm Hg). The esophageal acid exposure decreased sufficiently to promote some alleviation of the esophagitis. Radiologic signs of stenosis regressed in 6 of 7 patients. Postoperative endoscopic assessment revealed complete or partial healing of erosions seen preoperatively in 6 of the 7 patients so studied, and healing of all ulcers in 3 patients. Twelve patients continued to have columnar metaplasia. Manometric studies disclosed no significant changes in propulsion and contractility. Distal esophageal resting pressures rose significantly from 6.2 to 9.4 mm Hg (p0.05 mm Hg), suggestive of stasis. Radionuclide transit studies, however, showed no significant decrease in the esophageal emptying capacity after operation. It is concluded that conventional antireflux operations in patients with scleroderma can palliate reflux damage without jeopardizing esophageal function.

Despite the absence of definitive explanations regarding either the physiologic or surgical factors which curtail gastro-esophageal reflux, effective antireflux operations exist. This article explores the theoretical factors relevant to the surgical control of reflux. These theoretical features include: (1) the pressure, length, and location of the manometrically defined lower esophageal sphincter (LES); (2) the gastro-esophageal valve as defined by the angle of His and a mucosal flap valve; and (3) the mechanical effects of a fundoplication which serve to increase the opening pressure of the cardia and optimize the physical relationships described by the law of La Place. Finally, the relation of these theoretical factors to actual operations is discussed.

Due to the frequent presence of latent gastroesophageal reflux (GER) in mentally impaired children, it is now standard to perform upper gastrointestinal contrast (UGI) and pH probe studies in all children referred for feeding gastrostomy, even if they are without clinical evidence for GER. For patients with documented GER, an antireflux operation performed in conjunction with gastrostomy is usually considered mandatory. Some authors have suggested that a “protective” antireflux operation be performed at the time of gastrostomy placement in all brain-damaged children, citing a high incidence of postoperative GER in this group of patients following gastrostomy, even with a negative preoperative evaluation for GER. To evaluate this theory, we prospectively studied, over the past 6 years, all mentally retarded children referred for feeding gastrostomy with UGI contrast and esophageal pH probe studies. In total, 148 children were studied; 105 had a positive evaluation for GER and underwent gastrostomy and antireflux surgery. Of the 43 children with a negative preoperative evaluation for GER, 37 are doing well following gastrostomy alone without clinical reflux at an average follow-up of 21 months. Six of the 43 (14%) developed symptomatic GER occurring at an average of 10 months following gastrostomy placement. Five of these children have been successfully treated with an antireflux operation and the sixth patient has been successfully man-aged nonoperatively. Given the significant morbidity and mortality that has been documented with antireflux operations in mentally retarded children, we conclude that a protective antireflux operation at the time of gastrostomy placement is not indicated because the data suggest that 86% of children with a negative preoperative evaluation for GER would undergo the operation needlessly.

The majority of patients who receive modern antireflux operations obtain substantial long-term relief of their symptoms. About 10% to 15% will have persistent or recurrent problems, some severe enough to warrant reoperation for correction. With careful symptom review, barium study, endoscopy, and manometry, the mechanism of failure becomes evident, and remedial surgical treatment may proceed. The results at reoperation are not as good as those of the primary procedure, which emphasizes the need for proper diagnosis and choice of procedure and for reliable execution of technique at the initial treatment.

Nissen fundoplication is a commonly used antireflux operation. After this operation symptoms such as dysphagia, inability to belch and vomit, and gas bloating are frequently reported in the literature. In 32 patients who underwent Nissen fundoplication 3.5-18 years ago, postprocedure dysphagia was studied using conventional manometry and 24 h ambulatory pressure and pH recording. Our study indicates that dysphagia tends to decrease after surgery. Neither conventional nor ambulatory pressure recording revealed motor abnormalities that could be held responsible for the dysphagia. Therefore, the data do not support the concept that dysphagia is a major complication of Nissen fundoplication.

In 1957 J. Leigh Collis published his innovative operation for treating the difficult problem of the irreducible hiatal hernia, esophagitis, and stricture. The design of the operation was based on the relatively primitive understanding of hiatal hernia and the newly emerging concept of reflux esophagitis. A variety of antireflux operations by different surgeons emerged over the years to follow. The original Collis gastroplasty has been subsequently modified with the addition of both partial and complete fundoplication procedures. The place of the modified Collis gastroplasty-fundoplication operations in today's approach to the problems of hiatal hernia and gastroesophageal reflux disease remains unsettled.

Antireflux surgery was performed in 234 children over a 5-year period; 153 were neurologically impaired (NI) and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 26% in the NI group and 12% in the NN group (P less than .01). During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% v 5%, respectively; P less than .01). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 6% in NN (P less than .01). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure.