Laparoscopic Antireflux Surgery What is Real Progress?

ANNALS OF SURGERY Vol. 220, No. 2, 146-154 C) 1994 J. B. Lippincott Company Laparoscopic Antireflux Surgery What is Real Progress? Jean M. Collard, M.D.,* Charles A. de Gheldere, M.D.,* Marc De Kock, M.D.,t Jean B. Otte, M.D.,* and Paul J. Kestens, M.D.* From the Digestive Surgery Unit,* and the Anesthesiology Unit, t Louvain Medical School, Brussels, Belgium Objective The authors aim to substantiate, with objective arguments, potential advantages of laparoscopic versus open antireflux surgery in the light of the recent crude experience of the Louvain Medical School Hospital. Methods Seventy-two consecutive patients with disabling gastroesophageal reflux disease ([GERD], n = 56), symptomatic hiatal hernia without GERD (n = 5), or unsatisfactory outcome after unsuccessful antireflux procedure (n = 11) were operated on by laparotomy (n = 28), laparoscopy (n = 39), or thoracotomy (n = 5). The antireflux procedure was a subdiaphragmatic Nissen fundoplication (n = 60), an intrathoracic Nissen fundoplication (short esophagus, n = 3), a subdiaphragmatic 2400 fundoplication (severe motility disorders, n = 3), a Lortat-Jacob repair (hiatal hernia without GERD, n = 5), and a duodenal diversion (delayed gastric emptying, n = 1). Results Major postoperative morbidity included two pulmonary embolisms (one laparoscopy patient and one laparotomy patient), and one hemothorax (one thoracotomy patient). Mean hospital stay was 6.4 days for laparoscopy, 7.8 days for laparotomy, and 12.5 days for thoracotomy. Postoperative morphine consumption (patient-controlled analgesia) averaged 47 mg/48 hrs (laparoscopy) versus 46 mg/48 hrs (laparotomy with primary antireflux surgery) (p > 0.05). Although 93% of the laparoscopy patients returned to work within 3 weeks after surgery, 92% of the laparotomy and thoracotomy patients resumed their activity after more than 6 weeks. At follow-up, 87.5% of the patients were asymptomatic or had inconsequential symptoms, 9.8% had disabling side effects, and 2.7% had persistent or recurring esophageal symptoms. There were four parietal herniations, i.e., one incisional hernia and one recurrence of a repaired umbilical hernia in the laparotomy group, and two herniations of the wrap into the chest-probably related to a premature return to manual work-in the laparoscopy group. Three laparoscopy patients were dissatisfied with the esthetics of their scars. Lower esophageal sphincter pressure and esophageal acid exposure in the laparoscopy patients who were investigated were normal in 100% and 95%, respectively. Conclusions Laparoscopy is a good approach for achieving successful antireflux surgery in selected cases. However, its fails to substantially reduce postoperative complication rate and discomfort, duration of the hospital stay, and the risk of esthetic sequella. Early return to work is questionable for manual workers. The subdiaphragmatic Nissen fundoplication is not an all-purpose antireflux procedure. 146

Vol. 220 * No. 2 Recent developments in minimal access surgery have modified the surgical approach to gastroesophageal reflux disease (GERD) so that the laparoscopic antireflux fundoplication appears to be a very attractive alternative to open surgery. Early proponents oflaparoscopic surgery claimed several advantages of the laparoscopic versus the conventional approaches, taking for granted that laparoscopic antireflux surgery results in less postoperative complications and discomfort, shorter hospital stay, lower risk of parietal problems, earlier social rehabilitation, and less esthetic sequella. However, most communications in the numerous congresses that were devoted to the subject since 1991 focused on the feasibility of "an all-purpose Nissen or Nissen-Rossetti subdiaphragmatic fundoplication," and discussions were restricted to discovering whether technical steps that are not always easy to perform by laparoscopy were necessary. Moreover, to our knowledge, no study has been published yet that substantiates all the aforementioned statements by objective arguments. In an attempt to fill this void, we reported the recent crude experience with both laparoscopic and open antireflux surgery at the Louvain Medical School Hospital, a Belgian surgical center in which management of complex reflux problems such as esophageal shortening' and failures