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Laparoscopic anterior fundoplication

Monday, July 19, 2010 @ 12:07 PM
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Laparoscopic fundoplication has become the standard surgical method of treating gastro-oesophageal reflux dis-ease. Although Nissen total fundoplication is the most commonly performed procedure, partial fundoplication, either anterior or posterior, is becoming more aceptable because of a suggested lower risk of long term side effects. This article describes a technique of laparoscopic anterior fundoplication.

 

BACKGROUND

Currently, there is increasing interest in the surgical management of gastro-oesophageal reflux disease (GORD). There are a number of reasons for this. Despite the fact that current medical management is very effective for the majority a small number of patients do not get complete relief of symptoms. Secondly, some patients, particularly those who are in their twenties or thirties, face the prospect of a lifetime of continuous proton pump inhibitor therapy with the possible risk of, as yet, unknown side effects. In addition, the laparoscopic approach with its benefits of reduced operative trauma and less time off work has become more commonplace. As a consequence, general practitioners and gastroenterologists are more ready to refer patients with disabling symptoms for surgical treatment. The gold standard anti-reflux operation is undoubtedly the Nissen type of total fundoplication and many studies have affirmed its effectiveness in controlling acid reflux. However, new symptoms after fundoplication such as gas bloat and dysphagia, which probably result from a hyper-competent lower oesophageal sphincter produced by the Nissen operation, are common.

Surgeons have investigated alternative procedures including anterior and posterior partial fundoplication. Anterior fundoplication was described by Dor in 1962 as an anti-reflux operation for patients who had a Heller’s myotomy for achalasia. In the 1970s, Watson developed an operation for GORD. The main elements of this operation consist of: (a) mobilisation of 5cms of intra-abdominal oesophagus; (b) insertion of posterior sutures to tighten the crural opening; (c) approximation of the posterior aspect of the oesophagus to the crural repair using the same sutures as for the crural repair, (d) construction of a 120º fundoplication anterior to the oesophagus. The results were published by Watson and his colleagues in 1991; symptomatic improvement was achieved in 94% of patients, symptomatic cure in 82% and restoration of normal ph profile in 84% of cases. A further positive feature of this operation was the absence of gas bloat, inability to belch and vomit and the fact that only 2% of patients had troublesome dysphagia afterwards.

The Watson operation was first performed in our department in 1986; between 1986 and 1995 open Watson procedures were performed on 49 patients with GORD assessed clinically and by 24 hour ambulatory ph studies. A structured follow-up was performed by an independent observer at a median of 5 years after the operation. This included modified Visick grading in all patients and 24 hour ambulatory ph studies in those willing to undergo this assessment; 53% of all patients had post-operative ph studies . Visick 1 or 11 grading was achieved by 93% of patients whereas 82% of the series had a normal post-operative ph profile.

The first randomised double-blind trial comparing laparo-scopic anterior partial fundoplication with Nissen fundoplication, has recently been reported by Watson and colleagues from Adelaide. The operating time for both procedures was similar. Heartburn control at 6 months after the operation was equally effective for both operations but there was a significantly higher incidence of dysphagia for solid food at 6 months after Nissen fundoplication, compared with anterior fundoplication. Significantly more patients who had anterior fundoplication were satisfied with the post-operative result.

 

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