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Fundoplication
Kinds of Fundoplication Selected AbstractsFUNDOPLICATION: IS LESS MORE?ANZ JOURNAL OF SURGERY, Issue 3 2008FRACS, John A. Windsor MBChB No abstract is available for this article. [source] HP09 REFLUX AFTER OESOPHAGECTOMY: CAN A FUNDOPLICATION PREVENT IT?ANZ JOURNAL OF SURGERY, Issue 2007A. Aly Introduction Oesophagectomy for oesophageal carcinoma is a major undertaking with a definite morbidity and mortality. Long term survival rates are low and post operative quality of life becomes increasingly important. When the anastomosis is in the thorax, gastro-oesophageal reflux, particularly volume reflux symptoms are common and may significantly affect quality of life. It is proposed that a fundoplication at the anastomosis may help prevent reflux symptoms. Aims The aim of this study was to compare reflux after a fundoplication type anastomosis with a standard anastomosis in patients undergoing Ivor , Lewis Oesophagectomy. Study Design Prospective randomised trial utilising standardised symptom questionnaires applied in blinded fashion. Results The fundoplication anastomosis was associated with a significant reduction in the incidence of reflux (30% vs 70%) as well as reducing the incidence of severe reflux (7% vs 25%). A total fundoplication was more effective than a partial fundoplication in preventing severe reflux. Disturbance of sleep due to reflux was significantly reduced in the fundoplication group (18% vs 47%) as was the incidence of respiratory symptoms. The fundoplication anastomosis was not associated with an increase in dysphagia. Conclusion The fundoplication anastomosis protects patients from the symptoms of reflux after oesophagectomy and improves quality of life particularly with regard sleep disturbance. [source] Medium-term outcome of fundoplication after lung transplantationDISEASES OF THE ESOPHAGUS, Issue 8 2009P. R. Burton SUMMARY Gastroesophageal reflux disease (GERD) in lung transplant recipients has gained increasing attention as a factor in allograft failure. There are few data on the impact of fundoplication on survival or lung function, and less on its effect on symptoms or quality of life. Patients undergoing fundoplication following lung transplantation from 1999 to 2005 were included in the study. Patient satisfaction, changes in GERD symptoms, and the presence of known side effects were assessed. The effect on lung function, body mass index, and rate of progression to the bronchiolitis obliterans syndrome (BOS) were recorded. Twenty-one patients (13 males), in whom reflux was confirmed on objective criteria, were included, with a mean age of 43 years (range 20,68). Time between transplantation and fundoplication was 768 days (range 145,1524). The indication for fundoplication was suspected microaspiration in 13 and symptoms of GERD in 8. There was one perioperative death, at day 17. There were three other late deaths. Fundoplication did not appear to affect progression to BOS stage 1, although it may have slowed progression to stage 2 and 3. Forced expiratory volume-1% predicted was 72.9 (20.9), 6 months prior to fundoplication and 70.4 (26.8), six months post-fundoplication, P= 0.33. Body mass index decreased significantly in the 6 months following fundoplication (23 kg/m2 vs. 21 kg/m2, P= 0.05). Patients were satisfied with the outcome of the fundoplication (mean satisfaction score 8.8 out of 10). Prevalence of GERD symptoms decreased significantly following surgery (11 of 14 vs. 4 of 17, P= 0.002). Fundoplication does not reverse any decline in lung function when performed at a late stage post-lung transplantation in patients with objectively confirmed GERD. It may, however, slow progression to the more advanced stages of BOS. Reflux symptoms are well controlled and patients are highly satisfied. Whether performing fundoplication early post-lung transplant in selected patients can prevent BOS and improve long-term outcomes requires formal evaluation. [source] Fundoplication in children with gastro-oesophageal reflux diseaseJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 2 2002AW Norrashidah Objectives: The associations between gastro-oesophageal reflux (GOR), chronic respiratory symptoms and gastrointestinal complications have been well described. The aim of this study was to compare the characteristics of children in whom the main indication for fundoplication was respiratory disease with children who had gastrointestinal indications for surgery. Methods: A retrospective review of 79 children who underwent fundoplication between January 1995 and December 1999. Results: Forty-nine of the children (62%) had a respiratory indication for fundoplication. Children with neurological impairment tended to have a respiratory rather than a gastrointestinal indication for surgery. Congenital anomalies were present in 47%. Fundoplication in older children was more likely to be for a gastrointestinal indication. Children with neurological impairment were more likely to have a gastrostomy compared to children with normal neurological status (P < 0.01). Children with a respiratory indication were more likely to have three or more diagnostic investigations (P < 0.001). Ninety-two per cent of children with a respiratory indication and 90% with a gastrointestinal indication for fundoplication had at least one positive test for GOR (barium meal or 24-h oesophageal pH monitoring). Oesophagoscopy showed reflux oesophagitis in 46/61. Eighty-five per cent of the children had complete resolution of their symptoms after fundoplication. Conclusions: Neurological comorbidity was common in children who had surgery for gastro-oesophageal reflux disease, whether for gastrointestinal or respiratory indications. The majority of fundoplications were performed for respiratory indications. [source] Characterization of reflux events after fundoplication using combined impedance,pH recording,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 1 2007S. Roman