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Laparoscopic Fundoplication

Roy V Patankar*, Ravindra Ramadwar**, Vardhan Bhobe***
 

Historical Background
In 1956, Rudolf Nissen reported that a patch of fundus of stomach wrapped around the distal oesophagus relieved the symptoms of gastroesophageal reflux (GERD).1 Since then GERD is reported to be increasingly common disorder that substantially impacts the patient’s quality of life. The laparoscopic fundoplication was first reported in 1991 by Dallemagne et al.2

Review of Literature
In 1993, Cuschieri studied the outcome of 116 laparoscopic fundoplication in a multicentre study and reported excellent results in more than 95% patients.3 Coller et al reported on 758 laparoscopic fundoplication in 1995 with a postoperative morbidity in 4% and conversion to open surgery in 4%.4 Dallemagne et al (1998) reported symptomatic relief of symptoms in 98% of 622 patients with morbidity in 2% and conversion to open surgery in 1%.5 Laparoscopic fundoplication for paraoesophageal hernia was able to relieve symptoms in 91% patients on 3 year follow up.6 Laparoscopic fundoplication is the second most common laparoscopic surgery after laparoscopic cholecystectomy. Laparoscopic fundoplication has significantly tilted the balance towards early surgical intervention in GERD and has stood the test of time unlike endoscopic methods.7

The prevalence of GERD in Asia is on the rise.8

Indications
Antireflux surgery is indicated in all patients with

  1. Large hiatus hernia
  2. Oesophageal stricture due to GERD
  3. Barrett’s oesophagus
  4. Patients with atypical or respiratory symptoms
  5. Unwilling for long term proton-pump inhibitors (PPI)
  6. Side effects of PPI
  7. Financial burden of long term PPI
  8. High risk group – lower oesophageal sphincter (LES) pressure less than 10 mm Hg, nocturnal reflux on pH study

All patients must undergo upper gastrointestinal tract endoscopy. If findings are equivocal, 24 hour pH study should be performed. All patients should also have a pre-operative manometry performed.

Contraindications to laparoscopic fundoplication are 1) Hypertensive LES and 2) Short oesophagus where oesophageal lengthening is required. Other relative contraindications based on the experience of the surgeon are – patients with large left lobe of liver, morbid obesity, previous upper gastrointestinal surgery, and large paraoesophageal hernia.

Preoperative evaluation involves assessment that GERD is the cause of patient’s symptoms, evaluating the severity of GERD, whether oesophageal shortening is present and motility of the oesophagus and gastric emptying.

Principles of laparoscopic fundoplication
1. Tightening of the crura and closure of defect in the diaphragm
2. Placement of at least 5 cms of oesophagus in the abdomen
3. Reconstruction of the angle of His preserving both the vagus nerves
4. Creating a antireflux valve by wrapping fundus of the stomach on the lower end of oesophagus

Technique

  • Head high 300, patient in lazy lithotomy (French) position
  • Modified Nathanson liver retractor used to expose crurae with monitor placed above left shoulder and surgeon between patient's legs
  • 300 Telescope and 5 ports are used
  • Meticulous dissection around oesophagus with a Foleys catheter looping GE junction.
  • Fundus of stomach is completely mobilized using harmonic shears to include anterior and posterior attachments so that entire upper ½ of greater curvature is freed
  • Intercrural suturing with 2-0 prolene without use of a bougie, which may lead to oesophageal perforation and makes no difference to incidence of post-operative dysphagia9
  • 360° loose wrap Nissen type
  • Nasogastric tube is removed immediate post-operatively and patient commenced on clear liquids 12 hours after the surgery

We have performed 142 Nissen fundoplication over last 8 years and have developed a standardized technique of a full, floppy wrap combined with intercrural repair.

Predicting Outcomes
Patients with atypical symptoms or those that do not respond to PPI therapy, do poorly. Improved quality of life and overall satisfaction are more likely with male gender, no previous abdominal surgery, hiatus hernia and abnormal pH studies. No association is seen with age, weight and duration of symptoms.10 Use of Fundoplication in the elderly populations remains limited due to a perception of “High Surgical Risk” among referring physicians. A study by Khajanchi has shown that laparoscopic fundoplication in elderly patients is not only safe but has equally good results as in young patients.11 Problems associated with surgery are dysphagia less than 1% in our series, which was temporary and lasted for maximum 20 days in one patient. Good mobilization of the stomach with a quantified intercrural repair avoids the problem. Gas bloating and inability to vomit though described has not been a problem in our patients. Incidence of side effects and results of laparoscopic fundoplication is surgeon dependent and high volume centres offer better results.12

Laparoscopic versus alternative approaches
Open fundoplication following the same principles as mentioned above has equally good results. However open fundoplication is more cumbersome to perform, visualization of the oesophageal hiatus is poor, mediastinal dissection required for oesophageal mobilization is blind, time to postoperative feeding is longer, with higher rate of postoperative chest complications, more analgesia requirements, longer hospital stay and a large midline scar.

