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Let the patient beware: the evolving truth about laparoscopic antireflux surgery

2003; Elsevier BV; Volume: 114; Issue: 1 Linguagem: Inglês

10.1016/s0002-9343(02)01389-x

1555-7162

Joel E. Richter,

Helicobacter pylori-related gastroenterology studies

Since its description in 1991 by Dallemagne et al. (1Dallemagne B. Weerts J.M. Jehoes C. et al.Laparoscopic Nissen fundoplication preliminary report.Surg Laparosc Endosc. 1991; 1: 138-143PubMed Google Scholar), laparoscopic antireflux surgery has grown in popularity as the treatment for severe gastroesophageal reflux disease. In a survey of U.S. hospitals by the National Center for Health Statistics, patient discharges with the International Classification of Diseases, Ninth Revision, Clinical Modification code 44.66 ("other procedures for creation of esophagogastric sphincter competence," or fundoplication) were 13,000 in 1988, 22,000 in 1993, and 40,000 in 1998 (2Carlson M.A. Frantzides C.T. Complications and results of primary minimally invasive antireflux procedures a review of 10,735 reported cases.J Am Coll Surg. 2001; 193: 428-439Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar). Much of this growth has come with the advent of the minimally invasive laparoscopic operation through the abdomen. However, now that five proton pump inhibitors are available, and omeprazole will soon be available over the counter at its prescription dose, more patients with gastroesophageal reflux disease are asking their family practitioner, internist, or gastroenterologist to help them choose the appropriate long-term treatment for their chronic disease. Two articles by Klaus et al. (3Klaus A. Hinder R.A. DeVault K.R. Achem S.R. Bowel dysfunction after laparoscopic antireflux surgery incidence, severity, and clinical course.Am J Med. 2003; 114: 1-5Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar) and Vakil et al. (4Vakil N. Shaw M. Kirby R. Clinical effectiveness of laparoscopic fundoplication in a U.S. community.Am J Med. 2003; 114: 000-000Abstract Full Text Full Text PDF Scopus (152) Google Scholar) that appear in this month's Journal give some perspective on the evolving truth about laparoscopic antireflux surgery. Despite marketing terms, such as "minimally invasive" or "keyhole surgery," laparoscopic antireflux surgery is a fairly involved procedure. General anesthesia is required; most patients are hospitalized for at least 24 hours; and the 30-day surgical mortality ranges from 0.08% to 0.2% (2Carlson M.A. Frantzides C.T. Complications and results of primary minimally invasive antireflux procedures a review of 10,735 reported cases.J Am Coll Surg. 2001; 193: 428-439Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar, 5Rantanen T.K. Salo J.A. Sipponen J.T. Fatal and life-threatening complications in antireflux surgery analysis of 5502 operations.Br J Surg. 1999; 86: 1573-1577Crossref PubMed Scopus (91) Google Scholar). Causes of death include missed esophageal, gastric, or duodenal perforations; ischemic bowel associated with mesenteric thrombosis; and myocardial infarctions. About 4% to 6% of patients experience immediate perioperative complications that delay their hospital discharge (2Carlson M.A. Frantzides C.T. Complications and results of primary minimally invasive antireflux procedures a review of 10,735 reported cases.J Am Coll Surg. 2001; 193: 428-439Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar, 6Perdikis G. Hinder R.A. Lund R.J. et al.Laparoscopic Nissen fundoplication where do we stand?.Surg Laparosc Endosc. 1997; 7: 17-21Crossref PubMed Scopus (210) Google Scholar). The most common complication (1.3%) is early wrap herniation, usually from uncontrolled postprocedure nausea and vomiting, which frequently requires re-operation. Other complications include pneumothorax (1%), which is usually due to a pleural tear during mediastinal dissection of the hiatal hernia; bowel perforation (0.78%); wound infection (0.11%); and splenectomy (0.06%). The likelihood of splenectomy in the laparoscopic procedure has dropped dramatically to about a hundredth of that reported for the open antireflux operation (2Carlson M.A. Frantzides C.T. Complications and results of primary minimally invasive antireflux procedures a review of 10,735 reported cases.J Am Coll Surg. 2001; 193: 428-439Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar). Postoperative complications after laparoscopic antireflux surgery are common, may be prolonged, and may affect quality of life. A frank discussion of these complications is often overlooked in the enthusiasm to discuss the minimal postoperative abdominal pain from the small port incisions and the more rapid return to full activity and work. However, as emphasized by the authors of the two articles (3Klaus A. Hinder R.A. DeVault K.R. Achem S.R. Bowel dysfunction after laparoscopic antireflux surgery incidence, severity, and clinical course.Am J Med. 2003; 114: 1-5Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 4Vakil N. Shaw M. Kirby R. Clinical effectiveness of laparoscopic fundoplication in a U.S. community.Am J Med. 2003; 114: 000-000Abstract Full Text