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ABSTRACT: Many centers practice a tailored approach to laparoscopic antireflux surgery in attempt to prevent postoperative side effects in gastroesophageal reflux disease (GERD) patients with an impaired esophageal motility. As a result of controversial findings reported in literature no worldwide accepted consensus exists regarding the appropriate indication for this tailored approach. The aim of this prospective study was to evaluate quality of life and symptomatic outcome in selected patients for a follow-up of 3 to 5 years.
A total of 155 patients with esophageal dismotility underwent laparoscopic Toupet fundoplication (LTF). Basic requirements for surgery included in all patients a detailed evaluation of symptoms and quality of life (Gastrointestinal Quality of Life Index [GIQLI]), esophagogastroduodenoscopy, 24-hour pH monitoring, and esophageal manometry. Patients were evaluated 6 weeks, 3 months, 1 year, and 3 to 5 years after LTF.
GERD-related symptoms such as heartburn, regurgitation, dysphagia, or chest pain showed a significant improvement (P <0.05 to 0.001) in all gradings immediately after surgery. During the complete follow-up, a total of 4 patients (2.6%) required laparoscopic redo surgery because of recurrent GERD symptoms. Two patients (1.3%) were adequately maintained on short-term proton pump inhibitor therapy because of mild symptoms. All these patients have shown a pathological DeMeester score within the early period after surgery (3 months or 1 year control). Severe and persistent side effects have been present in 7 patients (4.5%), mild to moderate side effects in 11 patients (7.1%). Other side effects have been temporary and resolved spontaneously. GIQLI improved significantly (P <0.05 to 0.01) in all dimensions and persisted for at least 5 years with mean values comparable with healthy individuals.
LTF is effective, well tolerated, and improves quality of life, improving long-term outcome with an acceptable rate of long-term side effects in GERD patients with moderate to severe esophageal dismotility for a follow-up period of 3 to 5 years.
The American Journal of Surgery 03/2002; 183(2):110-6. · 2.78 Impact Factor
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ABSTRACT: Antireflux surgery has a failure rate between 5 and 20%. Laparoscopic redo-surgery is feasible, but little is known about the surgical outcome in elderly patients. The aim of this prospective study was to evaluate early surgical experience and outcome, including quality of life, after laparoscopic refundoplication in patients older than 65 years.
Eleven patients, mean age of 71 years (range: 65-78), underwent laparoscopic redo-surgery. Six patients had the former antireflux procedure performed by the open technique, one having had it twice, one had both laparoscopic and open antireflux procedures, and in 4 the primary intervention was performed laparoscopically. Quality of life was evaluated by using the Gastrointestinal Quality of Life Index. All patients were evaluated prior to surgery, and at 3 months and 12 months after laparoscopic refundoplication, as well as with esophageal manometry and 24-hour pH-monitoring.
Redo-procedures were completed laparoscopically in 10 patients. In one patient conversion to an open laparotomy was necessary because of severe bleeding from the spleen. One patient had an injury to the gastric wall, successfully managed laparoscopically. Postoperatively, one patient had moderate dysphagia for a period of two months, another had epigastric pain for the same period. Esophageal manometry and 24-hour pH-monitoring showed normal values in all patients after redo-surgery. Prior to redo-surgery, the mean Gastrointestinal Quality of Life Index was 85.2 points. Three months (mean: 119.8 points) and one year (mean: 119.2 points) after laparoscopic reoperation the general score increased significantly (P < 0.01) and attained the equivalent level of comparable healthy individuals (118.7 points).
Laparoscopic refundoplication in the elderly patient is feasible, safe and an effective treatment after failed antireflux surgery. Older patients with failed antireflux surgery have poor quality of life. Laparoscopic redo-surgery improves quality of life significantly to the level of healthy individuals and normalizes objective outcome criteria without any long-term restrictions in daily life.
Hepato-gastroenterology 49(45):865-8. · 0.66 Impact Factor
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ABSTRACT: It is well known that there is an interaction between physiological and psychological aspects of gastrointestinal diseases, also in esophageal symptoms. Based on this bio-psycho-social interaction, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) is really unknown. The present article reviews the basic pathophysiological factors of GERD including psycho-physiological aspects and presents potential concepts of multidisciplinary GERD treatment.
PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie 52(3-4):159-65. · 1.02 Impact Factor
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ABSTRACT: One of the most frequent complications after laparoscopic antireflux surgery is intrathoracic migration of the wrap ("slipped" Nissen fundoplication). The most common reasons for this are inadequate closure of the crura or disruption of the crural closure. The aim of this prospective study was to evaluate surgical outcomes in patients who underwent laparoscopic antireflux surgery with simple nonabsorbable polypropylene sutures for hiatal closure in comparison to patients who underwent routine mesh-hiatoplasty. Between 1993 and 1998, a group of 361 patients underwent primary laparoscopic Nissen or Toupet fundoplication with the use of simple nonabsorbable polypropylene sutures for hiatal closure. Since December 1998, in all patients (n = 170) who underwent laparoscopic antireflux surgery, a 1 x 3 cm polypropylene mesh was placed on the crura behind the esophagus to reinforce them. Functional outcome, symptoms of gastroesophageal reflux disease, and postoperative complications such as recurrent hiatal hernia with or without intrathoracic migration of the wrap have been used for assessment of outcomes. In the initial series of 361 patients, postoperative herniation of the wrap occurred in 22 patients (6.1%). Of these 22 patients, 17 of them (4.7%) had to undergo laparoscopic redo surgery. The remaining five patients were free of symptoms. In comparison to these results, in a second group of 170 patients there was only one (0.6%) who had postoperative herniation of the wrap into the chest. There have been no significant differences in objective data such as DeMeester scores or lower esophageal sphincter pressure between the two groups. Postoperative dysphagia was increased during the early period after surgery in patients undergoing mesh-hiatoplasty but resolved without any further treatment within the first year after laparoscopic antireflux surgery. We concluded that routine hiatoplasty with the use of a polypropylene mesh is effective in preventing postoperative herniation of the wrap and leads to a significantly better surgical outcome than closure of the hiatal crura with simple sutures, without any additional long-term side effects.
Journal of Gastrointestinal Surgery 6(3):347-53. · 2.83 Impact Factor