Background: Laparoscopic fundoplication effectively controls symptoms of gastro-oesophageal reflux disease (GORD) and decreases acid reflux, but its impact on non-acid reflux is not known. The aim of the study was to characterize reflux events after fundoplication using oesophageal combined multichannel intraluminal impedance (MII),pH monitoring, to demonstrate its efficacy on acid as well as non-acid reflux events. Methods: Thirty-six patients in whom ambulatory MII,pH recording was performed after laparoscopic fundoplication were reviewed retrospectively. There were 23 symptomatic and 13 asymptomatic patients, whose results were compared with those of 72 healthy volunteers. Results: Oesophageal acid exposure was low in all but one operated patient, and there was no difference between those with and without symptoms. The median number of reflux events over 24 h was lower after fundoplication (11 in operated patients compared with 44 in healthy volunteers; P < 0·001). Almost all reflux events were non-acid after surgery whereas acid reflux episodes were predominant in healthy volunteers. Proximal reflux events were less common in operated patients. Non-acid reflux events were significantly associated with symptoms after surgery in some patients. Conclusion: Fundoplication restores a competent barrier for all types of reflux. Reflux events are mostly non-acid after surgery, and such events may be positively correlated with symptoms. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Laparoscopic Heller myotomy with Dor fundoplication for achalasia: long-term outcomes and effect on chest painDISEASES OF THE ESOPHAGUS, Issue 4 2010A. Sasaki SUMMARY The aim of the present study was to evaluate the long-term outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD) and its effect on chest pain. Between June 1995 and August 2009, a total of 35 patients with achalasia underwent an LHD. The symptom scores were calculated by combining the frequency and the severity. Pre- and postoperative evaluations included symptom score, radiology, manometry, and 24-hour pH manometry. Median total symptom score was significantly lower than the preoperative score (19 vs 4, P < 0.001) at a median follow-up of 94 months. Among the 35 patients, 18 (51%) had chest pain. The frequency of chest pain was similar for the pre- and postoperative scores, but the severity tended to be less. Median esophageal diameter (5.4 cm vs 3.5 cm, P < 0.001) and lower esophageal sphincter pressure (41 mmHg vs 8.9 mmHg, P < 0.001) were significantly reduced after surgery. Median age, duration of symptoms, esophageal diameter, and lower esophageal sphincter pressure were similar between patients with and without chest pain prior to surgery. No significant differences were observed between the two groups in terms of amplitude, duration, and frequency of contractions from the findings of postoperative 24-hour esophageal manometry. Chest pain resolved in three patients (17%) and improved in seven patients (39%) after surgery. LHD can durably relieve achalasic symptoms of both dysphagia and regurgitation, and it can be considered the surgical procedure of choice. However, achalasic chest pain does not always seem to be related with patient characteristics and manometric findings. [source] Diagnosis of eosinophilic esophagitis after fundoplication for ,refractory reflux': implications for preoperative evaluationDISEASES OF THE ESOPHAGUS, Issue 3 2010Evan S. Dellon SUMMARY A small percentage of patients who carry the diagnosis of refractory gastroesophageal reflux disease (GERD) actually have eosinophilic esophagitis (EoE). The purpose of this study was to describe a series of patients who underwent fundoplication for presumed refractory GERD, but subsequently were found to have EoE. We performed a retrospective analysis of our EoE database. Patients diagnosed with EoE after Nissen were identified. Cases were defined according to recent consensus guidelines. Five patients underwent anti-reflux surgery for refractory GERD, but were subsequently diagnosed with EoE. None had esophageal biopsies prior to surgery, and in all subjects, symptoms persisted afterward, with no evidence of wrap failure. The diagnosis of EoE was typically delayed (range: 3,14 years), and when made, there were high levels of esophageal eosinophilia (range: 30,170 eos/hpf). A proportion of patients undergoing fundoplication for incomplete resolution of GERD symptoms will be undiagnosed cases of EoE. Given the rising prevalence of EoE, we recommend obtaining proximal and distal esophageal biopsies in such patients prior to performing anti-reflux surgery. [source] Influence of psychopathological changes on quality of life after laparoscopic fundoplication for the treatment of gastroesophageal refluxDISEASES OF THE ESOPHAGUS, Issue 1 2010Á. Díaz de Liaño SUMMARY There are references in medical literature to the influence of psychopathological changes and their negative impact on the results of laparoscopic fundoplication. The objective of this study is to analyze the influence of psychological changes, as assessed by the General Health Questionnaire-28 (GHQ-28), on patients undergoing surgery for gastroesophageal reflux. This is a prospective study in a series of 103 consecutive patients (62 males and 41 females with a mean age of 40 years) undergoing laparoscopic fundoplication. In addition to functional studies, patients completed the SF-36, Gastrointestinal Quality of Life Index, and GHQ-28 before surgery. Functional tests and questionnaires were repeated 6 months after surgery. Patients were also questioned about their degree of satisfaction. Postoperative results of patients with a normal GHQ-28 and patients showing psychopathological changes as defined by the GHQ-28 questionnaire before surgery were compared. Overall, all patients experienced an improvement in their quality of life. Forty-one patients showed a pathological result in the preoperative GHQ-28 questionnaire. No differences were