Accepted: 10 April 2002Published online: 30 May 2002© Springer-Verlag 2002

Abstract Background and aims: Inthe past decade laparoscopic antire-flux surgery has become the standardoperation for treating severe gastro-esophageal reflux disease. Severalstudies have been published showingthat it can achieve good to excellentresults at short- and medium-termfollow-up. We present our experi-ence with 668 laparoscopic antire-flux procedures. Patients andmethods: Between September 1993and July 2001 we performed 668laparoscopic antireflux procedures(76% laparoscopic 360° “floppy”Nissen fundoplications in patientswith normal esophageal motility,24% laparoscopic 270° Toupet par-tial fundoplications in patients withpoor esophageal motility or severelydisordered peristalsis). Patients withachalasia were excluded from analy-sis. Preoperative and postoperativedata including 24-h pH monitoring,

esophageal manometry, and analysisof failure were prospectively re-viewed. Results: Overall complica-tion rate was 7.6%. Conversion toopen surgery was necessary in fivepatients (0.8%). Seventy-four lapar-oscopic redo procedures were per-formed due to failed primary inter-vention. There was no death. At amean follow-up of 4.8 years (range3–94 months) 24-h pH monitoringand esophageal manometry showednormal values in 93% of patients.Conclusion: Laparoscopic antirefluxsurgery is feasible and effective andcan be performed safely withoutmortality and low morbidity withgood to excellent functional andsymptomatic results.

Keywords Gastroesophageal refluxdisease · Laparoscopic antirefluxsurgery · Long-term results Laparoscopic refundoplication

Int J Colorectal Dis (2003) 18:73–77DOI 10.1007/s00384-002-0405-8 O R I G I N A L A RT I C L E

Frank Alexander GranderathThomas KamolzUrsula Maria SchweigerRudolph Pointner

Laparoscopic antireflux surgery for gastroesophageal reflux disease: experience with 668 laparoscopic antirefluxprocedures

Introduction

Antireflux surgery (ARS) has been shown to be a safeand effective therapeutic alternative to long-term medi-cal treatment for gastroesophageal reflux disease(GERD). In the era of open antireflux surgery manystudies have been published showing that ARS yieldsgood to excellent long-term results, with success rates inup to 90% of GERD patients [1, 2]. Since laparoscopicNissen fundoplication was first described by Dallemagneet al. [3] in 1991, laparoscopic antireflux surgery(LARS) has replaced the open approach in centersworldwide and has become the standard surgical proce-

dure in the treatment of severe GERD. It has been shownthat the laparoscopic approach in ARS has made the pro-cedure more acceptable to patients and also to their re-ferring physicians. Several studies have described LARSas being as safe and effective as the open procedure withall the advantages of minimally invasive surgery, such asshorter postoperative stay and less postoperative pain [4, 5]. Numerous studies have reported excellent func-tional outcome by LARS, with symptom relief in thevast majority of the patients and a significant improve-ment in patients’ quality of life at short- and medium-term follow-up [6, 7]. Many outcome studies haveshown that LARS is equivalent to or even better than

F.A. Granderath (✉) · U.M. SchweigerR. PointnerDepartment of General Surgery, Hospital Zell am See, Paracelsusstrasse 8,5700 Zell am See, Austriae-mail: fagzellamsee@yahoo.comTel.: +43-6542-7772210Fax: 43-6542-77756

T. KamolzDivision of Clinical Psychology, Paracelsusstrasse 8, 5700 Zell am See, Austria

open ARS at short- and medium-term follow-up [8, 9].Recently some studies also have reported long-term re-sults after LARS in larger patient populations [10 11,12].

This study prospectively reviewed preoperative andpostoperative data including functional parameters andsymptomatic outcome after 668 LARS procedures at amean follow-up period of 4.8 years.

