Elsevier

The Annals of Thoracic Surgery

Volume 84, Issue 5, November 2007, Pages 1704-1709
The Annals of Thoracic Surgery

Original article
General thoracic
Laparoscopic Clam Shell Partial Fundoplication Achieves Effective Reflux Control With Reduced Postoperative Dysphagia and Gas Bloating

Presented at the Poster Session of the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
https://doi.org/10.1016/j.athoracsur.2007.05.085Get rights and content

Background

We describe a novel laparoscopic “clam shell” partial fundoplication, incorporating a modified Toupet with an anterior fundic flap for the management of medically recalcitrant gastroesophageal reflux disease. We hypothesize that this clam-shell–like mechanism allows a dynamic rather than rigid circumferential antireflux barrier allowing effective reflux control (compared with partial fundoplication) with reduced occurrence of postoperative dysphagia, gas bloating and vagal nerve injury (compared with Nissen fundoplication).

Methods

Between November 2002 and May 2006, 140 patients (82 female; mean age, 53 years) underwent this laparoscopic clam shell fundoplication procedure for medically recalcitrant gastroesophageal reflux disease (n = 94) or large paraesophageal hernias (n = 46). Preoperative invasive studies (endoscopy, manometry, pH monitoring) and noninvasive studies (barium swallow and radionuclide gastroesophageal motility) revealed esophageal dysmotility in 26 patients. Routine barium swallow and radionuclide studies were performed 6 months postoperatively and then at yearly intervals.

Results

There was no mortality or conversions to open procedures. Mean operative time was 45 minutes; median hospital stay was 1 day (range, 1 to 4). Overall control of reflux symptoms was seen in 95% of patients. Postoperative gas bloating and significant dysphagia occurred in only 11% and 6% of patients, respectively. Three patients (2%) experienced postoperative complications (pneumonia, 2; pleural effusion requiring drainage, 1). Postoperative studies demonstrated reflux in 8 patients (5%) and the presence of small hiatal hernias in 5 patients (4%) during a mean follow-up 19 months (range, 7 to 42). Twenty five patients (17%) underwent postoperative esophageal dilation (median dilations, 1; range, 1 to 3) for dysphagia (11 of these patients had preoperative esophageal dysmotility). Five patients underwent repeat fundoplication (recurrent reflux, 2; gas bloating, 1; dysphagia, 2).

Conclusions

Clam shell near-circumferential fundoplication may be considered as an attractive alternative antireflux approach to Nissen fundoplication, particularly among patients at risk for postoperative dysphagia or gas bloating.

Section snippets

Patients and Methods

We reviewed our series of patients undergoing clam shell partial fundoplication operated on between November 2002 and May 2006. In all, 140 patients (82 female; mean age, 53 years) underwent laparoscopic clam shell procedure. This study was approved by the University of Pittsburgh Institutional Review Board. Because this was a retrospective review, individual consent was waived.

Ninety-four of these patients were referred to us for surgical management of medically recalcitrant gastroesophageal

Results

This clam shell hybrid of a standard Toupet and Dor fundoplication was safely and expediently performed. There was no need for intraoperative conversion to an open procedure to complete the antireflux surgical repair. Mean operative time was 45 minutes, with a range of 30 to 140 minutes. The average hospital stay was slightly less than 2 days, with a range of 1 to 5 days. Symptomatic relief of gastroesophageal reflux symptoms was noted in 95% during the period of follow-up. Gas bloating was

Comment

The primary goal of this report is to describe the technical details of a new partial fundoplication approach to symptomatic gastroesophageal reflux disease. This intermediate-term clinical evaluation of this dynamic, near-circumferential, clam shell like fundoplication has provided promising results.

Nissen fundoplication has a high long-term control of reflux, ranging from 85% to 95% [12]. Although its efficacy is well documented in terms of gastroesophageal reflux control, the postoperative

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