Novel surgical concept in antireflux surgery: Long-term outcomes comparing 3 different laparoscopic approaches

doi:10.1016/j.surg.2011.06.024

Surgery

Volume 151, Issue 1, January 2012, Pages 84-93

https://doi.org/10.1016/j.surg.2011.06.024 Get rights and content

Background

The Nissen fundoplication procedure is the most widely used type of antireflux surgery. The results are not always as good as expected, and several modifications to the original technique have been proposed. Long-term effectiveness studies comparing different techniques of antireflux surgery are limited. Our group developed a new concept in antireflux surgery (complete fixed “nondeformable” fundoplication) in order to improve its outcome; we present the long-term comparative results of this novel concept/technique.

Methods

Overall, 512 patients were included in the study and assigned into 1 of 3 fundoplications groups: partial (131), Nissen (133), and fixed “nondeformable” (121). We compared the groups with each other and with a group who chose to receive medical treatment (MT) (127). All patients underwent clinical evaluation, upper gastrointestinal endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and the SF-36 health status survey prior to operation and at 1, 5, 10, and 15 years of follow-up.

Results

At the 15-year follow-up, we were able to complete the protocol in 319 patients: 103 patients from the partial group, 102 patients from the Nissen group, 97 patients from the fixed “nondeformable” group, and 17 patients from the medical treatment group. A lower prevalence of erosive gastroesophageal reflux disease (GERD) was observed in the fixed “nondeformable” group (7.20%) versus 21.56% for Nissen, 39.80% for partial, and 47.05% for MT (P < .01). Lower esophageal sphincter (LES) pressure and LES length were more constant in the fixed “nondeformable” group (14.7 mm Hg/2.2 cm) compared with the Nissen (9 mm Hg/0.7 cm), partial (7 mm Hg/2 cm), and MT (5.64 mm Hg/1.3 cm) groups (P < .01). Reflux recurrence was observed in 168 patients (13 in fixed “nondeformable,” 41 in Nissen, and 98 in partial (P < .01).

Conclusion

The complete fixed “nondeformable” fundoplication showed best results in studied parameters and had a lower long-term recurrence compared with Nissen and partial techniques.

Section snippets

Study design

This was a prospective, single-blinded, randomized, controlled clinical trial.

Patient selection

GEA Hospital patients with GERD were treated by the same medical–surgical group from February 1993 to December 1995 (35 months).

The age group was 18 years or older, with typical symptoms of GERD and mucosal injury detected by endoscopy, with 24 hours of esophageal pH monitoring that showed pathologic acid reflux, and LES resting pressure lower than 10 mmHg determined by esophageal manometry (EM). All patients included

Results and follow-up

A total of 512 patients with GERD documented by symptoms and additional studies were included: 57.6% were women and 42.4% were men. Overall, 131 patients underwent partial fundoplication, 133 subjects underwent Nissen fundoplication, and 121 patients underwent fixed “nondeformable” fundoplication. The MT group included 127 individuals who refused surgical treatment but agreed to continue their follow-up and control according to the study protocol.

No statistically significant differences in age,

Discussion

No ideal or definitive treatment for GERD has been developed. Studies supporting both the conservative and the surgical management are available. Unfortunately, the methodology is not always standardized, resulting in weak evidence to reach conclusions.16, 17, 18

Studies of different pharmacological and surgical techniques in recent decades indicate that both approaches are feasible.12, 19, 20

The history of antireflux surgical techniques begins in the mid-20th century (1950). Nissen is worldwide

Acknowledgments

We thank Julio Sotelo, MD, Claudia Díaz, MD, Margarita Torres, MD, Alberto Salazar, MD, Jesus Bahena, MD, Carlos Morales, MD, Rodrigo Davila, MD, Miriam Cota, and Myrna Limón for their valuable collaboration. This manuscript is dedicated to the memory of Alejandra Gil, MD.

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Original CommunicationNovel surgical concept in antireflux surgery: Long-term outcomes comparing 3 different laparoscopic approaches

Background

Methods

Results

Conclusion

Section snippets

Study design

Patient selection

Results and follow-up

Discussion

Acknowledgments

J Gastrointest Surg

Clin Gastroenterol Hepatol

Am J Surg

Pharmacologic management of gastroesophageal reflux disease

Curr Gastroenterol Rep

Impact of proton pump inhibitor utilization patterns on gastroesophageal reflux disease-related costs

Manag Care

Estado actual de la enfermedad por reflujo gastroesofágico y su tratamiento quirúrgico

Rev Hosp Gral M Gea González

Columnar mucosa and intestinal metaplasia of the esophagus. Fifty years of controversy

Ann Surg

National trends in utilization and outcomes of antireflux surgery

Surg Endosc

When fundopication falls redo?

Ann Surg

The MOS 36-item short-form health survey (SF-36). II. Psychometric and clinical tests of validity in measuring physical and mental health constructs

Med Care

Comparison of the performance of the gea extracorporeal knot with the roeder extracorporeal knot and the classical knot

Surg Endosc

A new technique for tying the gea extracorporeal knot for endoscopic surgery

J Laparoendosc Adv Surg Tech A

The Mexican experience with laparoscopic cholecystectomy and common bile duct exploration

Surg Endosc

Pharmacologic management and treatment of gastroesophageal reflux disease

Dis Esophagus

The floppy Nissen fundoplication, effective long-term control of pathologic reflux

Arch Surg

Acalasia: tratamiento laparoscópico

Cirujano General

Distal esophageal perforation during laparoscopic esophagomyotomy: evaluation of outcomes and review of surgical technique

J Laparoendosc Adv Surg Tech

Results of short-and long-term medical treatment of gastroesophageal reflux disease (GERD)

Langenbecks Arch Surg

Original Communication
Novel surgical concept in antireflux surgery: Long-term outcomes comparing 3 different laparoscopic approaches