Clinical surgery-International
Laparoscopic mesh-augmented hiatoplasty as a method to treat gastroesophageal reflux without fundoplication: single-center experience with 306 consecutive patients

Presented at the 15th Annual Congress of the European Association for Endoscopic Surgery, July, 2007, Athens, Greece.
https://doi.org/10.1016/j.amjsurg.2008.07.050Get rights and content

Abstract

Background

Laparoscopic fundoplication represents the surgical standard treatment of gastroesophageal reflux disease. However, because of persisting side effects the method is not without controversy. Laparoscopic mesh-augmented hiatoplasty might be an alternative.

Methods

In 306 consecutive patients the perioperative course and symptomatic outcome was analyzed after a mean follow-up period of 52 months.

Results

The mean DeMeester symptom score decreased from 5.3 to 2.0 (P < .001). Acid-suppressive therapy on a regular basis was discontinued in 79% of patients. The gas bloating value decreased from .7 to .5 (P = .031), and the dysphagia value increased from .5 to .9 (P < .001). Belching and vomiting were possible in 93% and 88% of patients, respectively. Mesh-related complications with the need for reoperation occurred in 1% of patients.

Conclusions

Laparoscopic mesh-augmented hiatoplasty is safe and does have an antireflux effect even without fundoplication. Side effects seem to be reasonable.

Section snippets

Patients

Medical records of 306 consecutive patients (165 men, 141 women) undergoing surgery with LMAH for symptomatic GERD at Bad Saulgau Hospital during the period from July 1999 to August 2006 were reviewed. Exclusion criteria were large hiatal hernias with para-esophageal involvement, primary gastroesophageal disorders entailing symptoms other than GERD, and an American Society of Anesthesiologists (ASA) score higher than III. The mean age of patients was 51.6 ± 14.1 years (range, 18–83 y), and the

Surgical procedure

Informed consent was obtained from every patient. All procedures were performed similarly as described previously17 by 1 of 3 different surgeons experienced in laparoscopy (at least 100 procedures). After placement of a 32-F esophageal bougie the lesser omentum and the peritoneum over the hiatus were incised. After complete mobilization of the distal esophagus the hiatus was narrowed by 3 to 5 nonabsorbable, multifilament sutures (Endostich 2-0; Tyco Healthcare, Neustadt, Germany). After

Perioperative course (in the hospital and/or within 30 postoperative days)

The mean surgical time for LMAH was 62.8 minutes (range, 30–130 min). There were 3 intraoperative complications (1%) with no need for conversion to open surgery: a small pleural opening (n = 2; .6%) and a small pericardial opening (n = 1; .3%). In total, there were 19 postoperative complications in 18 patients resulting in an overall morbidity rate of 6%: dysphagia with the need for intervention by endoscopy, intensive anti-inflammatory therapy, and/or parenteral nutrition (n = 6; 2%), pleural

Comments

A valuable surgical method to treat GERD has to fulfill several requirements. First of all, it has to be feasible and safe. Equally, it has to be effective and durable but should not have any disturbing side effects. Currently, laparoscopic fundoplication is the surgical standard antireflux procedure. It is characterized by a low intraoperative and postoperative complication rate and fair midterm and long-term results depending on the definition of success. However, the method also entails

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