Laparoscopic Fundoplication with Double Sided Posterior Gastropexy: a Different Surgical Technique

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International Journal of Surgery 10 (2012) 532e536

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International Journal of Surgery

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Original research Laparoscopic fundoplication with double sided posterior gastropexy: A different surgical technique

Fahri Yetis¸ira,*, A. Ebru Salman b,Dogukan Durak a, Mehmet Kiliç c

a Ataturk Research and Training Hospital, General Surgery Department, Turkey b Ataturk Research and Training Hospital, Anesthesiology and Reanimation Department, Turkey c Yildirim Beyazit University, General Surgery Department, Turkey

article info abstract

Article history: Background: Laparoscopic Nissen Fundoplication has become the gold standard surgical procedure for Received 18 April 2012 management of gastroesophageal reflux disease. Nissen fundoplication provides an effective barrier Received in revised form against reflux. The aim of this study was to evaluate early postoperative outcomes of a different surgical 3 August 2012 technique, laparoscopic fundoplication with double sided posterior gastropexy. Accepted 6 August 2012 Methods: Data of 46 patients who underwent laparoscopic fundoplication with double sided posterior Available online 21 August 2012 gastropexy between February 2010 and December 2011 were collected. Surgically, after Nissen fundoplication was completed, 2e4 sutures were passed through the uppermost parts of the posterior Keywords: Gastropexy and anterior wall of the gastric wrap and then passed gently 1 cm above the celiac artery from the denser fi Nissen fundoplication bers of uppermost part of the arcuate ligament. Demographic data, preoperative and postoperative Gastroesophageal reflux assesments of sympthomatic and functional outcomes of patients were recorded. Length of hospital stay, Hiatal hernia operative time, early postoperative complications and complications at 1 year follow up, early recurrence rate were also recorded. Results: This technique resulted in good symptomatic and clinical outcomes. Only one patient out of 45 patients was reoperated. The early recurrence rate was 2.2%. Conclusion: Laparoscopic Nissen fundoplication with double sided posterior gastropexy may prevent paraesophageal herniation. It is a reasonably feasible and effective method in surgical management of GERD. Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction life but, new postoperative complaints may occur up to 25% of e cases.4 7 Gastroesophageal reflux disease is one of the most prevalant Several modifications have been proposed to original technique gastrointestinal disorders of the Western world, affecting up to 20% since the results of LNF are not always as good as expected. Several of the population.1,2 Laparoscopic Nissen fundoplication (LNF) has techniques combined with LNF such as cruroplasty with polyglactin become the gold standard surgical procedure for the treatment of or vicryl mesh, fibrin glue, hepatic shoulder technique, anterior or e gastroesophageal reflux disease (GERD) with or without hiatal posterior gastropexy have been used with various success.3,8 11 hernia.3 Antireflux surgery is the only choice of treatment that may Recently new operative techniques combining the LNF with prevent the need for long term medical therapy by correcting the posterior gastropexy have been defined in order to lessen the e pathophysiology leading to reflux.1 Hence, excessive transient postoperative failure of LNF.11 13 lower esophageal sphincter (LES) relaxation is the most likely The aim of this article is to present the early postoperative mechanism.1 outcomes of patients undergoing laparoscopic fundoplication with Nissen fundoplication involves wrapping the fundus around double sided posterior gastropexy. LES, thereby increasing basal LES pressure and decreasing episodes of transient LES relaxations. Laparoscopic surgery may provide 2. Material methods a significant improvement in patients’s symptoms and quality of 46 consecutive patients with GER disease underwent laparoscopic fundoplication with double sided posterior gastropexy in our institution between February 2010 and December 2011. The patients with typical symptoms of GERD and mucosal * Corresponding author. Tel.: þ90 536 297 48 88. injury detected by endoscopy were included into the study. Ph monitoring was used E-mail address: [email protected] (F. Yetis¸ir). only in patients with diagnostic uncertainity or when the diagnosis cannot be

