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An Analysis of Operations for Gastroesophageal Reflux Disease
Identifying the Important Technical Elements
Marco G. Patti, MD;
Massimo Arcerito, MD;
Carlo V. Feo, MD;
Mario De Pinto, MD;
Jenny Tong, MD;
Walter Gantert, MD;
Dana Tyrrell, MD;
Lawrence W. Way, MD
Arch Surg. 1998;133:600-607.
Background Better understanding of the pathogenesis of gastroesophageal reflux disease in recent years has not been accompanied by appreciable advances in the design of antireflux operations. In many cases, operations are still being performed just as they were described 30 years ago. It is important now to go beyond the eponymous procedures traditionally associated with antireflux operations and to identify the technical elements that contribute to effective and durable fundoplications.
Objectives To compare antireflux operations and identify the important technical elements.
Design and Setting Retrospective study in a university-based tertiary care center.
Patients Two hundred one patients had laparoscopic fundoplications for gastroesophageal reflux disease. The first 22 patients underwent Nissen-Rossetti procedures (360° wrap; no division of short gastric vessels). Subsequently, 82 patients had a total (360° Nissen wrap) fundoplication and 97 patients had a partial (240° Guarner wrap) fundoplication (both with the short gastric vessels divided), with the choice between them based on the quality of esophageal peristalsis. The 3 groups of patients were similar in age, duration of symptoms, incidence of hiatal hernia, and incidence of esophagitis.
Main Outcome Measures Resolution of heartburn, incidence of postoperative dysphagia, and stability of the reconstruction.
Results The resolution of heartburn was achieved for 15 patients (68%) who had the Nissen-Rossetti procedure, 73 patients (89%) who had a 360° Nissen wrap, and 88 patients (91%) who had a 240° Guarner wrap. Postoperative dysphagia occurred in 3 patients (14%) having the Nissen-Rossetti procedure, 5 patients (6%) having a 360° wrap, and 2 patients (2%) having a 240° wrap. Herniation or disruption of the wrap occurred postoperatively in 9 patients (4.5%). Review of the videotapes of these 9 operations showed that important technical elements had been omitted in 8. Seven patients required a second operation.
Conclusion Laparoscopic antireflux operations control symptoms without producing adverse effects if the following technical elements are included: the hernia is repaired and the hiatus reduced to a normal size, the short gastric vessels are divided, a total or partial wrap is used based on the quality of esophageal peristalsis, and the wrap is anchored in the abdomen.
From the Department of Surgery, University of California, San Francisco, School of Medicine.
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