A PHYSIOLOGICAL APPROACH TO LAPAROSCOPIC FUNDOPLICATION FOR GASTROESOPHAGEAL REFLUX DISEASE

Objective The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal re flux through this single-institution study. Summary of Background Data Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surg ery. Methods Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48 ) for gastroesophageal reflux refractory to medical therapy or requiri ng daily therapy with omeprazole or high-dose H-2 antagonists. Preoper ative evaluation included symptom assessment, esophagogastroduodenosco py, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study perf ormed 6 weeks and 1 to 3 years after operation. Results The most frequ ent indication for surgery was the presence of residual typical and at ypical gastroesophageal reflux symptoms (64%) despite standard doses o f proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-ei ght percent of patients had an abnormal 24-hour pH study. Seventeen pe rcent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient(ble eding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follo w-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H-2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, ch est pain, or cough) were eliminated or improved in 87% and no better i n 13%. Overall patient satisfaction was 97%. Four patients have subseq uently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, ''slipped'' Nissen, and repair of ac ute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In pa tients with poor esophageal motility, esophageal body pressure improve d 1 year after operation in 75% and worsened in 10%. Conclusions Altho ugh long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic ap proach to evaluation and follow-up of patients with gastroesophageal d isease allows the surgeon to tailor antireflux surgery to esophageal b ody function and follow the function of the fundoplication and esophag us after operation.