An evaulation of patients undergoing laparoscopic nissens fundoplication

Prasanna Kumar, S (2016) An evaulation of patients undergoing laparoscopic nissens fundoplication. Masters thesis, PSG Institute of Medical Sciences and Research, Coimbatore.

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Abstract

INTRODUCTION: Over years the effective treatment for GERD has been antireflux medication and surgery. Patients who were not improving on medical therapy or are not conducive are nowadays surgically treated. This technique was originally pioneered by Rudolf Nissen. In a young male patient with penetrating oesophageal ulcer he did the first fundoplication to protect the oesophagogastric anastamosis . As he followed up the patient he noticed that the patient's reflux symptoms were no more present. Nissen again reattempted his fundoplication on a male patient with a paraesophageal hernia which had incarcerated. It produced excellent clinical results. Eventually he published the first description of his surgical procedure in 1956, which turned out to be the birthchild of the current era of antireflux surgery. In original Nissen’s fundoplication, he united the posterior wall of the stomach with the anterior wall completely around the fundus of the stomach to provide a full 360-degree wrap of 4-5cm around the lower esophagus. One or two stitches should include the wall of the esophagus to prevent slippage of the cardia. In Nissen-Rossetti’s modification of the original fundoplication, he used only the anterior wall of the fundus and constructed a 360-degree wrap enclosing the distal oesophagus. In the initial Nissen-Rossetti modification he did not divide the short gastric vessels. However, when a tension-free wrap could not be obtained, the short gastric vessels were sacrificed. The role of Operative treatment for Gastro Oesophageal Reflux Diseases and Hiatus Hernias have changed dramatically during the 90’s. The driving force behind increased surgical numbers is the development of minimal invasive surgery. 3,4,5 Although the techniques of Antireflux surgery has not changed, the approach has become more acceptable to the patient and referring physician because of small incisions, relatively short hospital stay and lack of post operative pain when compared to open approach. AIMS AND OBJECTIVE: Primary Aims : Assessment of the quality of life post surgery with a disease specific questionnaire and to assess the degree of improvement UGI scopy findings pre and post surgery Secondary Aims : To see if any patient is still having to rely on PPI’s Any complications post surgery(if any) Justification of the study : To assess whether Laparascopic fundoplication really improves the quality of life compared to medical manaement and to assess the usefulness of surgery based on risk vs benefit ratio MATERIALS: A Prospective / Retrospective study conducted in PSG Institute of Medical Sciences and Research to assess whether Laparoscopic fundoplication really improves the quality of life compared to medical management and to assess the usefulness of surgery based on risk vs benefit ratio by comparison of their preoperative and postoperative Quality of life with a questionnaire and endoscopic findings in 31 patients Type of Study Observational, Prospective and Retrospective. Inclusion Criteria: Clinical reflux symptoms - UGI endoscopy. Exclusion Criteria - H/o previous oesophageal surgery, Complicated reflux (eg. Ulcer, Short oesophagus). METHODOLOGY: In this study 30 patients who had clinical symptoms of gastro oesophageal reflux were included. Informed consent was obtained detailing the study process, need for the study and its benefits, elaborately. The history was recorded by the principal investigator. The questionnaire was filled diligently by the principal investigator. All 31 patients were subjected to clinical examination by the principal investigator in an unbiased manner. Their Upper GI endoscopy findings were recorded, along with Oesophageal manometry and USG abdomen as and when required. Clinical symptoms of patients, especially those refractory to long term medical management and findings with UGI scopy played a role in patient selection for surgery. After the patients underwent laparoscopic fundoplication, re evaluation of their symptoms and their quality of life was done with History, clinical examination and questionnaire and repeat UGI scopy. RESULTS: Analysis of Data: A total of 31 cases were included in the study 1 patient did not present for follow up For 30 cases informed written consent was obtained For all 30 cases preoperative and post operative history was elicited and questionnaire completed For 31 cases preoperative UGI scopy done For 5 cases preoperative Oesophageal manometry was done For 28 patients post operative USG was done. (2 patients were not willing for follow up USG) Pre operatively all 31 patients were taking either PPI’s, Antacids, Prokinetics or the combination of above. Post operatively 16 patients were still taking PPI’s. (It must be noted that there was marked relief of symptoms, with medication post Surgery compared to prior to surgery, in which a majority of patients were refractory to medical management). This compares favourably with the international standard of patients on pre and post surgical medication) According to the Health Related Quality of Life questionnaire, the relief of symptoms post surgical management is 93% which again compares favourably with international standards According to UGI scopy findings : 10 subjects had Grade 1 reflux oesophagitis post surgery 3 patients among them had antral gastritis 1 patient had erosive gastritis 3 patients had prolapse gastropathy 1 patient had a small hiatal hernia post surgery Rest of 27 patients had intact fundoplication wrap These recurrence rates are on par or better in comparison with international standards CONCLUSION: The advent and advances in Laparoscopic Fundoplication plays a pivotal role in the surgical treatment of clinically significant GERD not resolving with medical management and also in patients responding to PPI’s but not desiring long term medical management. It is also worthwhile mentioning that proper surgical techniques like completely mobilizing the fundus and GE junction, creating a floppy fundoplication, division of Short gastric vessels and right crus first approach led to decreased post operative complications and recurrences. Inspite of our study numbers being small and of shorter duration, we can conclude that our overall experience in evaluation of the patients who had undergone laparoscopic Nissen’s fundoplication, showed a significant reduction and relief of reflux symptoms. The proportion of patients who had to rely on medication post surgery was also significantly less than prior to surgery. Even if the patients relying on medication were slightly higher than international standards it is worth noting that post surgery these patients have relief through PPI’s compared to those prior to surgery who were refractory to medical management. Also repeat UGI scopy showed Grade 1 oesophagitis in approximately 1/3 of those operated, but most of them were asypmtomatic. Also patient satisfaction concluded from the study was very good and we thoroughly recommend Laparoscopic Fundoplication to all those patients having chronic and refractory Reflux disease.

Item Type: Thesis (Masters)
Uncontrolled Keywords: patients undergoing ; laparoscopic nissens fundoplication.
Subjects: MEDICAL > General Surgery
Depositing User: Subramani R
Date Deposited: 27 Sep 2017 03:39
Last Modified: 27 Sep 2017 03:39
URI: http://repository-tnmgrmu.ac.in/id/eprint/3391

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