found in functional results and degree of satisfaction with surgery between patients with normal and pathological results in the preoperative GHQ-28 questionnaire. However, patients with a pathological result in the preoperative GHQ-28 had poorer results in all domains of the postoperative Gastrointestinal Quality of Life Index and SF36 quality of life questionnaires as compared to patients with a normal preoperative GHQ-28 questionnaire. Patients with pathological results in the preoperative GHQ-28 had poorer results in terms of postoperative quality of life despite having normal postoperative physiological studies; this decreased quality of life did not have an impact on the degree of satisfaction with surgery performed. The GHQ-28 does not therefore appear to serve as a predictor of postoperative satisfaction. [source] Medium-term outcome of fundoplication after lung transplantationDISEASES OF THE ESOPHAGUS, Issue 8 2009P. R. Burton SUMMARY Gastroesophageal reflux disease (GERD) in lung transplant recipients has gained increasing attention as a factor in allograft failure. There are few data on the impact of fundoplication on survival or lung function, and less on its effect on symptoms or quality of life. Patients undergoing fundoplication following lung transplantation from 1999 to 2005 were included in the study. Patient satisfaction, changes in GERD symptoms, and the presence of known side effects were assessed. The effect on lung function, body mass index, and rate of progression to the bronchiolitis obliterans syndrome (BOS) were recorded. Twenty-one patients (13 males), in whom reflux was confirmed on objective criteria, were included, with a mean age of 43 years (range 20,68). Time between transplantation and fundoplication was 768 days (range 145,1524). The indication for fundoplication was suspected microaspiration in 13 and symptoms of GERD in 8. There was one perioperative death, at day 17. There were three other late deaths. Fundoplication did not appear to affect progression to BOS stage 1, although it may have slowed progression to stage 2 and 3. Forced expiratory volume-1% predicted was 72.9 (20.9), 6 months prior to fundoplication and 70.4 (26.8), six months post-fundoplication, P= 0.33. Body mass index decreased significantly in the 6 months following fundoplication (23 kg/m2 vs. 21 kg/m2, P= 0.05). Patients were satisfied with the outcome of the fundoplication (mean satisfaction score 8.8 out of 10). Prevalence of GERD symptoms decreased significantly following surgery (11 of 14 vs. 4 of 17, P= 0.002). Fundoplication does not reverse any decline in lung function when performed at a late stage post-lung transplantation in patients with objectively confirmed GERD. It may, however, slow progression to the more advanced stages of BOS. Reflux symptoms are well controlled and patients are highly satisfied. Whether performing fundoplication early post-lung transplant in selected patients can prevent BOS and improve long-term outcomes requires formal evaluation. [source] Short-term symptom and quality-of-life comparison between laparoscopic Nissen and Toupet fundoplicationsDISEASES OF THE ESOPHAGUS, Issue 1 2009R. Radajewski SUMMARY Laparoscopic antireflux surgery is an established method of treatment of gastroesophageal reflux disease (GERD). This study evaluates the efficacy of Nissen versus Toupet fundoplication in alleviating the symptoms of GERD and compares the two techniques for the development of post-fundoplication symptoms and quality of life (QOL) at 12 months post-surgery. In this prospective consecutive cohort study, 94 patients presenting for laparoscopic antireflux surgery underwent either laparoscopic Nissen fundoplication (LN) (n = 51) from February 2002 to February 2004 or a laparoscopic Toupet fundoplication (LT) (n = 43) from March 2004 to March 2006, performed by a single surgeon (G. S. S.). Symptom assessment, a QOL scoring instrument, and dysphagia questionnaires were applied pre- and postoperatively. At 12 months post-surgery, patient satisfaction levels in both groups were high and similar (LT: 98%, LN: 90%; P = 0.21). The proportion of patients reporting improvement in their reflux symptoms was similar in both groups (LT: 95%, LN: 92%; P = 0.68), as were post-fundoplication symptoms (LT: 30%, LN: 37%; P = 0.52). Six patients in the Nissen group required dilatation for dysphagia compared with one in the Toupet group (LT: 2%, LN: 12%; P = 0.12). One patient in the Nissen group required conversion to Toupet for persistent dysphagia (P = 0.54). In this series, overall symptom improvement, QOL, and patient satisfaction were equivalent 12 months following laparoscopic Nissen or Toupet fundoplication. There was no difference in post-fundoplication symptoms between the two groups, although there was a trend toward a higher dilatation requirement and reoperation after Nissen fundoplication. [source] Total esophagogastric dissociation in adult neurologically impaired patients with severe gastroesophageal reflux: an alternative approachDISEASES OF THE ESOPHAGUS, Issue 8 2008E. J. Hazebroek SUMMARY Patients with neuromuscular impairment, such as cerebral palsy or myotonic dystrophy, often suffer from oropharyngeal neuromuscular incoordination and severe gastresophageal reflux (GER). In 1997, Bianchi proposed total esophagogastric dissociation (TEGD) as an alternative to fundoplication and gastrostomy to eliminate totally the risk of recurrence of GER in neurologically impaired children. Little information exists about the best management for adult patients with severe neurological impairment in whom recurrent GER develops after failed fundoplication. We present our experience in three adult patients with neurological impairment in whom TEGD with Roux-en-Y esophagojejunostomy and feeding gastrostomy was performed for permanent treatment of GER. [source] Lung transplantation in patients with connective tissue disorders and esophageal dysmotilityDISEASES OF THE ESOPHAGUS, Issue 7 2008Warren J. Gasper