Hypothesis Laproscopic Nissen Fundoplication provides long-term relief of symptoms of gastro-esophageal reflux disease. Patients From November 2006 to March 2009, we performed more than 140 laparoscopic antireflux procedures. The outcome for patients who underwent surgery between November 2006 and October 2009 (108 cases) was determined. This included all patients having laparoscopic Nissen fundoplication, from the first procedure onward. Interventions Long-term follow-up for 2 or more years after laparoscopic Nissen fundoplication was obtained. Results Outcome data covering a period of 2 or more years after surgery was available for 108 patients (95%), with 6 patients lost to follow-up. Two patients died (unrelated causes) at some stage following surgery, and the outcome was difficult to determine in 1 patient with cerebral palsy. Hence, questionnaire data were available for 99 patients at a median follow-up of 1.6 years (range, 1–3.4 years). 87% of the 99 patients remained free of significant reflux. Reoperation was required for dysphagia in 2 patients (2%), 1 for a tight wrap and 1 for a tight diaphragmatic hiatus. In addition, reoperation was necessary for a paraesophageal hiatus hernia in 1 patient (1%). Of the reoperations, 50% were performed within 12 months of the original procedure, and 50% during the second year of follow-up. The long-term outcome was considered “good or excellent” by 90% of patients. Conclusions The short-term outcome of laparoscopic Nissen fundoplication is “good or excellent” with most of the patients are free from drugs / diet change / life-style change.

1. Laproscopic Fundoplication for Gastro-
Esophageal Reflux Disease

2. Original Article
INTRODUCTION
Gastroesophageal reflux disease (GERD) has long
been recognized as a significant public health concern.
GERD occurs in many Indians, with nearly 44%
experiencing monthly “heartburn” and 50% of these
individuals using nonprescription medication for this
problem. GERD is a chronic progressive disorder, often
prompting patients to seek medical advice for further
treatment.
Surgical treatment of GERD is well established and
provides well recognized benefits [1-5]. This article
outlines the indications and appropriate surgical treatment
of GERD.
DEFINITION
GERD is defined as the failure of the antireflux barrier,
allowing abnormal reflux of gastric contents into the
esophagus. It is a mechanical disorder which is caused by a
defective lower esophageal sphincter, a gastric emptying
disorder or failed esophageal peristalsis. These abnormali-
ties result in a spectrum of disease ranging from
“heartburn” to esophageal tissue damage with subsequent
compli-cations. While the exact nature of the antireflux
barrier is incompletely understood, the current view is
that the lower esophageal sphincter (LES), the
diaphragmatic crura, and the phreneosophageal ligament
are key components.
PATIENTS AND METHODS
Follow-up data for a period of 2 or more years was
sought for all patients undergoing a laparoscopic Nissen
fundoplication between November 2006 and October
2009 at the Department of Minimal Access Surgery,
Apollo Speciality Hospitals, Madurai. This included
every patient having the laparoscopic procedure since its
inception in our institution in November 2006. During
this period, all patients admitted for antireflux surgery
were offered a laparoscopic approach, irrespective of any
difficulties perceived by preoperative assessment such as
obesity, large hiatal hernia, previous upper abdominal
surgery, esopha-geal stricturing, or Barrett esophagus.
Gastroesophageal reflux was initially diagnosed by the
presence of endo-scopic esophagitis in patients with
typical reflux symptoms, and 24-hour pH monitoring was
used to confirm the diag-nosis of reflux in patients with
atypical symptoms or who did not have endoscopic
evidence of esophagitis.
129 Apollo Medicine, Vol. 7, No. 2, June 2010
LAPROSCOPIC FUNDOPLICATION FOR GASTRO-ESOPHAGEAL REFLUX DISEASE
A Suresh Kumar
Consultant Laproscopic Surgeon, Apollo SpecialIty Hospitals, Madurai 625 020, India.
E-mail: suran74@yahoo.co.in
Hypothesis: Laproscopic Nissen Fundoplication provides long-term relief of symptoms of gastro-esophageal
reflux disease.
Patients: From November 2006 to March 2009, we performed more than 140 laparoscopic antireflux
procedures. The outcome for patients who underwent surgery between November 2006 and October 2009
(108 cases) was determined. This included all patients having laparoscopic Nissen fundoplication, from the
first procedure onward. Interventions: Long-term follow-up for 2 or more years after laparoscopic Nissen
fundoplication was obtained. Results: Outcome data covering a period of 2 or more years after surgery was
available for 108 patients (95%), with 6 patientslost to follow-up. Two patients died (unrelated causes)at some
stage following surgery, and the outcome was difficult to determine in 1 patient with cerebral palsy. Hence,
questionnairedata were available for 99 patients at a median follow-up of1.6 years (range, 1-3.4 years). 87%
of the 99 patientsremained free of significant reflux. Reoperation was requiredfor dysphagia in 2 patients (2%),
1 for a tight wrap and 1 for a tight diaphragmatic hiatus. In addition, reoperation was necessary for a
paraesophageal hiatus hernia in 1 patient(1%). Of the reoperations, 50% were performed within 12 monthsof
the original procedure, and 50% during the second year offollow-up. The long-termoutcome was considered
“good or excellent” by 90% of patients. Conclusions: The short-term outcome of laparoscopic Nissen
fundoplication is “good or excellent” with most of the patients are free from drugs / diet change / life-style
change.
Key words: Gastro-Esophageal Reflux Disease (GERD), Hiatus hernia, Fundoplication.