of primary antireflux operations2 has been routine for many years. METHODS Patients From September 1991 to March 1993, 72 consecutive patients were operated on for symptoms of GERD poorly alleviated by medical therapy (n = 56), symptomatic hiatal hernia without GERD (n = 5), or unsatisfactory outcome of previous antireflux surgery performed in another institution (n = 1 1). Two ofthe latter patients had undergone laparoscopy, and one had undergone laparoscopy converted into laparotomy. They were 47 men and 25 women with an average of 49 years in age (range 21 to 78 years). Eighty per cent of the patients were referred to us from different parts of Belgium outside Brussels city, and 5% were from abroad. Two patients (2.7%) were symptomatic for less than 1 year, 42 (58.3%) for 1 to 5 years, 18 (25%) for 5 to 10 years, and 10 (13.8%) for more than 1O years. Address reprint requests to J.M. Collard, M.D., Digestive Surgery Unit, St-Luc Academic Hospital, Hippocrate Avenue, 10, B-1200 Brussels, Belgium. Accepted for publication September 13, 1993. Laparoscopic Antireflux Surgery 147 Presenting Objective Abnormalities of the Foregut Barium swallow study showed a sliding hiatal hernia in 42 of the 61 patients without prior antireflux surgery, a large paraesophageal hernia in 5 of them, and a radiologic gastroesophageal reflux without hiatal hernia in 14. Five of the 11 patients referred to us after unsuccessful antireflux surgery had herniation of the repair into the chest, 2 had slippage ofthe repair around the stomach, 1 had gastroesophageal fistula, 1 had fistula of a Nissen wrap into the subcardial area of the stomach, 1 had gastric volvulus, and 1 had radiologic gastroesophageal reflux only. In addition, the gastroesophageal junction of five patients, i.e., the level at which upper gastric folds merge with the unwrinkled mucosa of the esophagus, was not reducible down to the abdomen, and the upward esophagus was not tortuous on roentgenograms taken in the erect position. This condition led to suspect esophageal shortening. Reflux-induced esophagitis at endoscopy was graduated according to the Skinner-Belsey classification (3) before and after antacid therapy, i.e., ranitidine (Zantac, Glaxo Belgium S.A., Brussels, Belgium) or omeprazole (Losec, Astra, SodertalUe, Sweden) (Fig. 1). Eleven patients had Barrett's metaplasia without dysplasia. Esophageal motility was studied in 70 patients. Motility of the esophageal body was normal in 67 patients, dysmotility (numerous synchronous or repetitive waves) was detected in 2, and dyscontractility (low amplitude waves or no motor activity) was detected in 1. Lower esophageal sphincter resting pressure was evaluated according to the Demeester's criteria.4 It was less than 6 mm Hg in 37 patients, more than 6 mm Hg in 30, and was not evaluated in 3 patients. Twenty-four hour esophageal ph monitoring was done for 41 patients. The percentage of time that the esophageal ph was 4 or less was recorded for the total, supine, and upright periods and checked according to the Demeester's criteria5 (normal values: % time ph < 4: total period: <4.45, supine period: <3.45, upright period: <8.42). Esophageal ph monitoring was abnormal in all but three of the patients who were investigated. The percentage of time that the esophageal ph was less than 4 averaged 9.5% for the total period, 9.7% for the supine period, and 10.3% for the upright period. Surgery Surgical Principles (Table 1) Preoperative data of each patient were analyzed by two or three senior surgeons of the team (P.J.K., J.B.O., J.M.C.) at the weekly staff meeting before the operation to ensure constancy to the surgical indication. Critical factors for making the choice of the repair

148 Collard and Others Ann. Surg. * August 1994 % patients 80..., 60-50.: 70-40- 30... 20.: 10 -.......:...,..,.,,.... _, :.. t....-. *-..::::::::::..' noesopha.it.. ::::I :... U Dl initial preop. o.: staoe I 1..: stage 2 stage 3...