SUCCESSFUL MANAGEMENT OF SEVERE GASTROESOPHAGEAL REFLUX DISEASE WITH LAPAROSCOPIC NISSEN FUNDOPLICATION

BACKGROUND: Nissen fundoplication has been shown to be superior to med ical treatment in the management of severe or complicated gastroesopha geal reflux disease (GERD). Rapid advances in minimally invasive surgi cal techniques and recognition of the advantages of reduced incision-r elated morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 10 patients undergo ing laparoscopic Nissen fundoplication for severe GERD was undertaken. PATIENTS AND METHODS: Rigid selection criteria for laparoscopic Nisse n fundoplication included severe or refractory disease with documentat ion of abnormal esophageal acid exposure by 24-hour pH probe monitorin g, documentation of a mechanically defective lower esophageal sphincte r by esophageal manometry, and absence of severe esophageal and/or gas tric motility disorders. RESULTS: Sixty-eight of 70 patients were comp leted laparoscopically with an intraoperative morbidity rate of 9%. Ma jor postoperative complications occurred in 3 patients (4%) and includ ed deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and t rocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 1.0 days. All patie nts experienced relief of symptoms of reflux with mean follow-up of 7. 7 months. Transient, mild dysphagia was experienced by 37% of patients , and persistent, severe dysphagia by 7%. The mean increase in lower e sophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdom inal sphincter lengths increased an average of 1.5 and 1.4 cm, respect ively. CONCLUSIONS: These preliminary data suggest that laparoscopic N issen fundoplication can be performed by experienced laparoscopic surg eons with excellent symptomatic and physiologic results and a morbidit y rate comparable to conventional open antireflux procedures. Rigid pa tient selection criteria will help identify the patients most likely t o benefit from reconstruction of a mechanically defective lower esopha geal sphincter. Adherence to established operative principles for Niss en fundoplication will reduce the incidence of significant postfundopl ication symptoms.