1. Recurrence of Symptoms Obvious Anatomic Problem
Lessons Learnt From a Hundred Consecutive Laparoscopic Nissen’s Fundoplications
J. Ma 1,*, A. Rasheed 1
1General Surgery Department (Upper GI Surgery), Royal Gwent Hospital, Newport, United Kingdom
Results
Laparoscopic Nissen’s fundoplication (LNF) with routine division of short gastrics, posterior crurraphy and 360 degrees plication without a bougie is procedure of choice for surgical management of gastroesophageal reflux disease (GORD) at our institution.
Sub-optimal control of oesophageal or extra-oesophageal symptoms despite maximal medical therapy.
GORD-related complications (peptic stricture or Barrett’s oesophagus).
Patient’s choice (preference to stop chronic use of PPI).
Association of GORD with Para-Oesophageal Hernia (POH).
100 consecutive patients were identified over the 8 year period. One patient had passed away from unrelated disease. Table 2 demonstrates patients’ characteristics and their index presenting symptoms. x
Patient Characteristics
Patient Count / N (%)
Female
55%
Age (Years)
52.4 ± 14.5 (22-81)
Operation Duration (Min)
134.9 ± ( ; N= 66)
Barrett’s Oesophagus
14%
Microscopic Oesophagitis
63%
Typical Symptoms
Heartburn
84%
Regurgitation
20 %
Dysphagia
20%
Odynophagia 7%
Atypical Symptoms Vomiting
23 %
Cough/ Respiratory symptoms
10 /100
Chest pain
13 /100
Abdominal pain
22 /100
ENT symptoms
8 /100
Indications for LNF at our institution
Fig. 4 Results from GERD- HRQL (Total number of patients N= 39)
Side Effects of LNF
Transient symptoms such as mild dysphagia, mild heartburn and bloating are common, but should settle within 6 weeks postoperatively.
Failure following LNF
A significant failure/ re-operation rate is noted in the literature [3] with at least four main patterns of failure including disruption (I) or slippage/mal-positioning (II) of fundoplication; a tight or excessively long fundoplication (III), and hiatal failure with trans-mediastinal migration of fundoplication (IV).
Intra-Operative/ Immediately Post-Operative Complications
Fig. 5 Illustrating patient’s satisfaction with their current condition after LNF
A case was converted to open for suspected optical trocar-related retro-peritoneal bleed
One patient developed a splenic sub-capsularhaematoma that was treated conservatively
A case was converted to Toupet’s 48 hour
for persistent severe post-operative dysphagia.
Conclusion
Postoperative symptomatic evaluation revealed a suboptimal subjective outcome that is inexplicable by the endoscopic/ radiological findings, suggesting the need for a standardised procedure-specific postoperative objective evaluation tool. The use of functional MRI is a promising possibility; one study reported a 93% overall accuracy in deterring fundoplication wrap position with MR fluroscopy [4].
As LNF is not a curative procedure, and a degree of symptoms ‘trade-off’ is expected. We need to also conduct a standardised evaluation of patient’s preoperative symptoms using GERD- HRQL to better appreciate improvement of symptoms and most importantly, patients’ satisfaction with the procedure.
The high incidence of post operative gas bloat syndrome suggests the need for routine pre-operative evaluation of gastric motility and tailoring the fundoplication accordingly.
The higher than expected rate of anatomical failures highlighted the inadequacy of primary hiatorraphy, and the need for selective crural reinforcement. The ideal mesh should be biological, non-absorbable and non-crosslinked. 
The flow chart (Fig. 6) below has been devised to manage patient presenting to clinic with recurrence of symptoms after LNF.
(III)
(I)
(II)
(IV)
To evaluate a hundred consecutive LNFs performed by a single surgeon in relation to patients-reported functional outcome, anatomic and physiologic status of the procedure, assess the rate and study patterns of procedure failures to modify our practice accordingly. 
Objective
32 patients were investigated with OGD post-operatively due to persistent/ new symptoms. (Fig. 3) Only 5 reports were noted to have commented on problems with fundoplication or recurrence of hiatus hernia.