Materials and methods

Between September 1993 and July 2001 we performed 668 LARSprocedures in 633 patients (252 women, 381 men; mean age54 years) at our surgical unit, including 74 laparoscopic redo pro-cedures due to recurrent or persistent GERD symptoms after failedprimary open or laparoscopic ARS. The mean duration of GERDsymptoms before surgery was 7.4 years, and all patients had beenreceiving medical treatment with proton-pump inhibitors for amean period of 15.8 months (20–80 mg/daily). Indications for sur-gery were persistent or recurrent GERD symptoms despite medi-cal treatment, persistent or recurrent complications of GERD, un-satisfactory long-term medical treatment, decreased quality of life,and a weak pressure of the lower esophageal sphincter (LES pres-sure <6 mmHg). Indications for laparoscopic redo surgery werepersistent or recurrent symptoms or complications after previousARS.

Preoperative workup was standardized in all patients. Esoph-ago-gastro-duodenoscopy with biopsy and histological examina-tion of the gastroesophageal junction was performed routinely be-fore surgery. Esophageal manometry was performed in every pa-tient for esophageal motility testing and LES pressure. Patientswith normal esophageal motility were scheduled to a laparoscopic360° Nissen fundoplication (n=505, 75.5%) while patients withdisordered esophageal motility (<30 mmHg in the lower esopha-geal segments in response to wet swallows) or severely disorderedperistalsis (>40% simultaneous contractions in wet swallows)were scheduled to a laparoscopic 270° Toupet partial fundoplica-tion (n=163, 24.5%). Additionally 24-h pH-monitoring was per-formed routinely before surgery. A barium swallow (kinemato-graphic radiography) was performed routinely with complicationof a hiatal hernia or before laparoscopic refundoplication. Esopha-geal manometry was performed using a water-perfused pull-through system as described by Johansson and Peters [13]. The24-h esophageal pH monitoring was carried out using the methoddescribed by DeMeester et al. [14].

The surgical techniques of both laparoscopic fundoplicationand refundoplication have been described previously [11, 15].Hiatal closure has been performed routinely using nonabsorbablepolypropylene sutures. Since December 1998 in cases of a poten-tial disruption of the hiatal closure we have reinforced the crurawith a 1×3 cm polypropylene mesh as described previously [16].

Symptoms

In addition to functional parameters such as LES pressure andDeMeester score, the subjective extent of heartburn, dysphagia,

regurgitation, chest pain, and early satiety were evaluated using averbal rating scale with the following categories: none, mild tomoderate, severe.

Follow-up

Esophago-gastro-duodenoscopic surveillance was carried out6 weeks postoperatively at our Department or by the local gastro-enterologist. We also performed 24-h pH monitoring and esopha-geal manometry 3 months, 1 year, and 5 years after surgery. Pa-tients with Barrett’s esophagus (n=183, 29%) underwent esoph-ago-gastro-duodenoscopy every 12 months. Eighteen patients(2.7%) were lost to follow-up.

Statistics

For statistical analysis the SPSS program was used. All data arepresented as mean ±standard deviation or percentage. Data wereanalyzed using methods for repeated measurement procedures asappropriate. In some cases descriptive statistics are used to presentsurgical outcome. A P value less than 0.05 was regarded as statis-tically significant.

Results

Functional outcome

Preoperative esophageal manometry and 24-h pH moni-toring showed pathological values in all patients. MeanLES pressure increased significantly from 2.8 mmHgpreoperatively to 12.3 mmHg at 3 months and 13.1 mmHgat 1 year (P<0.05) and remained almost stable up to5 years after surgery. The preoperatively mean DeMeesterscore was 64.4 and decreased significantly (P<0.01) to13.7 3 months and to 13.2 1 year after surgery. Completedata of esophageal manometry and 24-h pH monitoringare shown in Table 1.

