Laparoscopic Nissen fundoplication in a community hospital: patient satisfaction survey.

Objectives: To assess the efficacy of laparoscopic Nissen fundoplication for esophageal reflux in a community hospital.

Methods: One hundred nineteen patients (76%) of 157 patients having laparoscopic fundoplication for symptomatic reflux disease completed a questionnaire. All patients were evaluated with esophagoscopy, esophageal motility, and pH studies.

Results: Mean follow-up was 49 months. Ninety-three patients (78%) no longer had heartburn. Seven patients still had daily heartburn (5.9%). One hundred three patients (86.6%) had no sour regurgitation. Seventy-five patients (63%) had no dysphagia after surgery. Forty-two patients had some dysphagia after surgery (36.8%). Six patients (5.0%) had significant dysphagia. Only 4 patients stated that dysphagia interfered with their quality of life. Twenty-six patients (22.8%) thought that belching and bloating were worse, whereas 42 patients (36.8%) thought that belching and bloating were better after surgery. Antacids, histamine-2 antagonist, and proton pump inhibitors were still being used by 12.6%, 14.3%, and 21.8% of patients, respectively.

Conclusions: Eighty-seven patients were completely satisfied (73.1%), 26 patients somewhat satisfied (22.8%), and 6 patients unsatisfied (5.3%) with surgery. Overall satisfaction with the surgery was 94.7%. One hundred five patients (88.2%) would recommend the surgery to others. Laparoscopic Nissen fundoplication can be effectively done in a community hospital setting.

Key Words: esophageal reflux, Nissen fundoplication, patient satisfaction

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Gastroesophageal reflux disease is common. Reflux disease can be well controlled with medical therapy in almost all patients with the use of proton pump inhibitors. (1) Surgical therapy is often advocated for patients, and has been shown to be equal to medical therapy on long-term analysis. (2) Patients suitable for surgery may include those with complicated reflux disease, those with recurring esophageal strictures, and those with medical intractability. Some patients elect to have surgery to avoid medication usage, or because of cost factors. Some authors question the effectiveness of surgery relative to medical therapy. (3) In an attempt to answer this question, we evaluated the first 157 patients having laparoscopic Nissen fundoplication at our hospital.

Materials and Methods

All patients had preoperative esophagogastroduodenoscopy. Esophageal motility was done in all, using the Medtronic 98 Polygram System. pH-probe studies were done in all patients who had no endoscopic evidence for esophagitis and were abnormal in all. All charts were reviewed for surgical indication, medication usage, comorbid illness, length of surgery, length of hospital stay, complications, morbidity, and mortality.

Operative technique

The patient was placed in the modified lithotomy position. Five laparoscopic ports were placed in the upper abdomen. A liver retractor was used to retract the left lobe of the liver anteriorly. The esophagus was circumferentially mobilized with blunt dissection until an adequate length of esophagus was noted to lie within the abdominal cavity. The short gastric vessels were transected with a Harmonic scalpel until the fundus was nicely mobile. The crura was reapproximated with interrupted 0 permanent sutures. A full 360 degree Nissen fundoplication was performed over a 52F Maloney dilator with interrupted 0 permanent sutures extending from the fundus of the esophagus and back to the fundus. The wrap was also secured posterior to the crura with an interrupted 0 permanent suture.

The patient was started on a clear liquid diet the day of surgery. This was advanced to a full liquid diet on the first postoperative day. All patients were routinely given 10 mg of metoclopramide intravenously every 6 hours to prevent nausea and 4 mg of ondansetron on an as-needed basis.

They were dismissed with a diet plan as well a prescription for hydrocodone elixir and simethicone as needed for gas and bloat. Gastrografin swallows were obtained only on a selective basis. The patients were reevaluated in the office at 1 week and usually returned to work at 2 weeks.

Method to assess patient satisfaction

A questionnaire was mailed to the first 157 patients having a laparoscopic Nissen fundoplication from February 1995 to April 2001. Initial mailing was on September 2001, with a repeat mailing being done in September 2002. Patients were questioned as to persistent reflux symptoms, such a heart-burn, sour regurgitation, and the need to take acid-reducing medications such as antacids, histamine-2 antagonists, or proton pump inhibitors. Patients were asked about difficulty with dysphagia and bloating. Patient satisfaction was assessed. Twenty-two patients could not be notified due to improper address, and no reply was received from 13 patients. Telephone calls were also made unsuccessfully in these patients. Hospital and office records were also reviewed in these patients, and no adverse complications were noted. One patient died as a result of unrelated cancer during follow-up. Another patient had lymphoma and did not feel that she could finish the survey. A completed questionnaire was received from 119 patients (76% of patients). These patients form the focus of our review.

Results

Mean follow-up was 49 months (range, 17 to 104 months). Ninety-three patients (78.0%) no longer had heartburn. Seven patients (5.01%) still had daily heartburn. One hundred three patients (86.6%) had no sour regurgitation. Four patients had daily regurgitation. Seventy-five patients (63.0%) had no postoperative dysphagia. Forty-four patients (37.0%) had some dysphagia. Only 7 patients (5.9%) had daily dysphagia. Sixteen percent of patients stated that dysphagia was worse after surgery. Seventy-four percent of patients stated that they swallowed better after surgery, and 10% noticed no change in swallowing. Only four patients stated that the dysphagia interfered with the quality of daily life.

