Symptomatic outcome following laparoscopic anterior partial fundoplication: follow-up of a series of 200 patients

S. ROSS*, A. JABBAR†, C.R. RAMSAY*, A.J.M. WATSON†, A.M. GRANT* and Z.H. KRUKOWSKI†
* Health Services Research Unit, University of Aberdeen, † Ward 49, Aberdeen Royal Hospitals Trust, Foresterhill, Aberdeen U.K.

Introduction Method

Results Discussion References

This article reports patient perceived symptomatic outcome at a median of 23 months after surgery for a consecutive series of 200 patients who underwent a laparoscopic anterior partial fundoplication for gastrooesophageal reflux disease (GORD). Responses to postal questionnaires indicated that for the majority of patients the outcome was good, with 62% reporting minimal GORD symptoms. However, for a significant minority, the outcome was less favourable, and for 10% the outcome was poor. Continuing evaluation of the procedure is needed to establish its place in the management of GORD.

Keywords: Case series, follow-up, laparoscopic anterior partial fundoplication, symptomatic outcome

J.R.Coll.Surg.Edinb., 45, December 2000, 363-365 

INTRODUCTION

The optimal technique for laparoscopic fundoplication is controversial. Anterior fundoplication is claimed to produce a 'more physiological alternative' without the hypertonic lower oesophageal sphincter pressure produced by a total wrap.¹ This article describes patient perceived symptomatic outcome at a median of 23 months after surgery for a consecutive series of 200 patients who underwent a laparoscopic anterior partial fundoplication for gastro-oesophageal reflux disease, with or without a hiatal hernia, over a five-year period.

METHOD

The study included all 200 patients of one consultant surgeon (ZHK) who underwent surgery for gastro-oesophageal reflux disease (GORD) in Aberdeen over a five-year period from August 1993. All patients had laparoscopic anterior fundoplication as described by Watson et al (1994)¹ This operation comprises routine closure of the hiatal opening with fixation of the mobilised oesophagus and anterior partial fundoplication.

In October 1998, each patient was sent a postal questionnaire that included:

• A self-completion DeMeester symptom score to evaluate GORD symptoms (heartburn, regurgitation and dysphagia): the total range varying from 0 (no GORD symptoms) to 9 (maximum symptoms).²
• The Gastrointestinal Symptom Rating Scale (GSRS), which produces five sub-scales (reflux, diarrhoea, constipation, abdominal pain, indigestion): mean sub-scale scores range from 1 (no discomfort) to 7 (very severe discomfort). ³
• Two additional items related to possible side effects of surgery: inability to vomit and belch. Patients were also asked if they had been prescribed any GORD medication in the past month, and to rate the success of their operation.

Results are presented using simple descriptive statistics.

RESULTS

The mean age of patients at the time of operation was 46 years (range 21 to 75), and 80 (40%) were female.

Early postoperative complications included pleural puncture during oesophageal mobilisation in 20 (10%) patients, with aspiration of pleural gas required on reversal of anaesthesia in seven (3%) cases. Four (2%) patients developed gastric dilatation requiring passage of a naso-gastric tube during their hospital stay. Hospital stay was a median of 1 day (range 0 to 17). Nine (4%) patients developed early postoperative dysphagia that required subsequent oesophageal dilatation. Ten re-operations for recurrent reflux had been performed by the time of assessment: these were carried out between 8 and 46 months after the initial operation.

Follow-up was carried out at a median of 23 months after operation (range 3 to 58). Three patients had died (one in a road traffic accident, and two of heart disease): completed responses were received from 171 of the remaining 187 for whom a correct address was available, a response rate of 91%. At the time of follow-up, the DeMeester symptom score indicated that the majority of patients reported minimal GORD symptoms (Table). However, seventeen patients (10%) had a score of four or more, with one patient complaining of maximum symptoms (score of 9). Among the GSRS scores the highest score was obtained for indigestion (mean 2.7, SD 1.4). The abdominal pain mean score was 2.0 (SD 1.2), diarrhoea 1.9 (SD 1.4) and constipation 1.8 (SD 1.1). The lowest symptom score was for reflux (mean 1.7, SD 1.2). The gastrointestinal symptoms, which most commonly caused discomfort, were excess flatus 38/171 (22%), bloating 36/170 (21%), borborygmi 27/171 (16%).