37 patients underwent barium studies to investigate their symptoms. (Fig. 4) Seven reports commented on the recurrence of hernia or wrap disturbances.
Methods
A list of patients who underwent LNFs from 2007 to 2014 under a single surgeon was obtained from the computerised theatre records. A retrospective data base was set up capturing the pre-operative clinical and patho-physiological characteristics, post-operative patient-related outcome using Viscik score, findings of follow-up investigations when performed and outcomes of re-do operations when needed.
Visick Grade
Characteristics I
Asymptomatic II
Mild Symptoms, Quality of life unaffected, No Medications needed
III
Moderate Symptoms, Quality of life affected, Medications required IV
Recurrent, incapacitating symptoms equal or worse to pre-operative situation
GERD-HRQL survey was conducted over the phone and mailed questionnaires; 57 patients have been contactable. Their clinical outcomes are as illustrated in table 3, and table 4. Figure 4 and figure 5 illustrate patient’s general satisfaction after LNF. Hiatal failure had been the attributing cause for failure of the fundoplication procedure. None of the patients had a disruption of the fundoplication.
Viscik Symptoms Evaluation Tool
A telephone survey was also conducted using the validated Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire to assess patients’ subjective functional outcome. Patients were also asked about their symptoms in relation to gas bloat syndrome. In this study, symptoms of bloatedness, flatulence and inability to belch are all considered manifestations of the condition.
Fig. 6 Flowchart depicting the proposed actions when patients present with recurrence of symptoms after LNF
Recurrence of Symptoms
OGD + Ba Swallow
Anatomically Normal
pH /Manometry
No GORD
Entertain other Dx
GORD
Symptom Correlation
Obvious Anatomic Problem
Consider Re-Do
Patient Outcome
Count/ N (%)
Viscik Classification I
49 (60.5%) II
18 (22.2%)
III
10 (12.3%) IV
4 (4.9%)
Re-operations
11 /100 (11%)
Gas bloat syndrome
23/ 57 (33.3%)
Table 3 Illustrating patient outcome in terms of Viscik classification, re-operation rate and frequency of gas bloat syndrome post LNF. N= Total patients.
Endoscopic Assessment of LNF
Endoscopic photograph of an anatomically correct NF (Retro-flexed View)
Fundoplication folds are located below the diaphragm and the folds run parallel to the distance line on the endoscope
We do not routinely perform post-operative or follow up endoscopy
Variables from Pre-op Investigations
Heartburn
Regurgitation
Absent
Present
Microscopic oesophagitis on pre-op OGD
18/25
11/20
22/30
7/14
pH<4 more than 5% time in pre-op pH study
7/12
9/11
11/16
8/9
Normal DeMeester Score (<14.8)
2/16
2/12
3/18
1/10
LOSP (mmHg)
<5
1/14
1/11
0/9
5-15
10/14
4/11
10/16
4/9
15-30
3/14
6/11
4/16
5/9
>30
0/14
0/7
0/16
References
Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut May;54(5):710-7.
Lundell L, Miettinen P, Myrvold HE, et al. Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis. Clin Gastroenterol Hepatol Dec;7(12):
Broeders JA, Roks DJ, Ahmed Ali U, et al. Laparoscopic Anterior 180-Degree Versus Nissen Fundoplication for Gastroesophageal Reflux Disease: Systematic Review and Meta- Analysis of Randomized Clinical Trials. Ann Surg May;257(5):850-9.
Kulinna-Cosentini C, Schima W, Ba-Ssalamah A, Cosentini EP. MRI patterns of Nissen fundoplication: normal appearance and mechanisms of failure. Eur Radiol Sep;24(9):
Radiological Assessment of LNF
Typical fundoplication defect (black arrows)
Circumferential narrowing of the distal oesophagus and OGJ (white arrow), extending for approximately 2–3 cm
The wrap is sub-diaphragmatic
We do not routinely perform post-operative or follow up contrast studies
Table 4 demonstrates the correlation of pre-opeartive Investigation results with post-operative symptoms as described in GORD –HRQL questionnaire (LOS = lower oesophageal sphincter pressure in mmHg)

2. Recurrence of Symptoms Obvious Anatomic Problem
Lessons Learnt From a Hundred Consecutive Laparoscopic Nissen’s Fundoplications
J. Ma 1,*, A. Rasheed 1
1General Surgery Department (Upper GI Surgery), Royal Gwent Hospital, Newport, United Kingdom
Results
Laparoscopic Nissen’s fundoplication (LNF) with routine division of short gastrics, posterior crurraphy and 360 degrees plication without a bougie is procedure of choice for surgical management of gastroesophageal reflux disease (GORD) at our institution.
