Author: David Watson


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Gastro-oesophageal reflux is common and its treatment consumes significant health resources in Australia. Whilst most individuals with this problem are managed using medication, surgery is required when reflux is more severe. In the 1980’s the “gold standard” surgical approach for reflux was the open Nissen fundoplication procedure. Whilst effective, Nissen fundoplication can be followed by troublesome side effects. To reduce the risk of side effects and improve overall outcome, various modifications to the Nissen procedure have been proposed.

Aiming to improve outcome following antireflux surgery a series of modifications to the Nissen fundoplication procedure were evaluated in eight prospective randomised controlled trials, conducted from 1993 to 2015. The modifications included laparoscopic surgery, non-division of the short gastric blood vessels, anterior hiatal repair, anterior 180 degree partial fundoplication, anterior 90 degree partial fundoplication, posterior partial fundoplication, and mesh repair for very large hiatus hernia. The trials addressed several questions:

• Can laparoscopic access reduce complications and speed recovery following Nissen fundoplication?

• Is division of the short gastric blood vessels necessary during Nissen fundoplication?

• Can an anterior 90 or 180 degree partial fundoplication achieve better outcomes following antireflux surgery than Nissen fundoplication?

• What type of partial fundoplication achieves the best overall outcome - anterior or posterior?

• Can dysphagia after Nissen fundoplication be reduced by anterior hiatal repair?

• Can mesh reinforcement of the oesophageal hiatus during repair of very large hiatus hernia reduce hernia recurrence?

The randomized trials demonstrated improved outcomes for antireflux surgery following appropriate technique changes. In particular;

• Laparoscopic Nissen fundoplication is followed by a quicker recovery, and less respiratory complications than open Nissen fundoplication, but offset by increased operating time. Reflux control and side effects are similar.

• Division of the short gastric blood vessels during laparoscopic Nissen fundoplication is unnecessary.

• Anterior hiatal repair is an effective technique during laparoscopic Nissen fundoplication and achieves outcomes which are at least as good as following posterior hiatal repair.

• Anterior 180 degree partial fundoplication achieves equivalent long term reflux symptom control and overall outcome satisfaction to Nissen fundoplication. At follow-up to 5 years anterior 180 degree partial fundoplication is followed by less side effects.

• Anterior 90 degree partial fundoplication achieves adequate reflux symptom control, less side effects and equivalent overall satisfaction compared to Nissen fundoplication at follow-up to 5 years, although more reflux symptoms are reported after anterior 90 degree partial fundoplication.

• At 12 months follow-up outcome satisfaction is similar for anterior 180 degree and posterior partial fundoplication. However, anterior partial fundoplication controls reflux symptoms less effectively, whereas posterior partial fundoplication is followed by more side effects.

• Posterior reinforcement of the hiatal repair with absorbable or non-absorbable mesh during laparoscopic repair of very large hiatus hernia does not reduce the early risk of hernia recurrence.

These randomized trials make a significant contribution to the evidence base underpinning surgery for gastro-oesophageal reflux and hiatus hernia. They support using the laparoscopic approach for antireflux surgery, simplifying the technique for Nissen fundoplication by not dividing the short gastric vessels, the wider use of anterior 180 degree partial fundoplication for the treatment of gastro-oesophageal reflux, and not using mesh for repair of large hiatus hernia. Future randomized trials provide an opportunity to refine other aspects of antireflux and hiatus hernia surgery.

Keywords: Randomised trial, fundoplication, gastro-oesophageal reflux disease, hiatus hernia, surgery

Subject: Medicine thesis

Thesis type: Doctor of Philosophy
Completed: 2015
School: School of Medicine
Supervisor: Professor Ross McKinnon