Full Text PDF Scopus (152) Google Scholar), complications, such as dysphagia, gas-bloat syndrome, increased flatus, and diarrhea, are common after surgery, with incidences ranging from 25% to 50%, at least in the short term (2Carlson M.A. Frantzides C.T. Complications and results of primary minimally invasive antireflux procedures a review of 10,735 reported cases.J Am Coll Surg. 2001; 193: 428-439Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar, 3Klaus A. Hinder R.A. DeVault K.R. Achem S.R. Bowel dysfunction after laparoscopic antireflux surgery incidence, severity, and clinical course.Am J Med. 2003; 114: 1-5Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 4Vakil N. Shaw M. Kirby R. Clinical effectiveness of laparoscopic fundoplication in a U.S. community.Am J Med. 2003; 114: 000-000Abstract Full Text Full Text PDF Scopus (152) Google Scholar, 5Rantanen T.K. Salo J.A. Sipponen J.T. Fatal and life-threatening complications in antireflux surgery analysis of 5502 operations.Br J Surg. 1999; 86: 1573-1577Crossref PubMed Scopus (91) Google Scholar, 6Perdikis G. Hinder R.A. Lund R.J. et al.Laparoscopic Nissen fundoplication where do we stand?.Surg Laparosc Endosc. 1997; 7: 17-21Crossref PubMed Scopus (210) Google Scholar). Dysphagia during the early postoperative procedure is probably related to edema and inflammation; it is common, occurring in up to 50% of patients (7Malhi-Chowla N. Gorecki P. Bammer T. et al.Dilation after fundoplication timing, frequency, indications, and outcome.Gastrointest Endosc. 2002; 55: 219-223Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). The condition generally resolves in 2 to 3 months and can be managed with a soft-food diet and intermittent bougie dilation. In 3% to 24% of patients, it may persist from 6 months to 1 year (8Wo J.M. Trus T.L. Richardson W.R. et al.Evaluation and management of post-fundoplication dysphagia.Am J Gastroenterol. 1996; 91: 2318-2322PubMed Google Scholar). In such cases, careful endoscopic and radiographic testing often reveal evidence of an overly long wrap, or a "slipped" fundoplication, which is when the fundoplication has slipped down onto the stomach or up the esophagus onto the chest. The slipped fundoplication usually results from tension on the wrap caused by an inadequately mobilized fundus from not taking down the short gastric vessels, or an unrecognized shortened esophagus (8Wo J.M. Trus T.L. Richardson W.R. et al.Evaluation and management of post-fundoplication dysphagia.Am J Gastroenterol. 1996; 91: 2318-2322PubMed Google Scholar). Fortunately, a repeat operation can correct both of these abnormalities, although redo operations are associated with increased morbidity and mortality of more than 1% (9Rice T.W. Why antireflux surgery fails.Dig Dis. 2000; 18: 43-47Crossref PubMed Scopus (19) Google Scholar). Postprandial bloating (gas-bloat syndrome) and excessive rectal gas occur in up to 45% of patients (2Carlson M.A. Frantzides C.T. Complications and results of primary minimally invasive antireflux procedures a review of 10,735 reported cases.J Am Coll Surg. 2001; 193: 428-439Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar). These syndromes, which have been poorly studied, result from persistent air swallowing and the inability of the swallowed gas to escape by belching after a successful fundoplication. Symptoms tend to be less troublesome with an incomplete (Toupet) fundoplication compared with a full (Nissen) fundoplication (10Rydlberg L. Ruth M. Lundell L. Mechanism of action of antireflux procedures.Br J Surg. 1999; 86: 405-410Crossref PubMed Scopus (81) Google Scholar), and they are usually self-limited and resolve in 1 to 3 months. Simple measures, such as avoiding carbonated beverages and smoking, and eating smaller meals with cessation of eating when full, may help to ease this problem. More severe cases may mimic anginal chest pain or biliary colic and may suggest vagal nerve injury with secondary gastroparesis. Revision surgery is rarely required, but conversion to an incomplete fundoplication may be helpful (10Rydlberg L. Ruth M. Lundell L. Mechanism of action of antireflux procedures.Br J Surg. 1999; 86: 405-410Crossref PubMed Scopus (81) Google Scholar). Klaus and colleagues (3Klaus A. Hinder R.A. DeVault K.R. Achem S.R. Bowel dysfunction after laparoscopic antireflux surgery incidence, severity, and clinical course.Am J Med. 2003; 114: 1-5Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar) call our attention to the least commonly discussed postoperative complication—diarrhea—which has been reported in 25% to 33% of patients after laparoscopic antireflux surgery. Some of this diarrhea may be previously unrecognized irritable bowel syndrome, or, as the authors found in 15 patients (18% of their series) within 6 weeks of surgery, new-onset diarrhea. The diarrhea ranged from mild to debilitating, with 4 patients experiencing fecal incontinence. Most patients (13 of 15) were still experiencing diarrhea after 2 years, although only 6 required chronic antidiarrheal medication. The mechanisms of this diarrhea are poorly understood, although some cases are likely due to enhanced gastric emptying or inadvertent