Laparoscopy
Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive value of preoperative assessment

https://doi.org/10.1016/j.amjsurg.2003.12.034Get rights and content

Abstract

Background

Laparoscopic Nissen fundoplication (LNF) has established itself as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). There are, however, few available data on the assessment of long-term failures after LNF.

Methods

We sought to clarify the mechanisms of failure among a group of patients who reported suboptimal results after LNF. In addition, we attempted to identify specific elements in the preoperative evaluation of GERD patients that might herald a predisposition to anatomical or physiological failure.

Results

One hundred and thirty-one consecutive patients who underwent LNF by a single surgeon were analyzed to identify reasons for surgical failure. Fourteen patients (10.6%) comprised the failure group. Detailed independent statistical analysis identified a hiatus hernia greater than 3 cm at operation (P = 0.003), abnormal preoperative pH analysis in the upright position (P = 0.039), failure to respond to proton pump inhibition preoperatively (P = 0.015), and a preoperative psychiatric history (P = 0.0012) as predictors of subsequent failure.

Conclusions

In patients who do not respond to proton pump inhibition preoperatively, the evaluating surgeon should be circumspect in advocating antireflux surgery. A detailed assessment of underlying psychiatric or psychological symptoms must also be made. If a large (>3 cm approximately) hiatus hernia is identified or there is abnormal pH analysis in the upright position preoperatively, the surgeon should be guarded about the long-term outcome, and patients should be advised accordingly.

Section snippets

Patient population and preoperative evaluation

Between October 1993 and December 1998, 131 consecutive patients underwent a completed LNF for documented GERD. Exclusion criteria from this study included previous antireflux procedure performed in another institution (n = 2), conversion (n = 2), and LNF buttressing a Heller's cardiomyotomy (n = 2). There were 69 female and 62 male patients. The mean age was 42.71 ± 13.56 years. Mean duration of previous medical therapy was 42.4 ± 32.1 months. Presenting symptoms included heartburn,

Perioperative and early postoperative results

Mean anesthetic time was 92 ± 26.3 minutes. There was no mortality. The morbidity rate was 5.3% and included one port site hematoma, one umbilical port site infection, postoperative urinary retention (requiring catheterization with subsequent urethritis), and new-onset atrial fibrillation. Two patients required blood transfusion as a result of intraoperative bleeding for a mean 3.5 g/dL (range 1 to 4 g/dL) fall in hemoglobin. One patient required overnight hospitalization and nasogastric

Comments

Few data are available regarding rates and mechanisms of failure after LARS. The spectrum of GERD scenarios and anatomy demands an array of procedural types. Authors who have described their experiences in this regard have thus included a variety of antireflux procedures in their analyzes. This has the potential to confuse as disparate operations are being considered. We report on the exclusive use of LNF as we believed this operation was appropriate to all patients in this series.

Soper [8] has

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