Additional potential side effects of surgery caused moderately severe to severe discomfort in a number of patients: inability to vomit in 4/167 (2%), inability to belch in 6/167 (4%), and diarrhoea in 19/170 (11%). Diarrhoea lasting for more than three months was reported by 41/165 (24%) patients and was still present at the time of follow up in 20 (12%) cases. Sixty-three (37%) patients reported taking prescribed medications for GORD over the last months (Table). The outcome of the operation was rated as good or excellent by 134/167 (80%); 152/165 (92%) would recommend the same operation to someone else. 

Table: Patient perceived outcome

DISCUSSION

Review of this large series of patients following laparoscopic anterior fundoplication indicates that for the majority, the patient perception of outcome was very satisfactory, with 62% having minimal GORD symptoms. Our results for reflux symptoms following anterior partial fundoplication are comparable with those following laparoscopic total fundoplication, and laparosocopic anterior fundoplication.^{4, 5}

However, for a significant minority, the outcome in this series was less favourable, and for 10% the outcome was poor, particularly for those with new and persisting symptoms such as diarrhoea lasting for more than three months.

Our finding of diarrhoea-causing significant symptoms for 11% of patients was similar to that among laparoscopic anterior fundoplication patients in a trial comparing outcome with that following Nissen fundoplication.⁵ In our study, diarrhoea persisted for up to three years post-operatively in some patients. It is unfortunate that neither in our study nor the trial above was the information available on diarrhoea before surgery, because diarrhoea may pre-date surgery.⁶

The initiation of anti-secretory drug treatment after surgery for GORD is often regarded as surgical failure. There is little control over the prescription of such medication and the threshold for initiating treatment for any upper abdominal dyspeptic symptoms can be low. Among our respondents, even though 37% had required drug treatment during the previous month, over 90% would recommend the operation to someone else. It is possible that patients are willing to accept reduction in symptoms as a result of surgery rather than a cure. Another explanation for the apparent discrepancy in our findings is that patients with a poor outcome regard themselves as special cases (as indicated by informal comments appended to the questionnaire) and consider that a similar poor outcome would not be expected in other patients. These and other possible explanations require further investigation.

The results of this study indicate that laparoscopic anterior fundoplication provides acceptable clinical outcomes, however, continuing evaluation of the procedure is needed to establish its place in the management of GORD.

REFERENCES

1. Watson A, Spychal RT, Brown MG, Peck N, Callander N. Laparoscopic 'physiological' anti-reflux procedure: preliminary results of a prospective symptomatic and objective study. Br J Surg 1994; 82: 651-6
2. DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Ann Surg 1986; 204: 9-20
3. Revicki DA, Wood M, Wiklund I, Crawley J. Reliability and validity of the gastrointestinal symptom rating scale in patients with gastroesophageal reflux disease. Qual Life Res 1998; 7: 75-83
4. Blomqvist A, Lˆnroth H, Dalenb per thousand ck J, Ruth M, Wiklund I, Lundell L. Quality of life assessment after laparoscopic and open fundoplication. Scand J Gastroenterol 1996; 31: 1052-8
5. Watson DI, Jamieson GG, Pike GK, Davies N, Richardson M, Devitt PG. Prospective randomised double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication. Br J Surg 1999; 86: 123-30
6. Hunter JG, Trus TL, Branum GD, Waring JP, Wood WC. A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 1996; 223: 673-87

ACKNOWLEDGEMENTS

We are grateful to Sharon McLeer for her assistance with developing, piloting and administering the postal questionnaire. This study was not funded externally. The Health Services Research Unit is funded by the Chief Scientist Office, Scottish Executive Health Department. However, the views expressed are those of the authors.

Copyright date: 11th September 2000

Correspondence: S. Ross, Co-ordinator of Clinical Research, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario M5G 1X5, Canada

©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb. 45, 6: 363-365