Prospective Double-Blind Randomized Trial of Laparoscopic Nissen Fundoplication With Division and Without Division of Short Gastric Vessels

Abstract

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

Risk factors for delayed gastric emptying following laparoscopic repair of very large hiatus hernias

“…Despite the rationale that division of short gastric vessels may facilitate the creation of a tension‐free fundoplication and minimize the risk of postoperative dysphagia25, multiple studies26, 27, 28, 29 have demonstrated that this intraoperative manoeuvre does not influence swallowing outcomes after antireflux surgery. Therefore, some surgeons no longer routinely divide the short gastric vessels30, 31, 32. The present study lends support to this practice.…”

Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation

“…The fi rst randomized clinical trial in the laparoscopic era, concerning the routine division of SGV, showed that no manometric, endoscopic and clinical improvement was detected after one-year follow-up. However, in that study, seven different surgeons performed the procedures and different techniques (metallic staples) were used for the SGV division 16 . Another randomized trial evaluated 90 patients and found no difference comparing clinical outcome one-year after the surgical procedure 17 .…”

“…The randomized clinical trials (RCT) during laparoscopic era present now different standards of technique: the mobilization extension, number of divided vessels and the technique to make those divisions. Watson et al 16 , used metallic staples; other techniques included monopolar cauterization and harmonic scalpel 17,18 . When the SGV were not divided, the anterior wall of gastric fundus was used for the fundoplication, and not the posterior wall 16,17,18 .…”

“…Watson et al 16 , used metallic staples; other techniques included monopolar cauterization and harmonic scalpel 17,18 . When the SGV were not divided, the anterior wall of gastric fundus was used for the fundoplication, and not the posterior wall 16,17,18 . A metanalysis published by Catarci et al 19 concluded that the routine division of SGV had no advantage.…”

Measuring Outcomes of Laparoscopic Anti‐reflux Surgery: Quality of Life Versus Symptom Scores?

“…For more than 20 years we have used standardised clinical assessment scores to measure outcome following laparoscopic fundoplication, and have found these outcomes correlate well with the findings from objective studies 2,3,5 . We have also used the Short-Form 36 (SF-36), a widely used general QoL measure, and the GERD-hr-QoL, a GERD health related quality of life measure, to assess quality of life in subsets of patients enrolled in specific studies 4,8 .…”