Long term clinical outcomes following laparoscopic Nissen fundoplication

Author: Stephen Kinsey-Trotman

Kinsey-Trotman, Stephen, 2019 Long term clinical outcomes following laparoscopic Nissen fundoplication, Flinders University, College of Medicine and Public Health

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The laparoscopic technique of Nissen fundoplication was developed locally and internationally during the early 1990s and remains an established procedure for gastro-oesophageal reflux disease. Reported response rates for the procedure have been consistently higher than for medical treatment with proton pump inhibitors. While a large proportion of patients who have undergone Nissen fundoplication remain symptom-free, a small group of patients experience troublesome symptoms following this procedure such as dysphagia and abdominal bloating. Some authors have suggested that division of the short gastric vessels during this procedure may reduce these symptoms, but progress in the area has been hampered by conflicting data from early and mid-term follow-up intervals. Further, while the current literature suggests the Nissen fundoplication technique has durable efficacy for ten years and beyond, very few studies report data beyond fifteen years follow-up.

The aim of this study was to review the outcome of a large patient cohort who had undergone laparoscopic Nissen fundoplication at up to twenty years of follow-up. Information regarding reflux-related symptoms, medication use, overall satisfaction and quality of life measures was sought to determine the efficacy and tolerability of the procedure at ultra-long term follow-up.

A literature review was completed in March 2016 to locate suitable articles documenting long-term (> ten years) follow-up of patients who had undergone Nissen fundoplication. Various studies of small patient number reported results up to fifteen years of follow-up with one study of fifty-one patients reporting results at twenty years.

The research methodology was approved for use through a local ethics and governance committee. All research was completed within Flinders University’s Department of Surgery, located at Flinders Medical Centre. The study involved collation of the twenty-year outcome data from a previous randomised-controlled trial of 102 patients randomised to short gastric division versus non division during laparoscopic Nissen fundoplication. Data was accessed via a surgical unit database containing patient demographic, procedure and outcome information. This database was used to identify suitable individuals who had undergone laparoscopic Nissen fundoplication within the previous twenty-four years. A new assessment tool in the form of a questionnaire containing questions relating to reflux-related symptoms, medications use, overall satisfaction ratings and quality of life measures was sent to patients with a return mail envelope.

From a study population of 252 individuals, clinical outcomes were obtained from 152 respondents with a mean follow-up of 265 months. Study respondents reported a high rate of satisfaction (>85%) with the laparoscopic Nissen fundoplication. Heartburn control remained high with a low incidence of troublesome procedure-related side effects. Outcome data from a subset of the above patient group showed no advantage from routine division of the short-gastric vessels during fundoplication but was associated with a slightly higher report of abdominal bloat symptoms. A strong correlation was found between typical reflux symptoms with total and symptom-aggregated scores for the disease-specific HRQL survey. In contrast the short-form 36 survey correlated poorly to patient symptom scores.

Keywords: Gastroesophageal reflux, antireflux, GORD, GERD, surgery, outcomes, Nissen, fundoplication, QOL, clinical

Subject: Medicine thesis

Thesis type: Masters
Completed: 2019
School: College of Medicine and Public Health
Supervisor: Professor David Watson