---- stage 4 Figure 1. Stage of reflux-induced esophagitis at upper digestive tract endoscopy before and after preoperative medical therapy. (Nissen fundoplication vs. posterior 2400 fundoplication vs. Lortat-Jacob repair6 vs. duodenal diversion7) were the esophageal body motility pattern evidenced at preoperative esophageal motility study, the presence of a voluminous hiatal hernia without GERD, and evidence of delayed gastric emptying. The choice of the surgical approach (transabdominal vs. transthoracic) was based on the radiologic reducibility of the gastroesophageal junction below the diaphragm at upper digestive tract roentgenography. Factors that accounted for the choice of the transabdominal approach (laparoscopy vs. laparotomy) are listed in Table 1. Remedial operations were carried out either by laparotomy or thoracotomy, depending on the residual anatomy of the foregut. The residual repair always was taken down. Surgical Technique Laparoscopic Principles. Laparoscopic antireflux procedures were done through five holes in the upper abdominal wall (Fig. 2), exactly following all the technical principles used for the corresponding operation by laparotomy. The abdominal cavity was invariably insufflated up to a 14-mm Hg pressure with CO2 through a Verres needle. All the knots were tightened inside the abdomen. The esophageal lumen was calibrated with a 50 French- Maloney bougie. Transabdominal Antireflux Procedures. Nissen fundoplication8 (Fig. 3A) invariably included retroesophageal approximation of the diaphragmatic crura, division of the short gastric veins and the posterior gastric vessels originating from the splenic vessels, and construction of a 1.5- to 2-cm tension-free wrap around the lower esophagus using a two-row suturing technique, with the first one taking the muscular wall ofthe esophagus. The lower border of the right limb was anchored into the gastroesophageal junction with a single stitch. Posterior 240 fundoplication8 (Fig. 3B) differed from the Nissen procedure because the two limbs ofthe poste- Table 1. CHOICE OF THE REPAIR AND THE APPROACH A. Choice of the repair GERD + normal esophageal body motility GERD + abnormal esophageal body motility Hiatal hernia without GERD GERD + delayed gastric emptying B. Choice of the approach Radiological irreducibility of the G-E junction: Radiological reducibility of the G-E junction or absence of hiatal hernia except multiple abdominal surgeries, abdominal incisional hernia, need for concomitant procedures (obvious obesity, voluminous hiatal hernia) Remedial antireflux surgery GERD = gastroesophageal reflux disease Nissen fundoplication Posterior 2400 fundoplication Lortat-Jacob repair duodenal diversion thoracotomy laparoscopy laparotomy thoracotomy or laparotomy

Vol. 220 - No. 2 Figure 2. Location of the five 1-cm holes in the upper abdominal wall. The videoendoscope is inserted into the abdomen through hole number 1, a liver retractor through hole number 2, graspers through holes number 3 and 5, and scissors and a needle holder through hole number 4. rior wrap were anchored into the two lateral sides of the esophagus. The Lortat-Jacob procedure8 (Fig. 3C) restored the normal anatomy ofthe gastroesophageal junction by reduction of the hiatal hernia into the abdomen, approximation of the crura behind a 5 cm-segment esophagus, and reconstruction ofthe esophagogastric angle.6 Duodenal diversion included distal gastrectomy, clo- I, I1 / a / l/ I d Figure 3. Technical aspect of the antireflux procedures used (A) subdiaphragmatic Nissen fundoplication, (B) posterior 2400 fundoplication, (C) Lortat-Jacob hiatal repair, (D) intrathoracic Nissen fundoplication. I I Laparoscopic Antireflux Surgery 149 sure of the duodenal stump, anastomosis of the remaining part of the stomach with a 50-cm Roux-en-Y jejunal loop, and truncal vagotomy. Transthoracic Nissen Fundoplication. When the gastroesophageal junction could not be reduced from the left chest into the abdomen, in spite of extensive mobilization of the esophagus up to the aortic arch, the fundus was brought into the chest and wrapped counterclockwise around the lower esophagus using a two-row suturing technique. The intrathoracic wrap eventually was anchored into the margin ofthe hiatus that was enlarged to prevent any strangulation of the "organized hiatal hernia."' (Fig. 3D) When the gastroesophageal junction eventually was reducible into the abdomen, the Nissen fundoplication was constructed in the chest and replaced into the abdomen, and the crura were approximated posterior to the esophagus. Operations Performed All the operations were performed by the first author (J.M.C.) or made under his direct supervision to ensure constancy to the surgical technique. Five operations were undertaken by thoracotomy, 28 by laparotomy and 