SUMMARY., Lung and esophageal dysfunction are common in patients with connective tissue disease (CTD). Recent reports have suggested a link between pathologic gastroesophageal reflux and bronchiolitis obliterans syndrome (BOS) after lung transplant. Because patients with CTD have a high incidence of esophageal dysmotility and reflux, this group may be at increased risk of allograft dysfunction after lung transplantation. Little is known about antireflux surgery in these patients. Our aims were to describe: (i) the esophageal motility and reflux profile of patients with CTD referred for lung transplantation; and (ii) the safety and outcomes of laparoscopic fundoplication in this group. A retrospective review of 26 patients with CTD referred for lung transplantation between July 2003 and June 2007 at a single center. Esophageal studies included manometry and ambulatory 24-h pH monitoring. Twenty-three patients had esophageal manometry and ambulatory 24-h pH monitoring. Nineteen patients (83%) had pathologic distal reflux and 7 (30%) also had pathologic proximal reflux. Eighteen patients (78%) had impaired or absent peristalsis. Eleven of 26 patients underwent lung transplantation. Ten patients are alive at a median follow-up of 26 months (range 3,45) and one has bronchiolitis obliterans syndrome-1. Six patients had a laparoscopic fundoplication, 1 before transplantation and 5 after. All fundoplication patients are alive at median follow-up of 25 months (range 19,45). In conclusion, esophageal dysmotility and reflux are common in CTD patients referred for lung transplant. For this group, laparoscopic fundoplication is safe in experienced hands. [source] Outcome of floppy Nissen fundoplication with intraoperative manometry to treat sliding hiatal herniaDISEASES OF THE ESOPHAGUS, Issue 4 2008Y. Lei SUMMARY., The aim of this study was to evaluate the effectiveness of floppy Nissen fundoplication with intraoperative esophageal manometry. Between February 1992 and July 2004, there were 102 patients with sliding hiatal hernia undergoing transabdominal Nissen fundoplication. They were divided into three groups: 27 patients were in the Nissen group (CNF), 44 in the floppy Nissen group (FNF, including 5 with laparoscopic Nissen fundoplication), and 31 in the intraoperative-esophageal-manometry group (INF, 13 with laparoscopic Nissen fundoplication). There were no operation-related deaths. Operation-related complications occurred in five patients within 1 month after operation: In CNF, two patients suffered from dysphagia and one from regurgitation; in FNF, one patient had slight dysphagia and two had regurgitation; in INF, there was no one who complained about dysphagia or regurgitation, but pneumothorax occurred in one case. After more than 2 years of follow-up, two patients, in CNF, suffered from severe dysphagia, one recurred and two with abnormal 24 h pH monitoring. In FNF, one patient had dysphagia, one recurred and three had abnormal 24 h pH monitoring; in INF, two patients had acid reflux on 24 h pH monitoring. The postoperative lower esophageal sphincter pressure was in the normal range in 30 of 31 patients (96.5%). The normal rate of postoperative tests in CNF, FNF and INF were 81.5%, 86.4% and 93.5%, respectively. Both the Nissen fundoplication and the floppy Nissen fundoplication are effective approaches to treat patients with sliding hiatal hernia. Intraoperative manometry is useful in standardizing the tightness of the wrap in floppy Nissen fundoplication and may contribute to reducing or avoiding the occurence of postoperative complications. [source] Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux diseaseDISEASES OF THE ESOPHAGUS, Issue 3 2008U. Fumagalli SUMMARY., Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively. [source] Outcomes after laparoscopic Nissen fundoplication are not influenced by the pattern of refluxDISEASES OF THE ESOPHAGUS, Issue 2 2008A. T. Meneghetti SUMMARY., The purpose of this study was to compare the outcomes of patients with different types of gastroesophageal reflux disease (upright, supine, or bipositional) after laparoscopic Nissen fundoplication and determine if patients with upright reflux have worse outcomes. Two hundred and twenty-five patients with reflux confirmed by 24-h pH monitoring were divided into three groups based on the type of reflux present. Patients were questioned pre- and post-fundoplication regarding the presence and duration of symptoms (heartburn, regurgitation, dysphagia, cough and chest pain). Symptoms were scored using a 5-point scale, ranging from 0 (no symptom) to 4 (disabling symptom). Esophageal manometry and pH results were also compared. There was no statistically significant difference in lower esophageal sphincter length, pressure or function between the three groups. There was no significant difference in any of the postoperative symptom categories between the three groups. The type of reflux identified preoperatively does not have an adverse effect on postoperative outcomes after Nissen fundoplication and should not discourage physicians from offering antireflux surgery to patients with upright reflux. [source] Levels of evidence available for techniques in antireflux surgeryDISEASES OF THE ESOPHAGUS, Issue 2 2007M. Neufeld SUMMARY., The objective of this study was to determine the levels of evidence and grades of recommendations available for techniques in antireflux surgery. Areas of technical controversy in antireflux surgery were identified and developed into eight answerable questions. The external evidence was surveyed using the databases Medline and EMBASE. Abstracts and appropriate articles were identified from January 1966 to December 2005. A set of search strategies was systematically employed to determine the levels of evidence available for each clinical question. Primary outcome measures included the determination of levels of evidence and grade of recommendation based on The Oxford Center for Evidence-Based Medicine. Secondary