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Laparoscopic antireflux surgery
Is laparoscopic Nissen fundoplication a logical alternative to long-term therapy for gastroesophageal reflux disease?
M. Anvari (Hamilton)
Surgery for gastroesophageal reflux disease (GERD) has traditionally been reserved for patients not responding to maximum medical therapy or for patients with repeated chest infections and severe respiratory symptoms attributed to reflux and aspiration [1-3]. Use of proton pump inhibitors (PPIs) has been associated with a significant drop in the number of non-responders. Between 71% and 90% of patients with moderate or severe esophagitis were healed after 8 weeks of omeprazole [4-8], but if omeprazole was then stopped 82% relapsed during the next 6 months [9]. These patients may then require therapy with omeprazole or other PPIs on a long-term basis. After 1 year of omeprazole 67-89% remained in remission [9], but by 4 years only 47% remained in remission [10]. Although the use of PPIs have been associated with very few side-effects, concerns remain about their long-term use in patients with GERD. Maintenance therapy with omeprazole was associated with a persistent rise in serum gastrin level, an increase in micronodular argyrophil cell hyperplasia, and subacute or chronic atrophic gastritis [10]. Case reports indicate that there may be other potential side effects with omeprazole including hemolytic anemia [11], hepatic failure [12], interstitial nephritis [13, 14], malabsorption [15, 16], angio-edema [17, 18], and interaction with drugs including diazepam, warfarin, phenytoin [19].
Laparoscopic Nissen fundoplication (LNF) first described by Dallemagne in 1991 [20] has been found to be associated with low morbidity and mortality, short hospital stay, and early return to full activity [21-23]. These benefits make it more attractive for the patients on long-term medication who may have considered open surgery but had opted away due to the morbidity, postoperative pain and long recovery period associated with open abdominal or thoracic fundoplication. LNF thus has the potential to become an alternative therapy for GERD patients who require long-term continuous omeprazole therapy for control of their daily symptoms [24].
No prospective randomized comparison of laparoscopic Nissen fundoplication versus long-term maintenance therapy for GERD is yet available. However, most institutions offering this surgery have experienced a sharp increase in the number of patients (usually younger patients), requiring long-term therapy with PPIs who are opting for the surgical option in preference to medical therapy [24]. In our institution the size of this group as percentage of total number of patients undergoing LNF has risen to 38%.
Prospective follow-up of patients undergoing LNF for either failure of medical therapy or as an alternative to long-term therapy, has shown that the surgery is effective in both groups of patients with excellent symptom control maintained at 2 year follow-up [25], as well as improvements in quality of life indices [26]. Recent data suggests [26] that in fact LNF provides superior symptom control to long-term omeprazole therapy even in patients considered good responders (symptom relief > 75%) to long-term omeprazole therapy (20-80 mg/day).
In addition, LNF may prove to be a more cost-effective means of treating patients requiring long-term therapy for GERD. The cost of surgery varies enormously between different countries, for example in the United States it averages to around $15,000 [27], while in Canada the same procedure costs $3,000 [28]. Even with such discrepancy in costs, in most situations the surgery will prove to be cheaper than long-term therapy with PPI for patients requiring therapy for 10 years or longer.
Several studies have demonstrated that open Nissen fundoplication is associated with 80-90% efficacy, 10 to 20 years after the operation [29]. Although no such data is available for LNF, it is safe to assume that if this surgery is performed using similar techniques, and with the same level of expertise, the long-term results should not be different. Strict adherence to the principles of appropriate preoperative investigations (24-hour pH study, manometry and gastroscopy), strict selection criteria, adequate patient preparation is necessary to ensure excellent postoperative results.
The primary concern with any operation is the risks associated with such surgery. Although, LNF has been found to be well tolerated by patients even those with significant medical problems, the procedure still caries a morbidity of 3-10% in most series. There is a relatively long learning curve associated with the performance of this operation and if this surgery is to be offered as an alternative to long-term medical therapy, adequate discussion of the risks and the surgeons experience is mandatory.
In summary, LNF has the potential to become an alternative to long-term therapy for GERD, particularly in patients requiring 10 years or more of therapy with proton pump inhibitors. The success of this surgery is dependent on adherence to well established principles of antireflux surgery and should not lead to any loosening of selection criteria. A prospective randomized trial of LNF and long-term omeprazole therapy is necessary to better evaluate the efficacy and cost benefits of these two treatment modalities.
References
13. Kuiper JJ. Omeprazole-induced acute interstitial nephritis. Am J Med 1993;95(2):248.
17. Haeney MR. Angio-edema and urticaria associated with omeprazole. Br Med J 1992;305(6858):870.