3. Apollo Medicine, Vol. 7, No. 2, June 2010 130
Original Article
Information about the preoperative assessment and
management, surgical procedure, and postoperative
outcome for each patient was collected prospectively and
stored on a computerized database. Postoperative clinical
follow-up was obtained through a standardized question-
naire both 3 months and 12 months following surgery and
annually thereafter.
The presence or absence of heartburn and liquid- and
solid-food dysphagia, as well as patient satisfaction with
the procedure,was graded from 0 to 10 (0 = no symptoms;
10 = severe symptoms) using visual analog scales. The
presence or absence of gaseous bloating, the ability to
belch, the ability to relieve abdominal distension, and the
ability to eat a normal diet, and patients’ opinions on
whether they would undergo the same procedure again
under similar circum-stances, were also determined.
Details of adverse outcomes such as hospital readmission,
complications,or surgical revision were recorded.
SURGICAL TECHNIQUE
Five trocars were sited in the upper abdominal wall. In
the initial procedure, Veress needle insufflation at the left
costalmargin was used, and a single laparoscopic grasping
instrument was used to retract the left lobe of the liver.
Both pillars of the esophageal hiatus were dissected using
electrocautery to expose the distal esophagus. In all
patients, irrespectiveof whether short gastric vessels were
divided or not, a short, loose total fundoplication was
constructed, calibrated over a 52Fbougie within the lumen
of the esophagus. Three interruptedpolypropylene sutures
were used to secure a total fundoplication of between 1.5
and 2 cm in length.
RESULTS
Outcome data covering a period of 2 or more years
after surgery was available for 108 patients (95%), with 6
patients lost to follow-up. Two patients died (unrelated
causes) at some stage following surgery, and the outcome
was difficult to determine in 1 patient with cerebral palsy.
Hence, questionnairedata were available for 99 patients at
a median follow-up of 1.6 years (range, 1-3.4 years). 87%
of the 99 patients remained free of significant reflux.
Reoperation was required for dysphagia in 2 patients
(2%), 1 for a tight wrap and 1 for a tight diaphragmatic
hiatus. In addition, reoperation was necessary for a
paraesophageal hiatus hernia in 1 patient (1%). Of the
reoperations, 50% were performed within 12 months of
the original procedure, and 50% during the second year of
follow-up.
The first re-operation which was performed by 3rd
month following fundoplication was for a tight fundal
wrap around esophagus, the second re-operation was by
16th month due to narrowing at the level of diaphragmatic
hiatus causing dysphagia.
One patient required re-laproscopy with repair of
paraesophageal hernia [6] by 12th month.
In the 99 patients for whom clinical follow-up was
obtained at 2 or more years after surgery, 60 patients
(60%) had no heartburn, and 27 (27%) had occasional
minor episodes of heartburn (heartburn score 1, 2, or 3).
Nine patients (9%) reported a heartburn score of 4 to 6,
and 4 patients (4%) graded their heartburn as 7 or higher
(significant troublesome heartburn). Most patients
reported a heartburn score of 7 or higher before surgery.
Hence, 87% of patients were free of significant reflux
symptoms at 2 or more years’ follow-up. Regular acid
suppression medication for “reflux” symptoms is being
taken by 11 patients(11%), who are included in the groups
experiencing more severesymptoms described previously.
DISCUSSION
Laparoscopic antireflux surgical procedures were
introduced into clinical practice a little more than a decade
ago. Today, they constitute a well-established treatment
modality for gastro-esophageal reflux disease. With the
introduction of laparoscopy, there has been a significant
increase in the number of antireflux procedures performed
annually in India. This most likely indicates more
willingness by patients and referring physicians to
consider the less invasive approach, rather than a change
in the indications of surgical therapy. The main indications
for surgical treatment continue to be relapse on medical
therapy, intolerance of medications or the patient’s choice
of not taking medications chronically. A key to successful
outcome following antireflux surgical procedures is
careful patient selection and work-up. The use of
endoscopy, contrast studies, esophageal manometry and
24-h pH studies is of paramount importance. Typical of
many laparoscopic operations, antireflux procedures
evolved with time and underwent several technical
refinements. There continues to be considerable debate on
some of the technical aspects of these procedures and on
the long-term difference in outcome between partial and
complete fundoplication. The superiority of the
laparoscopic approach over the open approach has been
established.
Of importance for the assessment of laparoscopic
Nissen fundoplication [7,8] is its ability to abolish reflux
symptoms, particularly heartburn. This symptom was not
experienced after surgery by 60% of patients. The 27% of
patients with a score of 3 or less reported an occasional
episode of mild heartburn that did not require medication.