outcome measures included for randomized controlled trials were Jadad scores, noting the presence of a sample size calculation, and the determination of an effect estimate and the reporting of a confidence interval. Higher quality randomized controlled trials (mostly level 2b, occasional level 1b) existed to answer three questions: whether to complete a 360° or partial wrap; whether or not to divide the short gastric vessels; and whether to perform laparoscopic or open surgery. Lower quality randomized controlled trials were available to determine whether the use of mesh was helpful, whether or not to use a bougie catheter for calibration of the wrap, and whether an anterior or posterior wrap results in a superior outcome. This was deemed to be of inferior grade of recommendation due to the lack (< 2) of trials available and the sole presence of level 2b evidence. The final two questions: whether to complete fundoplication using a thoracic or abdominal approach and whether to use intraoperative manometry relied exclusively upon level 4 evidence and thus received a lower grade of recommendation. A higher Jadad score seemed to be associated with studies having a higher level of evidence available to answer the question. Sample size calculations were given to answer three questions. Effect estimate was difficult to interpret given inconsistent findings, composite outcomes and lack of reported confidence intervals. In conclusion, antireflux surgery has many randomized controlled trials available upon which to base clinical practice. Unfortunately, these are generally of poor quality. We recommend that esophageal surgeons determine consistent outcome measures and endeavor to improve the quality of randomized controlled trials they perform. [source] The lower esophageal sphincter strength in patients with gastroesophageal reflux before and after laparoscopic Nissen fundoplicationDISEASES OF THE ESOPHAGUS, Issue 1 2007J. H. Schneider SUMMARY., Lower esophageal sphincter pressure (LESP) and sphincter strength (LESS) were measured before and after short and floppy laparoscopic Nissen fundoplication (LNF) in 38 patients with severe gastro-esophageal reflux disease (GERD). These patients were compared with a control group of 23 healthy volunteers. GERD was assessed by stationary manometry, 24-h pH recordings and endoscopy. LESS was verified by motorized pull-back of an air-filled balloon catheter from the stomach into the esophagus. The catheter assembly was well tolerated by all study participants. LESP increased significantly after operation from 8 mmHg to 14 mmHg (75% of normal values; P < 0.0001), but compared to the control group, LESP (22 mmHg) decreased significantly (P < 0.002). In the control group and in patients with GERD, LESP and LESS showed excellent correlation (r = 0.97, r = 0.94, respectively). After LNF, LESS increased significantly from 0.6 to 1.6 N (P < 0.0001), about 166%. We conclude that the measurement of LESS is able to explain the discrepancy between satisfactory NF operation and the distinct increase of postoperative LESP. The evaluation of LESS is a helpful tool in assessing functional understanding of laparoscopic Nissen fundoplication with a short and floppy wrap. [source] Multichannel intraluminal impedance for the assessment of post-fundoplication dysphagiaDISEASES OF THE ESOPHAGUS, Issue 5 2006T. Yigit SUMMARY., Dysphagia often occurs after fundoplication, although its pathophysiology is not clear. We sought to better understand postfundoplication dysphagia by measuring esophageal clearance with multichannel intraluminal impedance (MII) along with more traditional work-up (manometry, upper gastrointestinal imaging [UGI], endoscopy). We evaluated 80 consecutive patients after laparoscopic fundoplication between April 2002 and November 2004. Patients were evaluated clinically and underwent simultaneous manometry and MII, 24-hour pH monitoring, endoscopy, and UGI. For analysis, patients were divided into the following groups based on the presence of dysphagia and fundoplication anatomy (by UGI/endoscopy): (1) Dysphagia and normal anatomy; (2) Dysphagia and abnormal anatomy; (3) No dysphagia and abnormal anatomy; and (4) No dysphagia and normal anatomy. Patients with dysphagia (Groups 1 & 2) had similar peristalsis (manometry), but were more likely to have impaired clearance by MII (32 pts, 62%) than those without dysphagia (9 pts, 32%, P = 0.01). Patients with abnormal anatomy (Groups 2 & 3) were also more likely to have impaired esophageal clearance (66%vs. 38%, P = 0.01). Finally, of patients that had normal fundoplication anatomy, those with dysphagia were much more likely to have impaired clearance (12 pts, 52%) than those with dysphagia (4 pts, 21%, P = 0.03). MII after fundoplication provides objective evidence of esophageal clearance, and is commonly abnormal in patients with abnormal fundoplication anatomy and/or dysphagia. Esophageal clearance is impaired in the majority of patients with postoperative dysphagia, even with normal fundoplication anatomy and normal peristalsis. MII may detect disorders in esophageal motility not detected by manometry. [source] Laparoscopic fundoplication in mentally normal children with gastroesophageal reflux diseaseDISEASES OF THE ESOPHAGUS, Issue 2 2002K. V. Menon SUMMARY., Laparoscopic antireflux surgery has been performed in neurologically impaired and scoliotic children. We aimed to assess the effectiveness of laparoscopic fundoplication in mentally normal children with gastroesophageal reflux disease that failed to respond to medical therapy. Data were prospectively collected (symptoms, medical therapy, endoscopies' findings) on 12 children (nine boys, three girls) aged 9,15 years with gastroesophageal reflux disease. Pre- and postoperative ambulatory 24-h pH and DeMeester and Johnson scores were also recorded. Effectiveness of surgery was assessed by comparison of pre- and postoperative total acid exposure time, Visick grade, need for antireflux