Comparative analysis of clinical results of laparoscopic vs. open fundoplication

Introduction: Surgery has become frequently applied treatment option in gastroeosphageal reflux disease patients. This trend is enhanced by the advent of laparoscopic approach. Some recently published papers assert that the failure of surgery during the long-run outcome proved to be not as favorable as we thought earlier. We compared the results of patients who undergone antireflux surgery by open (OA) or laparoscopic (LA) approach and the follow up period was at least 5 years.

Material and methods: Between January 1995 and December 2000 88 antireflux procedures were performed. 59 patients were operated by LA while 29 by OA. The demographic data of the two subsets of patients were comparable. We compared the five year follow up data of the two groups. The patients were studied by questionnaire and in case of complain or recurrent reflux symptoms detailed examination protocol was applied.

Results: Surgery caused significant reflux control in both groups as can be seen on the changes of standard reflux parameters. The early postoperative findings in both groups proved to be satisfactory. Temporary dysphagia was reported by 18 of 59 LA patients and 9 of 29 OA ones. Recurrent reflux symptoms could be detected in 5 of 59 LA and 3 of 29 OA patients. Slipped wrap was found in 3 cases in the OA subset while in none of the LA subset of patients. However 4 recurrent herniation occurred in the LA group while 1 recurrent herniation developed in the OA group. In one case of recurrent herniation in the LA group due to severe mechanical symptoms (pain and dysphagia) an open repair was done 28 months after primary surgery.

Conclusions: The analysis of 5 year follow up data shown that the reasons of failed results following OA and LA antireflux surgery were different. Failures following laparoscopic fundoplication were mainly due to recurrent herniation while failures following open fundoplication were rather due to wrap slippage or too long or tight plication. In the laparoscopic era during the learning curve most probably the lack of crural repair, no adequate mobilization of the esophagus and the gastric fundus could have been the reasons of failed results. The best approach to failed antireflux surgery is to prevent it. The study was partly supported by Hungarian Scientific Research Fund, OTKA T38244.