AN ANALYSIS OF OPERATIONS FOR GASTROESOPHAGEAL REFLUX DISEASE - IDENTIFYING THE IMPORTANT TECHNICAL ELEMENTS

Background: Better understanding of the pathogenesis of gastroesophage al reflux disease in recent years has not been accompanied by apprecia ble advances in the design of antireflux operations. In many cases, op erations are still being performed just as they were described 30 year s ago. It is important now to go beyond the eponymous procedures tradi tionally associated with antireflux operations and to identify the tec hnical elements that contribute to effective and durable fundoplicatio ns. Objectives: To compare antireflux operations and identify the impo rtant technical elements. Design and Setting: Retrospective study in a university-based tertiary care center. Patients: Two hundred one pati ents had laparoscopic fundoplications for gastroesophageal reflux dise ase. The first 22 patients underwent Nissen-Rossetti procedures (360 d egrees wrap; no division of short gastric vessels). Subsequently, 82 p atients had a total (360 degrees Nissen wrap) fundoplication and 97 pa tients had a partial (240 degrees Guarner wrap) fundoplication (both w ith the short gastric vessels divided), with the choice between them b ased on the quality of esophageal peristalsis. The 3 groups of patient s were similar in age, duration of symptoms, incidence of hiatal herni a, and incidence of esophagitis. Main Outcome Measures: Resolution of heartburn, incidence of postoperative dysphagia, and stability of the reconstruction. Results: The resolution of heartburn was achieved for 15 patients (68%) who had the Nissen-Rossetti procedure, 73 patients ( 89%) who had a 360 degrees Nissen wrap, and 88 patients (91%) who had a 240 degrees Guarner wrap. Postoperative dysphagia occurred in 3 pati ents (14%) having the Nissen-Rossetti procedure, 5 patients (6%) havin g a 360 degrees wrap, and 2 patients (2%) having a 240 degrees wrap. H erniation or disruption of the wrap occurred postoperatively in 9 pati ents (4.5%). Review of the videotapes of these 9 operations showed tha t important technical elements had been omitted in 8. Seven patients r equired a second operation. Conclusion: Laparoscopic antireflux operat ions control symptoms without producing adverse effects if the followi ng technical elements are included: the hernia is repaired and the hia tus reduced to a normal size, the short gastric vessels are divided, a total or partial wrap is used based on the quality of esophageal peri stalsis, and the wrap is anchored in the abdomen.