F. Yetis¸ir et al. / International Journal of Surgery 10 (2012) 532e536 533 confirmed with endoscopy. The patients not contacted for follow up were excluded hospital stay was 2.72 1.4 days. There was no in hospital from the study (Fig. 1). mortality. There was no conversion to open surgery. Postoperative All patients had upper abdominal ultrasonography, esophagogastroduodeno- dysphagia was not seen in any patient at 1 year follow up. The mean scopy with or without biopsy. Upper gastrointestinal contrast study was performed to 71.1% of patients and pH monitorization to 44.4% of patients. follow up time was 12.2 4.3 months. Only one patient with Visick Surgery: Five ports were placed. The first one, 5 mm, was inserted above the score >3 underwent endoscopy and slipped LNF was seen. After umbilicus at a location according to the distance between xiphoid and umbilicus to confirming the slipped LNF laparoscopically, first fundoplication enter the telescope (30 ). Four of the ports were inserted under direct vision. The and gastropexy was opened. Slipped LNF was disappeared and second and fourth trocar was placed in the right and in the left midclavicular line respectively. The third and fifth trocar was inserted in the right and in the left fundoplication with posterior gastropexy was repeated on surgical anterior axillary line respectively. The operation table was placed in a reverse revision 4 months after the first surgery. 44 patients have a Visick trandelenburg position to allow the abdominal organs fall away from the dia- score 2.44 (97.8%) patients documented that their symptoms had phragm. All patients underwent laparoscopic fundoplication with double sided improved. Patient satisfaction rate was 92.6 9.2%. posterior gastropexy. The operations were always performed by the same surgical team. After retraction of the liver and complete mobilization of the gastroesophageal junction and gastric fundus, short gastric vessels were cut. A tunnel was performed 4. Discussion at the posterior part of the esophagogastric junction. All these steps were performed with ultrasonically activated coagulation shears. (Harmonic Ace; Ethicon Endo- Proton pump inhibitors (PPI’s) are the most frequently surgery Inc., Smithfield, RI, USA) Intraabdominal gas pressure was maintained at fl e prescribed medical treatment of gastroesophageal re ux disease it a level less than 12 mmHg. Routine hiatal repair was applied in all patients with 2 4 15 2/0 sutures (Ti-cron, Covidien). After hiatal hernia repair and retraction of the heals the esophagitis in 90% of cases. However, medical gastroesophageal junction with a penrose tube, which was passed around the lower management cannot solve the mechanical cause of the disease, esophagus, a grasper forceps was inserted behind the lower esophagus through the symptoms may recur in 80% of cases within 1 year of drug with- posterior esophageal window to grasp the fundus 5 cm lateral to the gastroesoph- drawal.16 Furthermore, study results have revealed that PPIs are ageal junction. Fundus was passed back and forth to be certain that it was slack and fl had no twist. This part of the fundus, passed behind the esophagus, was used for associated with osteoporosis-related fractures, rebound re ux, creation of the wrap of the fundoplication. Fixation of the fundoplication was per- refractory hypomagnesemia, pharmacologic interaction with ASA formed by (Ti-cron, Covidien) a suture passed through the lips of the wrap and and clopidogrel with long term use. This raises the question esophageal musculature, 2 cm above the gastroesophageal junction, located 1.5e whether side effects of conservative treatment may overweight the 2 cm above the anatomic cardia (Fig. 2). benefits versus antireflux surgery.17 After fundoplication completed, the gastroesophageal junction was retracted with a penrose tube. 2e4 sutures (Ti-cron, Covidien) were passed through the Nissen fundoplication which is based on wrapping last part of uppermost parts of the posterior and anterior wall of the gastric wrap and then the esophagus using the gastric fundus, is the worldwide used passed gently 1 cm above the celiac artery from the denser fibers of uppermost part surgical technique in the treatment of GERD. Inadequate fundo- ’ 14 of the arcuate ligament, similar to Vansant s gastropexy (Figs. 3 and 4) All plication or paraesophageal herniation may cause postoperative concomitant abdominal diseases except ventral hernia were treated before fundo- failure of LNF up to 25% of cases.4 Symons et al. have emphasized plication (Table 1). Demographic characteristics of patients, preoperative signs at admission, that laparoscopic revision surgery have a greater risk of conversion, operation time, length of hospital stay, early postoperative complications and higher morbidity, longer hospital stay and poorer outcomes than complications at 1 year follow up, Visick scores of the patients were recorded at the primary laparoscopic fundoplication.18 fi > postoperative follow up, endoscoping ndings of the patients with Visick score 3at Lately new operative techniques, alternative to standard LNF have follow up, early recurrence rate and patient satisfaction were the primary outcome measures. been proposed in order to lessen the postoperative failure. Rantanen et al. showed in their retrospective study that fibrin glue might be 3. Results worth utilizing the further decrease in the incidence of failure after LNF as a new method.8 However, it was also stated in the same study One of 46 patients was excluded from the study. A total of 45 that use of fibrin glue was terminated due to fear of increased inci- patients with GERD documented with symptoms and additional dence of dysphagia.8 Parsak et al. speculated that closure of hiatal studies were included into the study. Preoperative signs at admis- crura with a prosthetic polyglactin mesh at laparoscopic antireflux sion were summarized in (Table 2) The average time of preopera- surgery is a safe and effective procedure. The failure rate was 5.3% in tive PPI use of patients was 44.5 26 months. Female to male ratio vicryl mesh group and 4% in propylene mesh group in this study.3 was 1.64. The mean age on average was 43.8 11.2 years. The (Table 3) Kloek et al. found 23% failure rate in 208 pediatric average operation time was 89.7 34 min. The average length of patients undergoing anterior gastropexy at 7 year follow up.10

Fig. 1. Scheme of the study. ORIGINAL RESEARCH

534 F. Yetis¸ir et al. / International Journal of Surgery 10 (2012) 532e536

Fig. 2. Completed fundoplication with cruroplasty.