medication and symptom scores. In total, 11 children underwent a laparoscopic Nissen fundoplication and one underwent a Toupet procedure. Median length of stay was 2 (2,3) nights. The median preoperative pH acid exposure time (AET) was 4.7 (0.8,16.4) percent compared with postoperative AET of 0.4 (0,3) percent. Early postoperative dysphagia occurred in four out of 12 patients, requiring a total of six dilatations. Postoperative Visick scores were: grade I=7 and grade II=5. Laparoscopic fundoplication can be safely performed and is effective in children with GERD who have failed to respond to medical therapy. [source] Reproducibility, validity, and responsiveness of a disease-specific symptom questionnaire for gastroesophageal reflux diseaseDISEASES OF THE ESOPHAGUS, Issue 4 2000C. J. Allen The purpose of this study was to establish the reproducibility, validity, and responsiveness of a symptom questionnaire to assess patients with gastroesophageal reflux disease (GERD). A total of 300 patients with GERD completed questionnaires before and 6 months after laparoscopic Nissen fundoplication. Forty-six GERD patients who continued on omeprazole served as controls. Lower esophageal sphincter pressure, 24-h pH, and quality of life (SF36) were measured at baseline and follow-up. Reproducibility was calculated as an intraclass correlation coefficient (ICC) from a repeated-measures analysis of variance on symptom scores (SS) on two consecutive days. Validity was established by correlating SS with 24-h pH and SF36 scores. Responsiveness was calculated as the the ratio of the mean paired difference in score in the surgical group to the within-subject variability in control subjects. Reproducibility was very high, as revealed by an ICC of 0.92. Strong correlations between SS and SF36 scores at baseline and after surgery demonstrated high cross-sectional validity. Correlation between change in SS and change in pH, SF36 pain, general health, and physical health scores demonstrated longitudinal validity. The mean (95% confidence interval) paired differences in SS were 25.6 (23.7, 27.5) in the study and 2.0 (,3.2, 7.3) in the control groups, and the responsive index was 1.0. The estimated minimally important clinical difference was 7. We conclude that the symptom score is a reproducible, valid, and responsive instrument for assessing symptoms caused by GERD. [source] Non-erosive reflux disease, functional heartburn and gastroesophageal reflux disease; insights into pathophysiology and clinical presentationJOURNAL OF DIGESTIVE DISEASES, Issue 4 2006Eamonn MM QUIGLEY Non-erosive reflux disease (NERD) has emerged as a real entity in the spectrum of gastroesophageal reflux disease (GERD) and may, indeed, represent the most common manifestation of reflux disease. Recent information indicates NERD can be further subclassified based on the results of pH studies and suggests that functional heartburn needs to be differentiated as that subgroup of patients in which there appears to be no relationship between symptoms, however ,typical' of GERD, and acid exposure. Other aspects of NERD need to be appreciated, including overlap with functional dyspepsia and the potential variations in response to such therapeutic interventions as acid-suppressive therapy and fundoplication. It seems quite possible that our failure to separate functional heartburn from NERD, in general, has contributed, in large measure, to diagnostic difficulties and therapeutic disappointment in GERD. An appreciation of the range of entities, of different etiology and pathology, within NERD will foster the development of effective approaches to the assessment and therapy of this challenging disorder. [source] Fundoplication in children with gastro-oesophageal reflux diseaseJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 2 2002AW Norrashidah Objectives: The associations between gastro-oesophageal reflux (GOR), chronic respiratory symptoms and gastrointestinal complications have been well described. The aim of this study was to compare the characteristics of children in whom the main indication for fundoplication was respiratory disease with children who had gastrointestinal indications for surgery. Methods: A retrospective review of 79 children who underwent fundoplication between January 1995 and December 1999. Results: Forty-nine of the children (62%) had a respiratory indication for fundoplication. Children with neurological impairment tended to have a respiratory rather than a gastrointestinal indication for surgery. Congenital anomalies were present in 47%. Fundoplication in older children was more likely to be for a gastrointestinal indication. Children with neurological impairment were more likely to have a gastrostomy compared to children with normal neurological status (P < 0.01). Children with a respiratory indication were more likely to have three or more diagnostic investigations (P < 0.001). Ninety-two per cent of children with a respiratory indication and 90% with a gastrointestinal indication for fundoplication had at least one positive test for GOR (barium meal or 24-h oesophageal pH monitoring). Oesophagoscopy showed reflux oesophagitis in 46/61. Eighty-five per cent of the children had complete resolution of their symptoms after fundoplication. Conclusions: Neurological comorbidity was common in children who had surgery for gastro-oesophageal reflux disease, whether for gastrointestinal or respiratory indications. The majority of fundoplications were performed for respiratory indications. [source] Thoracic epidural catheters via the caudal and lumbar approaches using styletted multiple port catheters in pediatric patients: a report of three casesACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2006B. C. H. Tsui Advancing catheters from the lumbar and caudal epidural spaces to the thoracic level has been reported to be an alternative to the direct thoracic approach. However, as children grow, the threading of catheters in the epidural space becomes