39 by laparoscopy (Table 2). Laparoscopy was converted into laparotomy because of hard adhesions in the upper abdomen in one patient and liver parenchyma fragility in another. Reasons for open surgery (thoracotomy, laparotomy) are listed in Table 3. In addition, 20 patients (8 laparoscopy and 12 laparotomy) underwent a concomitant surgical procedure, i.e., a duodenal switch9 (n = 1), cholecystectomy (n = 4), vagotomy (n = 3), pyloroplasty (n = 1), management ofzenker's diverticulum (n = 4), cricopharyngeal myotomy (n = 1), incisional hernia repair (n = 2), inguinal or umbilical hernia repair (n = 2), circumcision (n = 1), and thyroid lobectomy (n = 1). Perioperative Management Each patient was monitored during the operation by the same anesthesiologist (M.D.K.) to ensure constancy to the intraoperative management. The anesthesia technique combined propofol (Diprivan, Kabivitrum, Stokholm, Sweden), sufentanil citrate (Sufenta, Janssen Pharmaceutica n.v., Beerse, Belgium), clonidine hydrochloride (Catapressan, Boehringer Ingelheim K.G., Ingelheim am Rhein, Germany), magnesium sulfate, and atracurium (Tracrium, Wellcome, London, Great Britain). At their admission to the recovery room, the patients were connected to a patient-controlled analgesia device (PCA Life Care 4200, Abbott, Chicago, MI), and instructed how to self-administer the analgesic drug. The PCA settings were as follows: 1) 1.5 mg bolus doses of morphine hydrochloride and 2) lockout intervals of 7 minutes; 3) 4-hour limit of 30 mg mor-

150 Collard and Others Ann. Surg. * August 1994 Table 2. OPERATIONS PERFORMED (N = 72) Initial approach Laparoscopy (LS) (n = 39) Laparotomy (LT) (n = 28) Thoracotomy (TT) (n = 5) Final approach LS: n = 37* LT: n = 30* TT: n = 5 Nissen: n = 33 Nissen: n = 24 intrathoracic Nissen: n = 3 2400 fundoplication: n = 2 Lortat-Jacob: n = 3 subdiaphragmatic Nissen: n = 2 Lortat-Jacob: n = 2 duodenal diversion: n = 1 Nissen + limited gastrectomy: n = 1 2400 fundoplication: n = 1 * 2 LS converted to LT. phine. Postoperatively, a nasogastric catheter was kept in place until bowel movements resumed. The patients were mobilized from the first postoperative day and were given subcutaneous anticoagulotherapy. Patients were discharged from the hospital when they were able to eat without major difficulty and after complete recovery from any postoperative complication. Patients who underwent laparoscopy were advised to return to work as soon as possible after operation, whereas those who underwent laparotomies or thoracotomies were warned not to resume their professional activity before 6 weeks after surgery in order not to stress the abdominal or thoracic wall repair. Follow-Up Evaluation All patients were interviewed for the presence of residual preoperative symptoms and disabling symptoms induced by surgery at the outpatient clinic 1 month after operation by the first author (J.M.C.), and later by the second author (C.A.d.G.) for the purpose of the study (mean follow-up: 11 months; range: 2-21 months) to ensure constancy to the evaluation. Moreover, every patient was asked to answer the following question: bearing in mind your present status, would you make the deci- Table 3. REASONS FOR OPEN SURGERY (1 OR 2 REASONS PER PATIENT) Reason Remedial operation 11 Radiological irreducibility of the gastroesophageal junction 5 Need for additional procedures requiring open surgery 4 Voluminous hiatal hernia 3 Conversion into laparotomy 2 Incisional abdominal hernia 2 Umbilical hernia 1 Multiple previous laparotomies 2 Obesity 7 Emergency conditions 1 Teaching 3 n sion of an antireflux operation again? All patients underwent a Barium swallow study 1 month postoperatively. Those patients operated on by laparoscopy were invited to submit to an esophageal motility and phmonitoring study. Statistical Analysis The Kruskall-Wallis test was used to compare morphine hydrochloride consumption in the different groups of patients. RESULTS Surgery Duration of the operation in the laparoscopy group dropped from several hours for the first patients (minimal experience of the surgeon with laparoscopy at that time), to 69 minutes for one ofthe last patients. Duration averaged 133 minutes in the laparotomy group, and 193 minutes in the thoracotomy group. There was no major intraoperative complication in any group. One patient previously operated on by laparoscopy had