Laparoscopic Nissen fundoplication: laparoscopic dissection technique and results

Abstract

Background/aims: Proton Pump inhibitors and laparoscopic techniques have had a dramatic impact on the therapy of gastroesophageal reflux disease. These techniques have introduced new complications associated with the treatment. This study compares the results of a laparoscopic Nissen fundoplication with life-long proton pump inhibitor treatment.

Materials and methods: Between May 1991 and February 1996, 274 patients were treated by laparoscopic Nissen fundoplication (LNF). Two hundred twenty-four patients were included in this prospective study. Thirteen patients presented stage V esophagitis (Barrett); 4 had esophagitis stage IV; 16 had stage III, 181 had stage II and 11 had stage I. Five trocars were needed for the operation. After mobilization of the greater curvature, a fundic wrap of 5 cm was created and fixed on the esophagus.

Results: Median operating time was 60 min (39-300). There were 5 perioperative complications (a gastric perforation, three pleural perforations, and one liver laceration treated by coagulation). Three conversions to laparotomy were necessary. There were 4 early complications: two pulmonary infections and two re-operations; one case of wrap necrosis with peritonitis, and one case of small bowel perforation. Gastroscopy was performed in 133 cases. The esophagus was normal in 121 cases, an esophagitis stage I was present in 9, esophagitis stage II in 2, esophagitis stage III in one. Median lower esophageal sphincter pressure was 10 mmHg (2.9-30) preoperatively and 19 mmHg (9-40) post-operatively. Median reflux time was 10% (0-65) preoperatively and 1% (0-38) post-operatively. One hundred fifty-four patients were interviewed with a median follow up of 30 months (1-58). One hundred thirty patients were Visick I, 11 Visick II, 8 Visick III and 5 patients needed re-operation; three reoperations because of dysphagia, 1 because of epigastric pain and 1 for heartburn recurrence.

Conclusions: From these results, we conclude that LNF seems to be an attractive alternative to long term medical treatment.