Sub-optimal control of oesophageal or extra-oesophageal symptoms despite maximal medical therapy.
GORD-related complications (peptic stricture or Barrett’s oesophagus).
Patient’s choice (preference to stop chronic use of PPI).
Association of GORD with Para-Oesophageal Hernia (POH).
100 consecutive patients were identified over the 8 year period. One patient had passed away from unrelated disease. Table 2 demonstrates patients’ characteristics and their index presenting symptoms. x
Patient Characteristics
Patient Count / N (%)
Female
55%
Age (Years)
52.4 ± 14.5 (22-81)
Operation Duration (Min)
134.9 ± ( ; N= 66)
Barrett’s Oesophagus
14%
Microscopic Oesophagitis
63%
Typical Symptoms
Heartburn
84%
Regurgitation
20 %
Dysphagia
20%
Odynophagia 7%
Atypical Symptoms Vomiting
23 %
Cough/ Respiratory symptoms
10 /100
Chest pain
13 /100
Abdominal pain
22 /100
ENT symptoms
8 /100
Indications for LNF at our institution
Fig. 4 Results from GERD- HRQL (Total number of patients N= 39)
Side Effects of LNF
Transient symptoms such as mild dysphagia, mild heartburn and bloating are common, but should settle within 6 weeks postoperatively.
Failure following LNF
A significant failure/ re-operation rate is noted in the literature [3] with at least four main patterns of failure including disruption (I) or slippage/mal-positioning (II) of fundoplication; a tight or excessively long fundoplication (III), and hiatal failure with trans-mediastinal migration of fundoplication (IV).
Fig. 5 Illustrating patient’s satisfaction with their current condition after LNF
2 patients were converted to open procedure.
One patient was converted to Toupet’s 48 hour after developing sever post-operative dysphagia.
One patient was complicated by splenic sub-capsular haematoma intraoperatively, which was treated with surgical successfully. Splenectomy should be performed for extensive splenic laceration or injury at the area of the hilum.
Conclusion
Postoperative symptomatic evaluation revealed a suboptimal subjective outcome that is inexplicable by the endoscopic/ radiological findings, suggesting the need for a standardised procedure-specific postoperative objective evaluation tool. The use of functional MRI is a promising possibility; one study reported a 93% overall accuracy in deterring fundoplication wrap position with MR fluroscopy [4].
As LNF is not a curative procedure, and a degree of symptoms ‘trade-off’ is expected. We need to also conduct a standardised evaluation of patient’s preoperative symptoms using GERD- HRQL to better appreciate improvement of symptoms and most importantly, patients’ satisfaction with the procedure.
The high incidence of post operative gas bloat syndrome suggests the need for routine pre-operative evaluation of gastric motility and tailoring the fundoplication accordingly.
The higher than expected rate of anatomical failures highlighted the inadequacy of primary hiatorraphy, and the need for selective crural reinforcement. The ideal mesh should be biological, non-absorbable and non-crosslinked. 
The flow chart (Fig. 6) below has been devised to manage patient presenting to clinic with recurrence of symptoms after LNF.
(III)
(I)
(II)
(IV)
To evaluate a hundred consecutive LNFs performed by a single surgeon in relation to patients-reported functional outcome, anatomic and physiologic status of the procedure, assess the rate and study patterns of procedure failures to modify our practice accordingly. 
Objective
32 patients were investigated with OGD post-operatively due to persistent/ new symptoms. (Fig. 3) Only 5 reports were noted to have commented on problems with fundoplication or recurrence of hiatus hernia.