increasingly difficult. This report describes three cases of thoracic epidural placement using a multiport catheter threaded from the caudal and lumbar spaces using electrical stimulation guidance. In the first case, a multiport catheter was threaded 22 cm from the lumbar space to T8 following a failed attempt with a single-port catheter in a 9-year-old boy scheduled to undergo a right nephrectomy. In the second case, a multiport catheter was threaded 26 cm from the caudal space to T9 in a 3-year-old girl undergoing fundoplication. In the last case, a multiport catheter was inserted at the completion of a fundoplication in a 2-year-old girl after it had been confirmed that the single-port catheter inserted prior to surgery had not advanced to the desired thoracic level. The multiport catheter was threaded 17 cm without resistance from the caudal space to T9. In all cases, electrical stimulation was used to confirm the location of the catheter tip at the time of insertion. The position of the catheters was later confirmed by X-ray. The multiport catheter incorporates a stylet, which extends to a closed distal tip, within a catheter body that ejects fluid from three lateral holes in a direction perpendicular to the advancing catheter. These properties may facilitate the reliable advancement of catheters in the epidural space. [source] Review article: the role of surgery in gastro-oesophageal reflux diseaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 12 2007N. VAKIL Summary Background, Rates for laparoscopic fundoplication are declining in the United States and there is no consensus on the indications for referral to surgery in gastro-oesophageal reflux disease. Aim, To highlight recent studies on the outcomes of laparoscopic fundoplication in adults that cast doubt on the traditional indications for surgery in reflux disease. Results, Patients who are well maintained on medical therapy have more to lose with surgical intervention than to gain, and should not be offered surgery. Likewise, the notion that surgery prevents oesophageal cancer is a hypothesis that is not supported by current evidence, therefore surgical intervention should not be offered to these patients. The only clear-cut candidates for surgery include: patients with anatomic abnormalities such as a large hiatus hernia, or those with persistent regurgitation that causes troublesome symptoms despite medical therapy; and carefully selected patients with extra-oesophageal disorders who have symptoms of reflux disease such as heartburn and regurgitation, an incomplete response to medical therapy and persistent plus demonstrable reflux on pH or impedance testing that is associated with their symptoms. Patients should be aware of the high likelihood of needing continued acid inhibitory therapy following surgery and the possibility of side-effects. Conclusion, Only a few carefully selected patients should undergo fundoplication for reflux disease. [source] Is epidural analgesia associated with an improved outcome following open Nissen fundoplication?PEDIATRIC ANESTHESIA, Issue 1 2001G.A.M. Wilson FRCA Postoperative epidural analgesia is increasingly popular in paediatric practice, although evidence of its benefit is scarce. We performed a retrospective analysis of a series of 104 consecutive open Nissen fundoplications, to determine whether mode of analgesia, epidural (n=65) or opioid infusion (n=39), influenced certain outcome measures, including intensive care utilization, duration of hospital stay, morbidity and mortality. The two groups were similar in terms of demographic characteristics and associated pathologies. Overall, morbidity and mortality (2%) rates were low. Mean duration of hospital stay was significantly greater for the opioid group, compared to those receiving epidural analgesia (13 vs. 8 days, P < 0.05). The number of patients who remained in hospital for more than 7 days was also significantly greater in the opioid group. Accepting the limitations of a retrospective study, these data suggest that epidural analgesia might be associated with an improved outcome following Nissen fundoplication and this merits a prospective study. [source] Laparoscopic surgery in neonates and infants weighing less than 5 kgPEDIATRICS INTERNATIONAL, Issue 6 2000Tadashi Iwanaka Background: Laparoscopic surgery in small infants is still an uncommon procedure in Japan. The present study was conducted to evaluate the advantages and disadvantages of laparoscopic surgery in neonates and infants weighing less than 5 kg. Methods: Between July 1997 and November 1999, 54 infants underwent laparoscopic surgery. They were evaluated for length of operation, intra- and postoperative complications, changes in intra-operative body temperature, time to postoperative feeding, length of hospital stay and changes in serum levels of C-reactive protein (CRP), creatinine phosphokinase (CPK) and interleukin (IL)-6 on days 0, 1 and 4. These parameters in the laparoscopic pyloromyotomy (LP) and laparoscopic fundoplication groups were compared with those in the open pyloromyotomy (OP) and open fundoplication groups, respectively, which were performed during the same period. Results: Three laparoscopy cases were converted to open procedures. One case of fundoplication had panperitonitis due to failed gastrostomy and required long-term parenteral nutrition. Time to postoperative feeding and length of hospital stay in the LP group were significantly shorter than in the OP group. In LP group, intra-operative body temperature did not markedly decrease during CO2 pneumoperitoneum. Although serum levels of CRP, CPK and IL-6 were elevated in all groups on postoperative day 1, there were no significant differences between the groups. Conclusions: Better quality of life after laparoscopy is a significant advantage over conventional surgical procedures. This advantage not only outweighs the incidence of intra- and postoperative complications in small infants, but further emphasizes the need to improve