a gastric volvulus caused by the absence of division of the short gastric veins and anchorage of the greater curvature into the subcardial area. Another patient underwent a wedge gastric resection for incarceration ofthe greater curvature into the hiatus and gastric necrosis 8 months after a laparoscopic Nissen fundoplication made without any approximation of the crura. In both patients, severe scarring of the lower esophagus and gastroesophageal junction and soft adhesions at the trocar sites were evidenced at reoperation. Postoperative Course Postoperative Discomfort As shown in Figure 4, morphine consumption (mean ± standard error) during the first 48 hours after operation was 47 ± 5.9 mg for the laparoscopy patients, 46 ± 4.6 mg for the laparotomy patients who underwent primary

Vol. 220 - No. 2 mean Mo consumption (mg /48 h) 70 _ 20 -,...-.- LS LT (primary op.) LT (redo) Figure 4. Mean consumption of morphine hydrochloride (Mo) during the first 48 hours after operation in laparoscopy patients, laparotomy patients without any history of previous antireflux surgery, and laparotomy patients reoperated on for failed antireflux procedure. antireflux surgery,, and 78 ± 27.8 mg for those laparotomy patients reoperated on for unsatisfactory outcome after primary antireflux surgery. Differences were not statistically significant (p > 0.05). In-Hospital Morbidity Two patients (one laparoscopy and one laparotomy) experienced pulmonary embolism requiring intravenous anticoagulotherapy only. One thoracotomy patient was reoperated on for hemothorax. Minor complications included subcutaneous emphysema (n = 4), pleural effusion (n = 1), and pneumothorax (n = 1) in the laparoscopy group, respiratory infection (n = 1), bronchospasm (n = 1) and brachial plexitis (n = 1) in the laparotomy group, and catheter-related sepsis (n = 1) in the thoracotomy group. Postlaparoscopy subcutaneous emphysema and pneumothorax resolved spontaneously within the few hours after operation. Postoperative Hospital Stay Postoperative in-hospital stay averaged 6.4 days for the laparoscopy patients, 7.8 days for the laparotomy patients, and 12.5 days for the thoracotomy patients. One-Month Morbidity Disabling symptoms at the outpatient clinic 1 month after operation are listed in Table 4. Most ofthe patients admitted that they were less disabled at 1 month of follow-up than immediately after the operation. Social Rehabilitation Ofthe 72 patients, 58 (33 laparoscopy and 25 laparotomy + thoracotomy) led active lives outside the home. Although 31 of 33 laparoscopy patients (93%) returned to work within 3 weeks after operation, all but two ofthe Laparoscopic Antireflux Surgery 151 Table 4. DISABLING SYMPTOMS EXPERIENCED AT ONE MONTH LS LT TT n (%) n (%) n (%) Flatulence 18 (48.6) 13 (43.3) 2 (40) Slight dysphagia for solids 11 (29) 6(20) 1 (20) Food impaction 4 (10.8) 0 (0) 0 (0) Epigastric pain 2 (5.4) 1 (3.3) 0 (0) Gastric air distension 0 (0) 1 (3.3) 0 (0) Sensation of "foreign body" in throat 1 (2.7) 1 (3.3) 0 (0) Thoracotomy-related pain 0(0) 0 (0) 1 (20) LS laparoscopy; LT = laparotomy; TT = thoracotomy. laparotomy and thoracotomy patients (92%) resumed their professional activity after more than 6 weeks. Follow-Up Evaluation Symptoms In all, 87.5% ofthe patients were asymptomatic or had inconsequential symptoms, 9.8% had more or less disabling side effects, and 2.7% had persistent or recurring esophageal symptoms. Furthermore, 97.3% of the patients gave an affirmative answer to the question of making the decision to undergo an antireflux operation again. However, three laparoscopy patients were dissatisfied with the esthetics of their abdominal scars. In the laparoscopy group, one patient, although no longer suffering of heartburn, complained persistently of dysphagia related to a severe esophageal dyscontractility pattern. Disabling side effects were severe flatulence (n = 1), persistent sensation of foreign body in throat (n = 1), and epigastric pain (n = 2). One ofthe two latter patients developed an ischemic gastric ulcer after combined proximal gastric vagotomy and Nissen fundoplication. In the laparotomy group, one patient complained of slight heartburn 1 year after a remedial antireflux operation; disabling side effects were epigastric pain (n = 1) and sensation of foreign body in throat (n = 1). In addition, one patient developed an incisional hernia and another one had recurrence of a repaired umbilical hernia. One thoracotomy patient had persistent post-thoracotomy discomfort. Objective Investigations Barium swallow roentgenograms were in accordance with the antireflux procedure performed regarding the absence of radiologic gastroesophageal reflux, the accurate location ofthe wrap and its completeness in 70 ofthe 72 patients (97.3%). In two asymptomatic laparoscopy patients (2.7%), the wrap (a Nissen fundoplication) was

