Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia

Background: Laparoscopic fundoplication has become the standard for operati ve treatment of gastroesophageal reflux disease (GERD). Methods: We reviewed our experience with 1,000 consecutive patients receivi ng laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and f ailed fundoplication were excluded from analysis. All the patients were eva luated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patien ts with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. P rocedures performed were 360 degrees floppy fundoplication (n = 879), 360 d egrees fundoplication without fundus mobilization (Rossetti) (n = 22), 270 degrees posterior fundoplication;(n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed i n combination with fundoplication in 15 patients. In seven patients the tre atment was converted to open fundoplication. Outcomes: The average length of hospitalization was 2.2 days, and 136 patie nts stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n = 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest(n = 1), pneumonia (n = 3), and tes ticular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with parae sophageal hernia. There were 35 late failures requiring reoperation for rec urrence of GERD or development of new symptoms: The treatment of 32 patient s was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients w ere satisfied with their surgical outcome.