Initial Experience with Laparoscopic Fundoplication in the Netherlands and Comparison with an Established Technique (Belsey Mark IV)

Abstract

Since the introduction of laparoscopic cholecystectomy as an alternative for conventional cholecystectomy, the number of cholecystectomies per year is showing an increased tendency, suggesting that indications for surgery have broadened now that the morbidity of the procedure has decreased so much. For gastro-oesophageal reflux disease (GORD) the current number of operations performed per year in The Netherlands is small compared with the calculated prevalence of complicated GORD. If the data on epidemiology of GORD by Richter are extrapolated to the population of The Netherlands, there must be at least 4,500 potential candidates for antireflux surgery currently available and only 250 operations are performed per year. Laparoscopic Nissen fundoplication is practised with acceptable results. If with this new development the same tendency as for laparoscopic cholecystectomy arises, this may mean either that too many patients will undergo antireflux surgery or that the potential candidates will now get their chance to have an effective operation with the prospect of low procedure-related morbidity. In The Netherlands, 62 laparoscopic Nissen fundoplications have been performed. There have been no deaths and in 5 patients the laparoscopic procedure had to be converted into a laparotomy. Forty-two of these 62 patients were treated according to a protocol and were included in the follow-up. At one month, 38 out of 42 patients were available for follow-up. At one month after surgery, 38 patients felt that their reflux symptoms had improved. Surgery-induced symptoms were present in 19 out of 38 patients. At three months after surgery, 26 out of 26 had improved GORD symptoms, while there were 4 patients with surgery-induced symptoms and 3 with persistent retrosternal pain. Of the 7 patients who were one year after surgery, 7 had improved. These data were compared with those of a cohort of patients prospectively studied before and after Belsey MK IV fundoplication; 87% had persistent subjective success with an 88% cure of oesophagitis. Normalization of 24 pH profile (total percentage of time with pH below 4) was observed in 50% of patients. We feel from these preliminary results of laparoscopic Nissen fundoplication that the procedure is feasible, but that it should be performed by experienced laparoscopic surgeons with a profound interest in upper GI pathology. Further results should be awaited before laparoscopic Nissen fundoplication can be performed on a greater scale.