152 Collard and Others LES pressure (mm Hg) preop. 24 20 16 12 8 4 0 Figure 5. Individual comparison of preoperative to postoperative lower esophageal sphincter resting pressure in 25 of the 26 laparoscopy patients who agreed to undergo follow-up esophageal motility study. (preoperative data not available for one patient). found to have herniated into the chest. One laparoscopy patient had a gastric ulcer. Esophageal motility was studied in 26 laparoscopy patients. Lower esophageal sphincter resting pressure was 6 mm Hg or more in all 26 patients (Fig. 5). Esophageal acid exposure (Fig. 6) was normal in 21 of the 22 laparoscopy patients who underwent 24-hour esophageal ph monitoring. It was excessive in one asymptomatic patient whose Barium swallow study was unremarkable. The percentage of time that the esophageal ph was less than 4 averaged 1.02 for the total period (0.01 to 12.3), 1.94 for the upright period (0 to 22.6), and 0. 16 for the supine period (0 to 0.5). DISCUSSION Our initial experience with laparoscopic antireflux surgery strongly suggests that laparoscopy is a good ap- %time ph < 4 12 8 21 preop. Figure 6. Mean esophageal acid exposure in the upright, supine, and total periods in 17 laparoscopy patients who underwent both preoperative and postoperative 24-hour esophageal ph monitoring. Ann. Surg. * August 1994 proach to hiatal area for surgical management ofgerd. It permits construction of various antireflux repairs following the same surgical steps as those followed in conventional surgery. Intraoperative conditions of safety are comparable to those that have existed in open surgery for many years, as attested to by the absence of any intraoperative and postoperative technical complications in patients of the present series operated on laparoscopically. Laparoscopic antireflux operations become less timeconsuming surgical procedures as the surgeon gains experience with the laparoscopy technique and applies ongoing developments in laparoscopic instrumentation. Moreover, early assessment of laparoscopic antireflux operations based on residual symptoms, upper digestive tract roentgenography, esophageal motility and phmonitoring study suggests that this kind of surgery can provide patients satisfactory outcomes similar to those achieved after conventional antireflux surgery. However, can the early enthusiastic statements originating from what we may call the "laparoscopy boom" be substantiated by objective arguments? Less Postoperative Complications? The present study shows that the classic complications of conventional surgery, such as pulmonary embolism, can occur after laparoscopy, as well. On the other hand, complications that are specific to antireflux surgery, such as transient dysphagia or flatulence, were experienced by our patients after laparoscopy and after laparotomy or thoracotomy. This is not surprising, bearing in mind that the laparoscopic antireflux repairs were performed following the same technical principles as those applied to open surgery. Moreover, new complications, i.e., pneumothorax and subcutaneous emphysema to be ascribed to the laparoscopy technique itself, were experienced by some of our patients. However, these complications resolved spontaneously within the few hours after operation. All this strongly suggests that the laparoscopic approach to the hiatal area, compared with the conventional approaches, fails to reduce the risk of postoperative complications. Less Postoperative Discomfort? The study fails to demonstrate any significant difference in intravenous morphine consumption between patients who underwent a primary antireflux operation by laparotomy and those operated on by laparoscopy. Postoperative morphine consumption in both groups was not ascribed to real painful conditions, but to discomfort resulting from the positioning on the operating table while the musculature was relaxed, or related to perioperative stress, presence ofa nasogastric catheter in throat, and some degree of meteorism before passing flatus. The