vagotomy. The durability of fundoplication for preventing the recurrence of reflux symptoms and the subsequent need for proton pump inhibitors are now just being understood. As I tell my patients: "It's not like you are getting a new valve for your car." Rather, the surgery is recreating the old lower esophageal sphincter by reducing the hiatal hernia back into the abdomen, closing the hiatus around the esophagus, and using the mobilized fundus to lengthen and buttress the new intra-abdominal sphincter. Over time, the wrap weakens, and symptomatic reflux sometimes recurs because of "abdominal stressors" that cause intermittent strain on the esophagogastric junction and the fundoplication. In the immediate perioperative period, this stressor is usually severe nausea and vomiting. More often, I have observed successful fundoplications, defined by no symptoms and normal 24-hour pH studies 3 months postoperatively, become dysfunctional with recurrent heartburn as a result of trauma to the chest (e.g., car accident, falling down stairs), heavy isometric exercises (e.g., weight lifting, more than 100 sit-ups daily), heavy lifting, excessive weight gain, bulimia, or paroxysms of severe coughing due to a drug reaction. Although difficult to discuss, all physicians involved with laparoscopic antireflux surgery must admit to their patients that the procedure may not be a "lifelong cure." These limitations first came to our attention with reports on the follow-up to the original VA Cooperative Study on open antireflux surgery (11Spechler S.J. Lee E. Ahnen D. et al.Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease. Follow-up of a randomized controlled trial.JAMA. 2001; 285: 2331-2338Crossref PubMed Scopus (850) Google Scholar). In these older men with severe gastroesophageal reflex disease, 62% (23/37) used antireflux medications regularly, 32% were taking proton pump inhibitors, and 16% required at least another antireflux operation during the 10 years after surgery. More recently, surgeons at several academic centers have reported the recurrence of typical reflux symptoms and the use of proton pump inhibitors in up to 38% of patients after 2 to 3 years of surgical follow-up (12Fernando H.C. Luketich J.D. Christie N.A. et al.Outcome of laparo-scopic Toupet compared to laparoscopic Nissen fundoplication.Surg Endosc. 2002; 16: 902-905Crossref Scopus (85) Google Scholar, 13Liu J.Y. Woloshin S. Laycock W.S. Schwartz L.M. Late outcome after laparoscopic surgery for gastroesophageal reflux.Arch Surg. 2002; 137: 397-401Crossref PubMed Scopus (37) Google Scholar), which are similar to the rates reported by Vakil et al. (4Vakil N. Shaw M. Kirby R. Clinical effectiveness of laparoscopic fundoplication in a U.S. community.Am J Med. 2003; 114: 000-000Abstract Full Text Full Text PDF Scopus (152) Google Scholar). Of these latter patients (4Vakil N. Shaw M. Kirby R. Clinical effectiveness of laparoscopic fundoplication in a U.S. community.Am J Med. 2003; 114: 000-000Abstract Full Text Full Text PDF Scopus (152) Google Scholar), 32% (26/80) were taking heartburn medications regularly after an average follow-up period of 20 months; 16 were taking proton pump inhibitors, and 6 (7%) had undergone repeat surgery for postoperative complications. How should we manage our patients who have severe gastroesophageal reflux disease? At the Cleveland Clinic, all patients with severe disease are evaluated by both gastroenterologists and surgeons. Because large studies now show equal efficacy in treating patients with proton pump inhibitors or antireflux surgery (14Lundell L. Miettinen P. Myrvold A.E. et al.Continued (5 year) follow-up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease.J Am Coll Surg. 2001; 192: 172-181Abstract Full Text Full Text PDF PubMed Scopus (334) Google Scholar), this debate adds little to the care of our patients. We use this opportunity instead to discuss the benefits and risks of both treatments, as well as unresolved long-term issues. No particular expertise is required for prescribing proton pump inhibitors. Morbidity associated with their use is rare; there has been no drug-related mortality; and their use has no irreversible consequences (15Garnett W.R. Consideration for long-term use of proton pump inhibitors.Am J Health Syst Pharm. 1998; 55: 2268-2279PubMed Google Scholar). However, many patients will require lifelong daily medications, which are expensive, and the long-term risks after 15 years are unknown. Surgery offers a unique opportunity to cure this disease, but success depends on a correct diagnosis and the experience of the surgeon. Disadvantages include frequent postoperative complications, the possibility of death, and the unknown long-term durability of antireflux surgery. The issue of surgical durability versus the long-term safety of medications is especially critical for young patients with chronic disease. We take the approach of openly discussing both options with our patients and allowing them to make informed decisions. This way, patients are proactive in their treatment, usually happy with the results, and not surprised, disappointed, or angry if complications or relapses occur.