Fig. 3. Fundoplication with double sided posterior gastropexy technique.

Fig. 4. Completed fundoplication with double sided posterior gastropexy. ORIGINAL RESEARCH

F. Yetis¸ir et al. / International Journal of Surgery 10 (2012) 532e536 535

Table 1 Table 3 Concommitant operations with fundoplication with double The comparison of different surgical techniques in patients with GER disease. sided posterior gastropexy. Type of operation Number Follow Failure Cholecystectomy 12 of up time rate (%) Umbilical hernia repair 2 patients (month) _ Incisional hernia repair 1 Mucio M.12 Nissen fundoplication 103 174 21.5 fi Modi ed radical mastectomy 1 Nissen fundoplication 97 174 7.2 with fixed nondeformable gastropexy Partial fundoplication 102 174 39.8 10 Posterior gastropexy that entailed anchoring the gastroesoph- Kloek JJ. Boerama anterior gastropeksi 208 92 23 Parsak CK.3 Cruroplasty with propylene 75 12 4 ageal junction to the median arcuate ligament was proposed by mesh and Nissen Lucius Hill in the late 1960’s. Dr.Hill reported only 5 (0.89%) fundoplication recurrences after using this approach for 559 patients undergoing Cruruplasty with vicryl mesh 75 12 5.3 hiatal hernia repair.13,19 Civello et al. compared the results of and Nissen fundoplication 11 modified Hill operation with Nissen fundoplication and they found Tsimogiannis EK. Nissen fundoplication 42 48 10 fi Nissen fundoplication with 40 48 2.5 that failure rate was 12.4% in nissen group, 10% in modi ed hill posterior gastropexy 20 group. Our study Fundoplication with double 45 12 2.2 Combining the LNF with posterior gastropexy provided better sided posterior gastropexy early and late postoperative complications. Mucio et al. compared long term results of Nissen fundoplication with their novel tech- 12 nique called complete fixed ‘nondeformable’ fundoplication. A required to compare the results of alternative techniques with lower prevalance of erosive gastroesophageal reflux was observed fundoplication with double sided posterior gastropexy. in fixed ‘nondeformable group’ (7.2%) versus (21.56%) for Nissen group. Lower esophageal sphincter pressure and length were more Ethical approval constant in the fixed ‘nondeformable group’14.7 mmHg, 2.2 cm, None. compared with Nissen 9 mmHg, 0.7 cm at the 15 year follow-up in 12 this study. But we think that, placing 15 sutures for gastric fixa- Funding tion is not reasonably feasible. Fundoplication with double sided None. posterior gastropexy in our study succeeds better intraabdominal fixation of the fundoplication and sufficient segment of the lower Author contribution esophagus at the intraabdominal cavity to prevent recurrence of Fahri Yetis¸ir: study design, writing. gastroesophageal reflux. A. Ebru Salman: data collection, writing. Tsimogiannis et al. compared the results of LNF combined with Dogukan Durak: data collection, data analysis. posterior gastropexy with standard LNF. The recurrence rate in Mehmet Kiliç: data analysis, study design. this study was 2.5% in LNF combined with posterior gastropexy, 11 10% in standard LNF group. They stated to place only one suture Conflict of interest to pexy the posterior part of the fundoplication to the approxi- None. mated part of the lower level of the crura. In our opinion, one suture may not provide adequate fixation. Fixation only from the References posterior side with only one suture may increase telescoping of the esophagus through repair. Using a PTFE mesh in patients with 1. Hazan TB, Gamarra FN, Stawick L, Maas LC. Nissen fundoplication and hiatal hernia >6 cm in the same study might affect the success gastrointestinal-related complications: a guide fort he primary care physician. rate. South Med J 2009;10:1041e5. 2. RAS giris¸e koy Rosemurgy AS, Donn N, Paul H, Luberice K, Ross SB. Gastro- The incidence of paraesophageal hiatus herniation ranges up to esaphageal reflux disease. Surg Clin North Am 2011;91(5):1015e29. 21 7% in published report series In our study, paraesophageal her- 3. Parsak CK, Erel S, Seydaoglu G, Akçam T, Sakman G. Laparoscopic antireflux niaton did not developed since gastropexy to arcuate ligament was surgery with polyglactin (vicryl) mesh. Surg Laparosc Endosc Percutan Tech 2011;21:443e9. made on both sides of fundus with at least two sutures. Our tech- 4. Perdikis G, Hinder RA, Lund RJ, Raiser F, Katada N. Laparoscopic Nissen nique also attenuated telescoping of the esophagus through the fundoplication: where do we stand? Surg Laparosc Endosc 1997;7:17e21. repair. Fundoplication was approximately 270 posterior and 90 5. Hinder RA, Filipi CJ, Wetcher G, DeMeester TR, Perdikis G. Laparoscopic Nissen fundoplication is an effective treatment for gastroesaphageal reflux disease. anterior in standard Nissen technique and it was approximately e Ann Surg 1994;220:472 83. 180 posterior and 180 anterior in fundoplication with double 6. Smith CD, McClusky DA, Rajad MA, Andrew B, Hunter J. When fundoplication sided posterior gastropexy. falls redo? Ann Surg 2005;241:861e9. As a result, the combination of LNF with double sided posterior 7. Furnee EJB, Draaisma WA, Broeders IAMJ, Gooszen HG. Surgical reintervention after failed antireflux surgery: a systematic review of the literatüre. J Gastro- gastropexy to arcuate ligament seems to give better early post- intest Surg 2009;13:1539e49. operative outcomes. Further prospective randomized trials are 8. Rantanen T, Neuvonen P, Livonen M, Tomminen T, Oksala N. The impact of fibrin glue in the prevention of failure after Nissen fundoplication. Scand J Surg 2011;100:181e5. 9. Quilici PJ, McVay C, Tovar A. Laparoscopic antireflux procedures with hepatic Table 2 shoulder technique for the surgical management of large paraesophageal Preoperative signs and symptoms of patients. hernias and gastroesophageal reflux disease. Surg Endosc 2009 Nov;23(11): 2620e3. Epub 2009 Apr 10. Retrosternal and epigastric pain 45 (100%) 10. Kloek JJ, Van de Laar GAG, Deurloo JA, Aronson DC, Benninga MA, Regurgitation 39 (86.7%) Taminiau JAJM, et al. Long term results of boerema anterior gastropexy in Coughing and respiratory problems 19 (42.2%) children. J Pediatr Gastroenterol Nutr 2006;43:71e6. Nausea, vomiting and flatulence 10 (22.2%) 11. Tsimogiannis EK, PappasGogos GK, Benatatos N, Tsironis D, Farantos C, Esophagitis at endoscopy 40 (88.9%) Tsimoyiannis EC. Laparoscopic Nissen fundoplication combined with Hiatal hernia 29 (64.4%) posterior gastropexy in surgical treatment of GERD. Surg Endosc 2010;24: 1303e9. ORIGINAL RESEARCH