laparoscopic techniques to avoid complications. [source] Robotic vs. laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease: systematic review and meta-analysisTHE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, Issue 2 2010S. R. Markar Abstract The aim of this meta-analysis was to compare clinical outcome following laparoscopic and robotic Nissen fundoplication. A systematic literature search of Medline, Embase and Cochrane Library databases was performed. Primary outcome measures were the requirement for re-operation, postoperative mortality and postoperative dysphagia. Secondary outcome measures were operative time, length of hospital stay, operative complications and cost. Six randomized trials, of 226 patients, were included in this meta-analysis. There was no significant difference in requirement for re-operation or in postoperative dysphagia. There was a significantly reduced total operative time in the laparoscopic group (weighted mean difference = 4.154; 95% CI = 1.932,6.375; p = 0.0002). There was no significant difference between robotic and laparoscopic groups for hospital stay or operative complications. Clinical results from robotic Nissen fundoplication were comparable to the standard laparoscopic approach, but there was associated increased operative time and procedure cost. Copyright © 2010 John Wiley & Sons, Ltd. [source] Randomized controlled trial of laparoscopic anterior versus posterior fundoplication for gastro-oesophageal reflux diseaseANZ JOURNAL OF SURGERY, Issue 7-8 2010Mansoor Khan Abstract Background:, The aim of the study was to compare the effect of laparoscopic anterior and posterior fundoplication on gastro-oesophageal reflux disease by means of a prospective randomized controlled trial. Methods:, One hundred and three patients were randomised to undergo either anterior (53) or posterior (50) fundoplication. Initial enrolment and subsequent clinical appointments were undertaken 1, 3, 6 and 12 months after the procedure using a standardized questionnaire. Ambulatory pH monitoring and manometry were undertaken both preoperatively and at approximately 3 months post-procedure. Results:, The mean operating time was similar in both groups (48 versus 52 min). Two operations in each group were converted to open surgery. Post-operative dysphagia in the first month was higher in the posterior fundoplication group compared with the anterior group (at 1 month, P= 0.002; and at 3 months, P= 0.014). The number of individuals suffering from post-operative heartburn was greater in the anterior fundoplication group (at 1 month, P= 0.008; at 3 months, P < 0.001; and at 6 months, P= 0.002). Eight individuals required reoperation in the anterior group and two individuals in the posterior group (P= 0.057). Conclusion:, Anterior and posterior fundoplication each have their advantages and disadvantages. There is an increased risk of early post-operative dysphagia after posterior fundoplication. Anterior fundoplication carries a greater risk of persistent or recurrent reflux. Overall, a posterior fundoplication produces a better management option for controlling gastro-oesophageal reflux disease when compared with an anterior fundoplication technique which utilizes unilateral fixation of the gastric fundus. [source] HP09 REFLUX AFTER OESOPHAGECTOMY: CAN A FUNDOPLICATION PREVENT IT?ANZ JOURNAL OF SURGERY, Issue 2007A. Aly Introduction Oesophagectomy for oesophageal carcinoma is a major undertaking with a definite morbidity and mortality. Long term survival rates are low and post operative quality of life becomes increasingly important. When the anastomosis is in the thorax, gastro-oesophageal reflux, particularly volume reflux symptoms are common and may significantly affect quality of life. It is proposed that a fundoplication at the anastomosis may help prevent reflux symptoms. Aims The aim of this study was to compare reflux after a fundoplication type anastomosis with a standard anastomosis in patients undergoing Ivor , Lewis Oesophagectomy. Study Design Prospective randomised trial utilising standardised symptom questionnaires applied in blinded fashion. Results The fundoplication anastomosis was associated with a significant reduction in the incidence of reflux (30% vs 70%) as well as reducing the incidence of severe reflux (7% vs 25%). A total fundoplication was more effective than a partial fundoplication in preventing severe reflux. Disturbance of sleep due to reflux was significantly reduced in the fundoplication group (18% vs 47%) as was the incidence of respiratory symptoms. The fundoplication anastomosis was not associated with an increase in dysphagia. Conclusion The fundoplication anastomosis protects patients from the symptoms of reflux after oesophagectomy and improves quality of life particularly with regard sleep disturbance. [source] Systematic review of day-case laparoscopic Nissen fundoplicationANZ JOURNAL OF SURGERY, Issue 3 2005Raphael Ng Background: Laparoscopic Nissen fundoplication is increasingly being performed on a day-case basis. The aim of the present paper was to systematically review published data on day-case or ambulatory laparoscopic fundoplication and discuss the differing criteria for patient selection, postoperative management and patient outcomes presented in each series. Methods: An optimally sensitive search strategy of subject headings and text words were used and the databases used included MEDLINE, PubMed and the Cochrane Library. All databases were searched from 1 January 1994 onwards. Results: A total of seven papers were included in the present review, of which six were prospective single-cohort studies. Overall, there was large heterogeneity among the studies but with similar complication and readmission rates. Conclusions: Short-term outcomes for laparoscopic Nissen fundoplication in terms of complications and readmission rates are comparable to inpatient procedures. However there is a paucity of published data. [source] | ||||||||||||||||||||||||||||