Symptomatic outcome

The leading symptoms before LARS as graded by thepatients were heartburn (97%), regurgitation (92%), andchest pain (89%). These symptoms showed significantimprovement (P<0.01–0.001) after surgery. Additionallywe found a significant improvement in symptoms suchas early satiety and dysphagia. Early satiety was reportedby 45% of our patients preoperatively, but 5 years post-operatively only 15% of patients suffered from mild tomoderate or severe early satiety. Preoperative dysphagiawas found in 37%, which improved significantly after

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Table 1 Mean lower esophage-al sphincter pressure (LES) andmean DeMeester score beforeand 3 months, 1 year, and5 years after laparoscopic anti-reflux surgery

Before 3 months 1 year 5 years(n=658) (n=650) (n=122)

LES pressure (mmHg) 2.8±1.8 12.3±4.1 13.1±3.9 10.9±3.9DeMeester score 64.4±28.2 13.7±12.6 13.2±11.1 13.6±10.9

surgery and remained almost stable up to 5 years aftersurgery (P<0.001). The grading of GERD symptoms inour patients before and after LARS is presented inFigs. 1, 2, 3, 4, 5.

Postoperative complications

The postoperative complication rate in patients who un-derwent primary LARS in our surgical unit was 7.6%,including 35 laparoscopic refundoplications in 32 pa-tients (5.1%). Three patients had to undergo two lapar-oscopic redo procedures. Nine patients (1.4%) sufferedmoderate to severe dysphagia for longer than 3 monthsafter surgery. After pneumatic dilatation these patientswere free of symptoms at follow-up. Six patients (0.9%)developed a nonsymptomatic recurrent hiatal herniawithin the first 3 months postoperatively, and therapywas therefore not necessary. One patient (0.2%) referredto our unit 1 year after primary intervention with a ne-crosis of the gastric wall due to an acute telescope phe-nomenon underwent reoperation and is free of symptomsup to 5 years after surgery.

Perioperative complications

In six patients (0.9%) a stomach wall injury occurredperioperatively during laparoscopic refundoplication af-ter primary open ARS. This complication was managedlaparoscopically, and these patients were also free of

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Fig. 1 Heartburn (%)

Fig. 2 Dysphagia (%)

Fig. 3 Regurgitation (%)

Fig. 4 Chest pain (%)

Fig. 5 Early satiety (%)

symptoms at follow-up. Conversion to open surgery dur-ing primary LARS was necessary in three patients: intwo patients during the early learning curve because ofstomach wall injury and in the remaining patient becauseof perioperative lesion of the thoracic aorta.

Redo surgery

There were 74 redo fundoplications for failure of the pri-mary intervention performed in 71 patients; three pa-tients had to undergo a second redo procedure for recur-rent GERD symptoms after the first refundoplication. In39 of these patients primary ARS was performed at othersurgical units, while 32 underwent primary LARS at ourunit. The types of previous surgery were open Nissenfundoplication (n=26), open Toupet fundoplication(n=2), laparoscopic Nissen fundoplication (n=39), andlaparoscopic Toupet fundoplication (n=7). In 28 casesthe primary operation was performed by the open tech-nique, 7 of them with two initial procedures. The leadingsymptoms in these patients were recurrent reflux in 17 cases and a combination of re-reflux and dysphagia in8. Dysphagia as a single symptom was seen in 3 patients.The morphological findings were telescope phenomenon(n=8), hiatal disruption (n=16), and wrap breakdown(n=4). In 46 patients who underwent laparoscopic Nissenor Toupet fundoplication as the initial procedure recur-rent reflux occurred in 20 cases, dysphagia in 20, and acombination of the two in 6. The underlying morpholog-ical complications were a telescope phenomenon in 6 cases, hiatal disruption in 34, and an excessively tightwrap in 6.

All redo procedures after initial laparoscopic surgerywere completed laparoscopically. In two patients conver-sion to open surgery was necessary, in one case becauseof an injury of the gastric wall and in the other becauseof severe bleeding from the spleen. In these two patientsthe primary procedure was carried out by the openapproach. In six patients an injury of the gastric wall oc-curred intraoperatively but was managed laparoscopical-ly without any further complication. In these patients theinitial procedure also was performed by the openapproach.