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12. Mucio M, Rojano M, Herrera JJ, Valdevinos MA, Cordova A, Bravo C, et al. Novel 17. Von Rahden BH, Scheurlen M, Filser J, Stein HJ, Germer CT. Newly recognized surgical concept in antireflux surgery: long- term outcomes comparing 3 side effects of proton pump inhibitors. Arguments in favour of fundoplication different laparoscopic approaches. Surgery 2012;151:84e93. for GERD? Chirurg 2012;83(1):38e44. 13. Davis CS, Fisichella PM. Laparoscopic Nissen fundoplication combined with 18. Symons NR, Purkayastha S, Dillemans B, Athanasiou T, Hanna GB, Darzi A, et al. posterior gastropexy in the surgical treatment of gastroesophageal reflux Laparoscopic revision of failed antireflux surgery: a systematic review. Am J disease (GERD). Surg Endosc 2011;25:2055. Surg 2011;202(3):336e43. 14. Vansant JH, Baker JW, Ross DG. Modification of the hill technique for repair of 19. Hill LD. Progress in the surgical management of hiatal hernia. World J Surg hiatal hernia. Surg Gynecol Obstet 1976 Oct;143(4):637e42. 1977;1:425e36. 15. Hall J, Dodd S, Durrkin M, Sloan S. Impact of proton pump inhibitör utilization 20. Civello IM, Brisinda G, Sganga G, De Fazio S, Maria G, Crucitti F. Modified hill patterns on gastroesophageal reflux disease costs. Manag Care 2002;11(Suppl. operation vs. Nissen fundoplication in the surgical treatment of gastroesoph- 7):14e8. ageal reflux disease. Hepatogastroenterology 1997;44:380e6. 16. Ramakrishnan A, Katz PO. Pharmacological management of gastroesaphageal 21. Collard JM, de Gheldere CA, De Cock M, Otte JB, Kestens PJ. Laparoscopic reflux disease. Curr Gastroenterol Rep 2002;4:218e24. antireflux surgery: what is real progress? Ann Surg 1994;220:146e54.