Outcome 5 years after 3600° fundoplication for gastro-oesophageal reflux disease

Abstract

Forty patients with a mean age of 45 (range 22-65) years were operated on between 1982 and 1985 for gastro-oesophageal reflux disease with a short floppy 360 degree fundoplication. The results of the operation were determined by endoscopy, oesophageal manometry, ambulatory 24-h pH recording and symptom evaluation 6 months and 5 years after operation. These results were compared with findings in healthy controls. The median pressure in the lower oesophageal high-pressure zone was 13.3 (interquartile range (i.q.r.) 11.3-21.3) mmHg after 5 years, which did not differ significantly from the value at 6 months' follow-up or from that in controls. It was, however, significantly higher than the preoperative pressure. The median intra-abdominal length of the high-pressure zone was 1.7 (i.q.r. 1.3-2.3) cm after 5 years, significantly less than at 6 months but equal to control length. Measurement of the proportion of total time at pH < 4 at 5 years (median 0.2 (i.q.r. 0.0-0.6) per cent) and 6 months after operation revealed a significant reduction in acid reflux compared with preoperative values and normal controls. There was no significant difference in acid exposure between the two postoperative investigations. Endoscopy showed that 27 patients had no oesophagitis, three had erythema and three persistent Barrett's oesophagus 5 years after operation. Normal belching was possible in 22 patients and 18 experienced increased flatulence 5 years after fundoplication. An independent gastroenterologist found that the result was excellent in 16 patients, good in 16 and fair in four; two patients had a poor overall outcome of the operation. It is concluded that a 360 degree fundoplication provides good long-term control of reflux and that slight symptoms of overcompetence are common among patients operated on without affecting the overall result.

Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations

“…The 6% incidence of dysphagia 12 months following surgery was comparable with previously reported experience following open fundoplication [6,13]. Some surgeons have advocated the routine use of a partial fundoplication to reduce the incidence of this problem.…”

“…Nearly 90% of patients achieved a good outcome, defined by patient-scored satisfaction and an expressed willingness to undergo laparoscopic fundoplication again in the same circumstances. These outcomes are similar to those achieved following open fundoplication [6,13,17]. Up to 10% of patients, however, may have been disadvantaged by the laparoscopic approach due to the significant early reoperation rate.…”

Quality-of-life assessments in evaluation of laparoscopic Rosetti fundoplication

“…Well-performed long-term studies of the effects of surgery are unfortunately uncommon. In published series, the results are generally very good [3,16,17,22]. However, surgery may give new specific problems like dysphagia, gas bloat, flatulence, early satiety, and other symptoms of varying frequency [18,23].…”

Update: Total versus Partial Laparoscopic Fundoplication

“…pH monitoring was performed in just over one third of patients, of whom 83% had a normal pH profile. In a group of 40 patients undergoing Nissen fundoplication who were all followed for 5 years, with independent symptomatic assessment and endoscopy as well as pH monitoring, 80% of patients were Visick grades 1–2, the patients being equally divided between the two grades [19]. Of the patients with endoscopic oesophagitis, healing occurred in 82%.…”

“…However, it should be noted firstly that three prospective randomised studies have shown equivalent reflux control with partial fundoplication procedures, and secondly, it is well recognised that those patients with gastro-oesophageal reflux disease and peristaltic impairment comprise the most severe group of refluxers, whether measured by the level of acid exposure [58] or the grade of oesophagitis [19]. The fact that the ‘tailored’ approach to anti-reflux surgery has not led to any diminution in efficacy of reflux control in those series which have employed this, reserving partial fundoplication of the more severe group of refluxers, militates against the perceived superiority of total fundoplication in reflux control.…”