Radiologic and Endoscopic Characteristics of Laparoscopic Antireflux Wrap: Correlation With Outcome

Abstract

After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe's classification of the postoperative valve was used for the definition of a ''normal'' or ''defective'' wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A ''normal'' antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P , 0.001). ''Defective'' antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.Key words: Antireflux surgery -Postoperative failures -Defective fundoplication P atients with gastroesophageal reflux disease (GERD) have anatomic defects of the esophagogastric junction (EGJ) as dilatation of the cardia and/or presence of hiatal hernia. [1][2][3][4] These defects have been associated with incompetence of the lower esophageal sphincter (LES) and pathologic acid reflux. The aim of antireflux surgery is to create an antireflux barrier by increasing the competence of the LES and to avoid this abnormal acid reflux. However, failure of antireflux surgery has been reported in several publications and pathologic acid reflux test can be observed in 5% to 15% of GERD patients. 5,6 Zaninotto et al 6 reported 13.2% of reflux recurrence in patients with GERD (6.2% in patients with grade 0 to I esophagitis and 7% in patients with grade-II esophagitis, respectively). Presence of abnormal acid reflux has been reported after Nissen fundoplication as well as after Toupet or cardial calibration in a very similar percentage of cases. 7-9The restoration of the cardial anatomic integrity is followed by a successful outcome after surgery. On the contrary, some authors have published endoscopic or radiologic failures after fundoplication, with defective antireflux wrap associated with a high rate of symptomatic and objective reflux recurrence reaching up to 25% of cases. 2,10The purpose of this prospective study was to correlate the presence of postoperative radiologic and endoscopic defects of the new antireflux barrier after surgery and its association with persistence of symptoms, endoscopic esophagitis, hypotensive LES, and abnormal 24-hour pH monitoring. Patients and Methods Patients studiedIn this prospective ...

Long‐Term Outcome and Quality of Life After Laparoscopic Treatment of Large Paraesophageal Hernia

“…The laparoscopic approach continues to be the standard technique for large PEHs. It offers a reasonable short-term outcome and long-term control of symptoms despite a recurrence rate that is higher than expected as compared with fundoplication for GERD or type I sliding hernias (Table 4) [3][4][5][6][7][8][9][10][11][12].…”

“…Initial successful experience encouraged the use of laparoscopy as the definitive approach for PEH, but the seminal report from DeMeester's group in 2002 [3], which showed a 42 % recurrence rate, raised concerns about the risk of poor results. Over the past decade, the endoscopic approach to PEH and a number of additional topics (e.g., recurrence rate, use of mesh, quality of life) have continued to generate controversy [3][4][5][6][7][8][9][10][11][12]. Furthermore, the long-term outcome ([10 years) of this approach is not well known.…”

Laparoscopic Redo Fundoplication Alone, Redo Nissen Fundoplication, or Toupet Fundoplication Combined With Roux-en-Y Distal Gastrectomy for Treatment of Failed Nissen Fundoplication

“…The gastroesophageal reflux symptoms, retrosternal pain, and dysphagia were reported in 18-61% of patients after Nissen fundoplication, and 4.5-18% of patients require reoperation 4,14,19,24,29,40 .…”

“…L aparoscopic Nissen fundoplication (LNF) is the surgical technique of choice to treat patients with gastroesophageal reflux disease (GERD). However, it fails in almost 15% of patients and most of them must be reoperated to treat postoperative symptoms 4,14,19,24,28,40 . The main clinical manifestation is the combination of heartburn, dysphagia, and retrosternal pain.…”

Failure After Fundoplication: Re-Fundoplication? Is There a Room for Gastrectomy? In Which Clinical Scenaries?

“…The mean reported failure after fundoplication is nearly 18% (3-33%) associated with recurrent reflux symptoms or erosive esophagitis, and 4.5-20% of these patients need re-operation 5 , 20 , 21 , 29 , 51 , 52 . The reported failure in non-Barrett´s patients is 5-12% and in Barrett´s failure is observed three times more frequently, from 12 to 39%.…”