Antacids, histamine-2 blocker therapy, and proton pump inhibitors were still being used by 12.6%, 14.3%, and 21.8% of patients, respectively. Twenty-six patients (22.8%) stated that bloating and belching were worse after surgery. Forty-two patients (36.8%) stated that bloating and belching were better.

Overall, 87 patients (73.1%) were completely satisfied with the surgery, and 26 patients (21.8%) were somewhat satisfied. Six patients (5.0%) were unsatisfied. One hundred five patients (88.2%) would recommend the surgery to others, whereas 14 patients would not.

Discussion

Booth et al reported on 140 patient responses from 179 patients, with a mean follow-up of 48 months. (4) Overall satisfaction with surgery was similar to ours, at 91%. Ninety percent of patients were free of significant reflux symptoms. Ninety-five percent of the 109 patients who had postoperative pH testing were within the normal range. Only 19 patients (14%) were taking anti-reflux medications, 12 of whom had normal 24-hour pH studies. Lafullarde et al (5) also reported that 87% of his 178 patients were free of significant reflux symptoms, with median follow-up of 6 years. Anvari and Allen (6) reported on 181 patients, with 86% patient satisfaction at 5 years. Bloomstem et al, (7) from the University of South Florida, reported 90% patient satisfaction for 100 consecutive laparoscopic Nissen fundoplication patients at 4-year follow-up. Similar results have been reported in other series. (8,9) Vakil et al (10) reported on 80 patients who responded to a questionnaire, from a total cohort of 157 patients operated at a community hospital by 24 different surgeons. He reported a total satisfaction of 61% and overall satisfaction of 87%. His study was different in that 46% of patients having surgery were medication failures. (10) Overall, 93% of our patients were very satisfied with their decision to have surgery. We avoided operations on patients who did not respond to medication. Only 5% were not satisfied.

Control of heartburn and sour regurgitation occurred in 78% and 86% of patients. Dysphagia was infrequent and interfered with daily life in only four patients. Use of histamine-2 antagonists and proton pump inhibitors were no longer used by 86.8% and 78.1% of patients. Of those taking proton pump inhibitors, 60% of patients were using them for reasons other than heartburn. These data are in marked contrast to the 62% usage of acid-reducing medication in 37 patients having had prior open Nissen fundoplication reported by Spechler et al. (3)

Conclusion

In our opinion, medical therapy is effective for reflux but is expensive and requires daily medication. Patients who have complicated reflux disease or who wish to avoid medication for cost or convenience reasons may elect to have surgery. In our opinion, laparoscopic Nissen fundoplication done at selected centers by competent surgeons is an effective alternative.

The man who does not read good books has no advantage over the man who
cannot read them.
--Mark Twain

Accepted August 13, 2004.

References

1. Klinkenberg-Knol EC, Festen HPM, Jansen JB, et al. Long-term treatment with omeprazole for refractory reflux esophagitis: efficacy and safety. Ann Intern Med 1994;121:161-167.

2. Lundell J, Miettinen P, Myrvold HE, 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;192:172-179.

3. Spechler SJ, 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;285:2331-2338.

4. Booth MI, Jones L, Stratford J, Dehn TCB. Results of laparoscopic Nissen fundoplication at 2-8 years after surgery. Br J Surg 2002;89:476-481.

5. Lafullarde T, Watson DI, Jamieson GG, et al. Laparoscopic Nissen fundoplication: five-year results and beyond. Arch Surg 2001;5:42-48.

6. Anvari M, Allen C. Five year comprehensive outcomes evaluation in 181 patients after laparoscopic Nissen fundoplication. J Am Coll Surg 2003;196:51-57.

7. Bloomstem M, Nields W, Rosemurgy AS. Symptoms and antireflux medication use following laparoscopic Nissen fundoplication: outcome at 1 and 4 years. J Soc Laparoendosc Surgeons 2003;7:211-218.

8. Granderath FA, Kamolz T, Schweiger UM, Pointner R. Quality of life, surgical outcome, and patient satisfaction three years after laparoscopic Nissen fundoplication. World J Surg 2002;26:1234-1238.

9. Nilsson G, Wenner J, Larsson S, Johnsson F. Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux. Br J Surg 2004;91:552-559.

10. Vakil N, Shaw M, Kirby R. Clinical effectiveness of laparoscopic fundoplication in a US community. Am J Med 2003;114:1-5.

RELATED ARTICLE: Key Points

* A patient survey revealed laparoscopic Nissen to be effective treatment for esophageal reflux.

* Overall patient satisfaction with surgery was 95%.

* Seventy-eight percent of patients no longer had heartburn, and 87% of patients no longer had regurgitation.

* Proton pump inhibitors were still being used by 22% of patients following surgery.

* Laparoscopic Nissen fundoplication can be effectively done in a community hospital setting.

Leslie E. Tucker, MD, Carl Blatt, MD, Norbert L. Richardson, MD, Donna T. Richardson, MD, James D. Cassat, MD, and Thomas B. Riechers, MD

From the Department of Medicine and Department of Surgery, St. John's Mercy Hospital, Washington, MO.

Reprint requests to Dr. Leslie E. Tucker, Division of Gastroenterology, St. John's Mercy Hospital, 951 East Fifth Street, Washington, MO 63090. Email: [e-mail]