4. Original Article
131 Apollo Medicine, Vol. 7, No. 2, June 2010
Moderate heartburn was reported by 9% of patients, and
4% reported severeheartburn. The outcomes are similar to
those following open Nissen fundoplication, suggesting
that the laparoscopic approach does not compromise
reflux control. Of interest, overall patient satisfaction
following surgery was high, with 90% of patientssatisfied
with their long-term outcome. However, our follow-up is
clinical only, and objective follow-up using either pH or
endoscopic studies was not sought. It is certainly possible
that a few patients who claimed relief of reflux symptoms
might demonstrate abnormalities if they underwent either
pH monitoring or endoscopy. On the other hand, some of
the patients who claimed to experience symptomatic
reflux following surgery had no objective evidence of
reflux when they underwent postoperative testing.For this
reason, in a clinical practice setting, the symptoms
experienced by patients ultimately determine the success
orfailure of the operations we perform, not the outcome of
follow-up tests or the surgeon’s opinion about technical
success. Hence, we believe that laparoscopic Nissen
fundoplication is an effective long-term treatment for
gastroesophageal reflux disease [9], yielding similar
results to open fundoplication [10] but with the short-term
advantages of quicker recovery and reduced wound-
related morbidity.
REFERENCES
1. Trus TL, Laycock WS, Branum G, Waring JP, Mauren S,
Hunter JG. Intermediate follow-up of laparoscopic
antireflux surgery. Am J Surg. 1996;171: 32-35.
2. Anvari M, Allen C. Laparoscopic Nissen fundoplication:
two-year comprehensive follow-up of a technique of
minimal paraesophageal dissection. Ann Surg.
1998;227:25-32.
3. 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.
4. Grande L, Toledo-Pimentel V, Manterola C, et al. Value of
Nissen fundoplication in patients with gastro-
oesophageal reflux judged by long-term symptom
control. Br J Surg. 1994;81:548-550.
5. Watson DI, Jamieson GG, Baigrie RJ, Mathew G, Devitt
PG, Game PA. Laparoscopic surgery for gastro-
oesophageal reflux: beyond the learning curve. Br J
Surg. 1996;83:1284-1287.
6. Watson DI, Jamieson GG, Devitt PG, Mitchell PC, Game
PA. Paraoesophageal hiatus hernia: an important
complication of laparoscopic Nissen fundoplication. Br J
Surg. 1995;82:521-523.
7. Jamieson GG, Watson DI, Britten-Jones R, Mitchell PC,
Anvari M. Laparoscopic Nissen fundoplication. Ann Surg.
1994;220:137-145.
8. Gotley DC, Smithers BM, Rhodes M, Menzies B, Branicki
FJ, Nathanson L. Laparoscopic Nissen fundoplication:
200 consecutive cases. Gut. 1996;38:487-491.
9. Anvari M, Allen C, Borm A. Laparoscopic Nissen
fundoplication is a satisfactory alternative to long-term
omeprazole therapy. Br J Surg. 1995;82:938-942.
10. Watson DI, Jamieson GG, Pike GK, Davies N,
Richardson M, Devitt PG. A prospective randomised
double-blind trial between laparoscopic Nissen
fundoplication and anterior partial fundoplication. Br J
Surg. 1999;86:123-130.

5. Apollo hospitals: http://www.apollohospitals.com/
Twitter: https://twitter.com/HospitalsApollo
Youtube: http://www.youtube.com/apollohospitalsindia
Facebook: http://www.facebook.com/TheApolloHospitals
Slideshare: http://www.slideshare.net/Apollo_Hospitals
Linkedin: http://www.linkedin.com/company/apollo-hospitals
Blog: http://www.letstalkhealth.in/