Discussion

This study examined the results of LARS with both 360°“floppy” Nissen or 270° Toupet partial fundoplicationafter 668 laparoscopic antireflux procedures including 74laparoscopic redo procedures after failed previous openor laparoscopic fundoplication at a mean follow-up peri-od of 4.8 years. Outcome was assessed with objectivefunctional parameters such as LES pressure andDeMeester score and subjective symptom assessment

such as pre- and postoperative grading of typical GERDsymptoms, including heartburn, regurgitation, chest pain,dysphagia, or early satiety. As our results show, LARS isable to improve typical GERD symptoms such as heart-burn, chest pain, regurgitation or dysphagia in 94–97%of patients up to 5 years after surgery.

Recently Terry et al. [11] reported in a large series of1000 consecutive LARS procedures for GERD and/orhiatal hernia about 76–95% of patients with improved orcured GERD symptoms at long-term follow-up. Laffullardeet al. [10] followed up 166 patients for 5 years or moreafter LARS and found that 60% had no heartburn, 27%occasional minor episodes of heartburn, and only 13%moderate to severe heartburn episodes. Altogether 87%of patients were free of significant reflux symptoms.

Apart from subjective outcome criteria, we also founda significant improvement in traditional outcome param-eters such as LES pressure and DeMeester score. LESpressure improved significantly postoperatively, and thisimprovement remained almost stable 1 and 5 years aftersurgery. Preoperatively all patients had pathological val-ues in 24-h pH monitoring. The mean DeMeester scoreimproved significantly in almost all patients at follow-up.

Similar to other authors [17, 18], we found some ad-verse outcome after primary ARS [19]. In the literaturethe most common anatomical reason for recurrent symp-toms is the breakdown of the wrap, which occurs in25–30% of patients requiring redo surgery [20]. A slid-ing or paraesophageal herniation has also been reportedin most of these patients. Therefore some surgeons per-form a prosthetic patch repair during reoperation [21].An excessively tight wrap refractory to dilatation leadsto redo surgery in 10–15% of patients, hiatal rupturewith wrap herniation into the chest in 10–15%, and tele-scope phenomenon in 10–25% [22, 23].

As published elsewhere [20], the intrathoracic migra-tion of the wrap was the most common anatomical fail-ure after ARS in our experience. The so-called “slippedNissen” may be the result of an inadequate closure of thehiatus or a postoperative rupture of the hiatal closure. Inour experience with laparoscopic refundoplication afterprimary open or laparoscopic fundoplication we foundthe “slipped Nissen” to be the most frequent complica-tion after ARS. Fifty of these patients (67%) had toundergo laparoscopic redo surgery due to a “slippedNissen.” The relatively high incidence of this complica-tion led us to the use of prosthetic material for crural clo-sure since December 1998. In a large nonrandomizedstudy we compared patients who underwent hiatal clo-sure with a 1×3 cm piece of polypropylene mesh withpatients who had hiatal closure with simple nonabsorb-able sutures [16]; Patients with mesh-hiatoplasty had asignificantly lower rate of postoperative intrathoracicwrap herniation.

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Conclusion

The present study demonstrates that laparoscopic Nissenor Toupet fundoplication is a safe and effective surgicaloption in the treatment of gastroesophageal reflux dis-ease. It can be performed without mortality and with lowmorbidity and yields good to excellent functional andsymptomatic outcome over the long term. With a careful

patient selection and a standardized technique, lapar-oscopic redo surgery after primary failed ARS can be asfeasible as primary LARS when performed by an experi-enced laparoscopic surgeon [24].

Acknowledgements These findings were presented at 26th Sym-posium on “Aktuelle Chirurgie” at Benjamin Franklin University,Berlin, 24 November 2001.

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