[Surgery of the hiatal hernia and gastroesophageal reflux dinase, Nissen or Toupet?]

Abstract

Introduction: In 2016 60 years will have elapsed from the first publication by Nissen about his surgical method of 360° fundoplication around distal esophagus and its final effect. Nissens fundoplication is currently the most common surgical method for the gastroesophageal reflux (GER) and hiatal hernia (HH) probably. Incidence of HH ranges between 25-50% in the western population. Current prevalence of GER ranges between 4-10% in Europe and 5-7% in North America, but some studies report even 10-20%.

Methods: From 2010 to 2015, 157 laparoscopic procedures for HH or gastroesophageal reflux disease (GERD) were done at the Department of Surgery, the Second Faculty of Medicine, Charles University and Central Military Hospital in Prague. Most of the patients were operated because of symptomatic HH with/without GERD. Only very few patients were operated only for GERD without HH. The group of the patients included 73 men and 84 women with the mean age 53.9 years in the range 20-88 years. 11 patients of the group were operated because of the upside-down stomach syndrome. 109 (69.4%) patients underwent Nissens 360° fundoplication (NFP) and 48 (30.6%) patients underwent Toupets 270° fundoplication (TFP). The patients were followed after 3 month, 6 month, 12 month and then once a year after the surgery. Symptoms such as heartburn, dysphagia, belching, bloating or recurrence of HH or GERD were collected prospectively and analyzed retrospectively. Methods of descriptive statistics and explorative unidirectional analysis were used.

Results: From 2010 to 2015, 157 laparoscopic procedures were done for HH or GERD. No death occurred in the group of the patients in connection with the surgery. Similar rates of considerable improvement or resolution of the symptoms such as the reflux, heartburn, and epigastric pain were observed after three months from the surgery among patients after NFP or TFP. Postoperative dysphagia resolved in 4-7 weeks in the group after NFP, and in 3-5 weeks in the group after TFP. Disease recurrence was observed in 36 (22.9%) patients in 2 to 5 years after the surgery. Recurrence of only the gastroesophageal reflux without HH was observed in 22 patients (14 after NFP; 8 after TFP), shown by endoscopy or x-ray assessment, with a satisfactory response to PPI medication. Laparoscopic rehiatoplasty and refundoplication according to Nissen were performed in 14 patients with HH recurrence with/without the reflux (8 after NFP; 6 after TFP).

Conclusion: Laparoscopic antireflux surgery of GERD and HH is safe and is associated with very low perioperative morbidity and minimal morbidity. Both NFP and TFP have a similar effect on restoration of the mechanical gastroesophageal barrier against gastric reflux, with significant effect on resolution of GERD and HH symptoms and with a marked improvement of the patients quality of life. As regards morbid obese patients, weight reduction is needed before the surgery. Hiatoplasty done at the same time with the bariatric procedure is recommended in morbid obese patients with HH indicated for the bariatric-metabolic surgery.