Laparoscopic anterior fundoplication achieved equivalent control of reflux, more physiological postoperative manometry parameters, and an improved clinical outcome at 6 months. Continued follow-up remains necessary to confirm the long-term efficacy of the partial fundoplication procedure.

ObjectiveTo determine whether division of the short gastric vessels (SGVs) and full mobilization of the gastric fundus is necessary to reduce the incidence of postoperative dysphagia and other adverse sequelae of laparoscopic Nissen fundoplication. Summary Background DataBased on historical and uncontrolled studies, division of the SGVs has been advocated during laparoscopic Nissen fundoplication to improve postoperative clinical outcomes. However, this modification has not been evaluated in a large prospective randomized trial. MethodsOne hundred two patients with proven gastroesophageal reflux disease presenting for laparoscopic Nissen fundoplication were prospectively randomized to undergo fundoplication with (52 patients) or without (50 patients) division of the SGVs. Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded. Patients were blinded to the postoperative status of their SGVs. Clinical assessment was performed by a blinded independent investigator who used multiple standardized clinical grading systems to assess dysphagia, heartburn, and patient satisfaction 1, 3, and 6 months after surgery. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, and distal esophageal acid exposure and radiologic assessment of postoperative anatomy were also performed. ResultsOperating time was increased by 40 minutes (median 65 vs. 105) by vessel division. Perioperative outcomes and complications, postoperative dysphagia, relief of heartburn, and overall satisfaction were not improved by dividing the SGVs. Lower esophageal 642

This study identifies a dosage (0.5-1 l/day) and duration (supplementation for 5-7 days before surgery) of IMPACT that contributes to improved outcomes of morbidity in elective surgery patients, particularly those undergoing GI surgical procedures. The cost effectiveness of such practice is supported by recent health economic analysis. Findings suggest preoperative IMPACT use for the prophylaxis of postoperative complications in elective surgical patients.

Operative mortality rates following oesophagectomy have continued to fall. However, the true rate is almost certainly higher than that reported here, for a variety of reasons. The 1-year survival of patients was only reported in about a quarter of the papers. It may be a more meaningful figure than postoperative mortality rate.

No abstract

Hypothesis: Laparoscopic anterior 90º partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication.

Preoperative comorbidity and smoking were risk factors for respiratory complications, whereas neoadjuvant treatment was not. MIE and the use of thoracic epidural analgesia decreased the risk of respiratory failure. Respiratory failure and ARDS were the only independent factors associated with an increased risk of in-hospital death, whereas anastomotic leakage was not.

ObjectiveThe authors' laparoscopic approach for a Nissen fundoplication is presented. Summary Background DataThe technique has been undertaken in 155 patients over 29 months, with 137 patients having been observed for more than 3 months. MethodsThree hundred sixty degree fundoplication was undertaken using three or four sutures to secure the wrap. Short gastric vessels were not divided, and the anterior wall of the stomach was used to construct the wrap around the esophagus with a large bougie in position. ResultsThe operation was not completed laparoscopically in 19 patients because a satisfactory wrap could not be achieved. Ten patients undergoing laparoscopic fundoplication underwent a subsequent operation related to the laparoscopic procedure within 6 months, and there was one postoperative death. Seven other patients were readmitted to the hospital several days subsequent to their discharge, four because of pulmonary emboli. Of 137 patients who have been observed for more than 3 months, 133 patients are well and currently are free from reflux symptoms. ConclusionsIn uncomplicated cases, laparoscopic fundoplication has similar advantages to laparoscopic cholecystectomy. In spite of the fact that it has not yet achieved the overall usefulness of open fundoplication, it seems likely that laparoscopic fundoplication will be used increasingly in the treatment of patients with gastroesophageal reflux disease.Since fundoplication was reported by Rudolf Nissen in 1956,12 this procedure or modifications of it have become widely accepted for the surgical management of gastroesophageal reflux disease, with long-term relief of symptoms reported in more than 90% of patients.3-5 Modifications to Nissen's original procedure have included shortening the 360°fundoplication to 2 cm, ensuring a loose, "floppy" fundoplication, and division of the short gastric vessels.3 Short gastric vessels were not divided by Nissen, who used either the posterior or the anterior wall of stomach to construct the fundoplica-2 tion.With the advent oflaparoscopic cholecystectomy6 and its rapid adoption by gastrointestinal surgeons,7 it has be-137