Laparoscopic antireflux surgery and the thoracic surgeon: what now?

Objective: Minimal invasive antireflux surgery is now a well accepted technique gaining a wide spread popularity. Simultaneously there is a growing tendency to fit all surgical candidates into one single type of operation, i.e. laparoscopic Nissen antireflux operation. This study evaluates the impact of this new technology on the strategy and practice of a major referral centre for antireflux surgery.
Methods: An analysis was made of indications for the different types of antireflux techniques performed between July, 1993 and 1995. If on Barium swallow the gastro-oesophageal (GO) junction proved to be reducible, a laparoscopic approach was proposed, if not, an open transthoracic access was preferred.
Results: One hundred and fifteen patients were operated. Fifty five patients underwent a minimal invasive approach: 49 Nissen (are the total fundoplication) and 3 Lind (are the partial fundoplication) operations through laparoscopy, 3 Belsey Mark IV through video assisted thoracic surgery (VATS). Sixty patients were treated by open surgery for following reasons: conversion to open surgery in 2 cases, redo surgery in 15 cases, previous other major abdominal surgery in 12, irreducible GO junction in 5, paraoesophageal or mixed type hernia in 12, Barrett and or oesophagitis IV in 4, combined antireflux surgery and feeding gastrostomy in 5, abdominal partial fundoplication by principle in 1, associated motility disorder in 1, combined reflux and gastric ulcer disease in 2, and severe emphysema in 1. In the laparoscopic series reflux control at 1 year post surgery as measured by 24 h pH study in 28 patients was obtained in 89.5%. One patient required a reoperation for symptomatic recurrence.
Conclusions: (1) Laparoscopic antireflux surgery is a feasible and well accepted technique; (2) careful study of each individual patient is of paramount importance to choose the correct type of operation and access as well. Therefore, fitting every patient into a single type of operation, i.e. laparoscopic Nissen, should be avoided; (3) thoracic surgeons with a major interest in GO reflux disease should familiarize themselves with laparoscopic antireflux procedures.