37 patients underwent barium studies to investigate their symptoms. (Fig. 4) Seven reports commented on the recurrence of hernia or wrap disturbances.
Method
A list of patients who underwent LNFs from 2007 to 2014 under a single surgeon was obtained from the computerised theatre records. A retrospective data base was set up capturing the pre-operative clinical and patho-physiological characteristics, post-operative patient-related outcome using Viscik score, findings of follow-up investigations when performed and outcomes of re-do operations when needed.
Visick Grade
Characteristics I
Asymptomatic II
Mild Symptoms, Quality of life unaffected, No Medications needed
III
Moderate Symptoms, Quality of life affected, Medications required IV
Recurrent, incapacitating symptoms equal or worse to pre-operative situation
GERD-HRQL survey was conducted over the phone and mailed questionnaires; 57 patients have been contactable. Their clinical outcomes are as illustrated in table 3, and table 4. Figure 4 and figure 5 illustrate patient’s general satisfaction after LNF. Hiatal failure had been the attributing cause for failure of the fundoplication procedure. None of the patients had a disruption of the fundoplication.
Viscik Symptom Evaluation Tool
A telephone survey was also conducted using the validated Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire to assess patients’ subjective functional outcome. Patients were also asked about their symptoms in relation to gas bloat syndrome. In this study, symptoms of bloatedness, flatulence and inability to belch are all considered manifestations of the condition.
Fig. 6 Flowchart depicting the proposed actions when patients present with recurrence of symptoms after LNF
Recurrence of Symptoms
OGD + Ba Swallow
Anatomically Normal
pH /Manometry
No GORD
Entertain other Dx
GORD
Symptom Correlation
Obvious Anatomic Problem
Consider Re-Do
Patient Outcome
Count/ N (%)
Viscik Classification I
49 (60.5%) II
18 (22.2%)
III
10 (12.3%) IV
4 (4.9%)
Re-operations
11 /100 (11%)
Gas bloat syndrome
23/ 57 (33.3%)
Table 3 Illustrating patient outcome in terms of Viscik classification, re-operation rate and frequency of gas bloat syndrome post LNF. N= Total patients.
Endoscopic Assessment of LNF
Endoscopic photograph of an anatomically correct NF (Retro-flexed View)
Fundoplication folds are located below the diaphragm and the folds run parallel to the distance line on the endoscope
We do not routinely perform post-operative or follow up endoscopy
Variables from Pre-op Investigations
Heartburn
Regurgitation
Absent
Present
Microscopic oesophagitis on pre-op OGD
18/25
11/20
22/30
7/14
pH<4 more than 5% time in pre-op pH study
7/12
9/11
11/16
8/9
Normal DeMeester Score (<14.8)
2/16
2/12
3/18
1/10
LOSP (mmHg)
<5
1/14
1/11
0/9
5-15
10/14
4/11
10/16
4/9
15-30
3/14
6/11
4/16
5/9
>30
0/14
0/7
0/16
References
Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut May;54(5):710-7.
Lundell L, Miettinen P, Myrvold HE, et al. Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis. Clin Gastroenterol Hepatol Dec;7(12):
Broeders JA, Roks DJ, Ahmed Ali U, et al. Laparoscopic Anterior 180-Degree Versus Nissen Fundoplication for Gastroesophageal Reflux Disease: Systematic Review and Meta- Analysis of Randomized Clinical Trials. Ann Surg May;257(5):850-9.
Kulinna-Cosentini C, Schima W, Ba-Ssalamah A, Cosentini EP. MRI patterns of Nissen fundoplication: normal appearance and mechanisms of failure. Eur Radiol Sep;24(9):
Radiological Assessment of LNF
Typical fundoplication defect (black arrows)
Circumferential narrowing of the distal oesophagus and OGJ (white arrow), extending for approximately 2–3 cm
The wrap is sub-diaphragmatic
We do not routinely perform post-operative or follow up contrast studies
Table 4 demonstrates the correlation of pre-opeartive Investigation results with post-operative symptoms as described in GORD –HRQL questionnaire (LOS = lower oesophageal sphincter pressure in mmHg)