Vol. 220 d No. 2 Laparoscopic Antireflux Surgery 153 comfort provided to our patients after laparotomy may reflect the refinements in our anesthesia technique, such as administration ofmagnesium sulfate, which decreases the wind-up of pain perception,10 and the use of a2-adrenergic agonists, which reduce the postoperative analgesic requirements." Moreover, the PCA system, by allowing the patient to be in control of the dose of morphine he/she receives, standardizes postoperative discomfort after upper abdominal surgery. Thus, laparoscopy fails to substantially reduce postoperative discomfort after antireflux surgery. Shorter Hospital Stay? Duration of the hospital stay after laparoscopy was similar to that recorded after laparotomy. The first reason for keeping the patients in the hospital for a few days after antireflux surgery is that the surgeon has to make sure they do not develop any postoperative complication before discharge to home, especially when they are not living close to the hospital; this was true for 85% of our patients. Premature discharge after laparoscopic antireflux surgery may lead to readmission of some of the patients to the hospital because of development of postoperative complications at home, such as pulmonary embolism, a complication which generally occurs 4 to 5 days after operation, pneumonia, or gastric obstruction.'2 In addition, the surgeon must instruct the patients on how to eat with their modified upper digestive tract anatomy before they leave the hospital. Here again, our experience failed to demonstrate any substantial advantage of laparoscopy versus laparotomy. Lower Risk of Parietal Complications Leading to Earlier Social Rehabilitation? The wall of the abdominal cavity cannot be restricted to the sole anterior muscular wall, but also includes the diaphragm and the crura (Fig. 7). Any increase in the intra-abdominal pressure can stress the parietal repair after laparotomy and the newly approximated diaphragmatic crura and expose the patient to herniation of the antireflux repair into the chest, one ofthe most common reasons for failure of antireflux surgery.2"3 The two herniations of the antireflux repair into the chest recorded in manual workers of the present series who returned to work immediately after laparoscopy sustain the point of view that it is no longer reasonable to send manual workers back to work a few days after laparoscopic antireflux operation, before the healing phase of the crura closure is over. Another purposed advantage of laparoscopy versus laparotomy was that the former approach theoretically sheltered the patient from the occurrence of a hernia through the anterior abdominal wall. However, hernias Figure 7. Any increase in the intra-abdominal pressure can stress the anterior wall repair, the diaphragm, and the crura closure. at the cannula insertion sites have been reported after laparoscopy, especially with diametrically large (10 mm or more) trocars and after wound infection. 4 Our experience with reoperations for failed laparoscopic antireflux surgery demonstrates that intra-abdominal adhesions also may develop after laparoscopy in the hiatal area as at the trocar sites. Less Esthetic Sequella? Esthetics is not an exact science and therefore, is difficult to appreciate. However, dissatisfaction of some of our patients with their cutaneous scars after laparos-

154 Collard and Others copy leads us to conclude that the esthetic result of any abdominal scar depends much more on the patient own ability to heal appropriately than on the type or the length of the incision. The last critical question is what is the room of the laparoscopic Nissen fundoplication in antireflux surgery? Although the Nissen fundoplication has been shown to be superior to the other techniques, i.e., the Belsey fundoplication,'5 the Hill gastropexy,'5 and the posterior hemifundoplication,'6 in uncomplicated cases, it cannot be used as an all-purpose antireflux procedure. Rather, the presence of a shortened esophagus with irreducibility of the gastroesophageal junction below the diaphragm requires a thoracic approach to construct either an intrathoracic Nissen' or a Collis-Nissen"7 fundoplication. Severe dysmotility or dyscontractility of the