The alternative approach that is described is endostitch where at upper GI Endoscopy a stitch is taken on the stomach to create the angle of His. The stitch is placed only in the mucosa. It does not follow the principles of antireflux surgery discussed above and hence the failure rates are high.7

Current Status
Laparoscopic fundoplication is the gold standard in the treatment of severe GERD and large hiatus hernia.

References

  1. Nissen R: Eine ainfache operation zur beeinflussung der refluxoesophagitis. Schweiz Med Wochenschr. 1956;86-:590-2.
  2. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: Preliminary report. Surg Laparosc Endosc 1991;1(3):138-43.
  3. Cuschieri A, Hunter J, Wolfe B, et al. Multicentre prospective evaluation of laparoscopic antireflux surgery: Preliminary report. Surg Endosc 1993;7:505-10.
  4. Coller D, Cadiere GB. Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease. Am J Surg 1995;169:622-6.
  5. Dallamagne B, WeertsJM, Jeahaes C, et al. Results of laparoscopic Nissen fundoplication. Hepatogastroenterology 1998;45:1338-43.
  6. Edye M, Salky B, Posner A, et al. Sac excision is essential to adequate laparoscopic repair of paraoesophageal hernia. Surg Endosc 1998;12:1259-63.
  7. Booth MI Jones L. Results of laparoscopic Nissen fundoplication at 2-8 years after surgery. Bri J of Surg 2002;89:476-81.
  8. Monabe N. Hazurro K. The increasing incidence of reflux oesophagitis during the past 20 years in Japan. Gastroenterology 1999;166:A244.
  9. Walsh JB, et al. Patient outcomes and dysphagia after laparoscopic anti-reflux surgery performed without use of intra-op esophageal dilators. Am Surg 2003;69(3):219-23.
  10. O Boyle CJ Watson DI De Beaux AC. Pre-op predictors of long term outcome after lap. fundoplication. Aust NJ Surg 2002;72:471-5.
  11. Khajanchi YS. Urbach DR. Butler. Laparoscopic anti-reflux surgery in the elderly. Surgical outcome and effect on quality of life. Surg Endosc 2002;16:25-30.
  12. Hent J Brun J Fendrich AM. An evidence based appraisal of reflux disease management. The Genval workshop report. Gut 1999;Suppl 2;44.

 

DOES HOMOEOPATHY WORK?

`There was no convincing evidence that homoeopathy was superior to placebo'
Despite the apparent implausibility of homoeopathy, favourable evidence in trials has been reported. Aijing Shang and colleagues investigated whether the positive findings for such treatment could be due to bias in the conduct and reporting of trials. In their comparative study of 110 homoeopathy trials and 110 matched conventional-medicine trials, smaller, lower quality trials showed more beneficial effects of homoeopathy. Restricting analysis to large, high-quality trials revealed weak evidence in favour of homoeopathy, but strong evidence for conventional medicine. In a Comment, Jan Vandenbroucke reflects that although science is prone to human bias, data such as these countribute to a more accurate picture of reality. An editorial calls for doctors "to be bold and honest with their patients about homeopathy's lack of benefit".

BMJ, 2005; 690, 691, 726.


THE FAILURE OF ANTIBIOTICS TO PREVENT HEART ATTACKS

Two recent trials have shed important light on the theory that the respiratory pathogen Chlamydia pneumoniae might cause atherosclerotic cardiovascular disease.
Although C pneumoniae organisms, whole or in part, often exist in diseased arteries, antibiotics with antichlamydial activity have no protective effect.
The result of a trial of clarithromycin in patients waiting for coronary artery bypass surgery is also discouraging because the antibiotic did not reduce the prevalence of the main outer protein of C pneumoniae.

BMJ, 2005; 331 : 361.

*Consultant Gastrointestinal and Laparoscopic Surgeon; ***Senior Registrar, Institute for Special Surgery, Joy Hospital, Chembur, Mumbai. **Honorary Consultant Paediatric Surgeon, Bombay Hospital, Mumbai
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