esophageal body leads to construction of a less obstructive Belsey or posterior 2400 fundoplication to prevent untractable dysphagia, and reflux-induced stenosis that is not responsible to any conservative therapy remains an indication for esophageal resection.'8 Contraindications of laparoscopy are remedial antireflux operation-a surgery that often is difficult to perform even through a large incision,2"3 the need for concomitant procedures that cannot be carried out laparoscopically, such as a duodenal switch for duodenogastric reflux,8 a history of multiple previous laparotomies, and the existence ofan incisional abdominal hernia to repair. Obvious obesity and a voluminous hiatal hernia are relative contraindications only. Laparoscopic antireflux surgery seems to be quite effective and safe in selected cases. However, advantages claimed by the early proponents on this new approach are difficult to substantiate by objective arguments. Any esophageal surgeon should carefully choose both the approach to the hiatus and the type ofantireflux procedure to provide good symptomatic relief to most of the operated patients and thus, not bring this comfort surgery that is highly challenged by long-life antacid therapy into disrepute. Acknowledgment The authors thank Mrs. Nadine Thiebaut for her kind assistance. References 1. Collard JM, Dekoninck XJ, Otte JB, et al. Intrathoracic Nissen fundoplication: long-term clinical and ph-monitoring evaluation. Ann Thorac Surg 1991; 51:34-38. Ann. Surg. * August 1994 2. Collard JM, Verstraete L, Otte JB, et al. Clinical, radiological and functional results of remedial antireflux operations. Int Surg 1993; 78:298-306. 3. Skinner DB, Belsey R. Surgical management of esophageal reflux and hiatus hernia: long-term results with 1030 patients. J Thorac Cardiovasc Surg 1967; 53:33-54. 4. Zaninotto G, Demeester TR, Schwizer W, et al. The lower esophageal sphincter in health and disease. Am J Surg 1988; 155:104-111. 5. Demeester TR. Prolonged esophageal ph-monitoring. In Read NW, ed. Gastrointestinal Motility: Which Test? Petersfield, England: Wrightson Biomedical Publishing Ltd, 1989, pp 41-51. 6. Lortat-Jacob JL, Robert F. Les malpositions cardio-tuberositaires. Arch Mal App Dig 1953; 42:750-774. 7. Holt CJ, Large AM. Surgical management of reflux esophagitis. Ann Surg 1961; 153:555-562. 8. Collard JM, Kestens PJ. Chirurgie de la hernie hiatale et du reflux gastro-oesophagien. In Mignon M, ed. Gastroenterologie, Precis des Maladies de l'appareil Digestif. Paris, France: Ellipses, 1992, pp 264-273. 9. Demeester TR, Fuchs KH, Ball CS, et al. Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux. Ann Surg 1987; 206:414-426. 10. Wilder-Smith 0, Hoffman A, Borgeat A, Rifat K. Fentanyl or magnesium analgesic supplementation for anesthesia: effect on postoperative analgesic requirements. Anesthesiology 1992; 77:A208 (abstract). 11. De Kock M, Pichon G, Scholtes JL. Intraoperative clonidine enhances postoperative morphine patient-controlled analgesia. Can J Anaesth 1992; 39:537-544. 12. Jamieson GG, Watson DI, Britten-Jones R, et al. An initial experience with laparoscopic Nissen fundoplication. First European Congress of the European Association for Endoscopic Surgery (E.A.E.S.); June 3-5 1993; Cologne, Germany. Book of Abstracts: 180. 13. Collard JM, Demeester TR. Principles for correction of failed antireflux procedures based on preoperative functional assessment and operative findings. Communication at the 28th Annual Meeting of the Society of Thoracic Surgeons; February 3-5, 1992; Orlando, Florida. 14. Crist DW, Gadacz TR. Complications of laparoscopic surgery. Surg Clin North Am 1993; 73:265-289. 15. Demeester TR, Johnson LF, Kent AH. Evaluation of current operations for the prevention of gastro-esophageal reflux. Ann Surg 1974; 180:511-525. 16. Abrahamsson H, Lundell L, Olbe L. Effects of two types of fundoplication on the gastroesophageal junction. Hepatogastroenterology 1988; 35:175. 17. Orringer MB, Orringer JS. The combined Collis-Nissen operation: early assessment of reflux control. Ann Thorac Surg 1982; 33:534-539. 18. Collard JM, Kint M, Otte JB, Kestens PJ. Esophageal resection for reflux-induced stenosis: residual indications in reference to the other therapies. In Giuli R, Demeester TR, Tytgat NG, Galmiche JP, eds. The Esophageal Mucosa. Amsterdam: Elsevier Sciences Pub, 1994 (in press).