The evolution of laparoscopic antireflux surgery and its influence on postoperative stay

Laparoscopic fundoplication is an established treatment for refractory gastro-oesophageal reflux disease. This study aims to compare the outcome of two laparoscopic antireflux techniques in a regional specialist unit. A sequential audit was carried out on patients undergoing laparoscopic Nissen (LN: performed May 1994 to November 2000) or laparoscopic anterior (LA: performed March 2001 to December 2004) fundoplication. Patient satisfaction was assessed by postal questionnaire. The cohorts undergoing each operation were also divided into two chronological groups of 51 patients, to study the effect of possible learning curve progression on the number of nights spent in the hospital postoperatively. In all, 142/204 (70%) questionnaires were returned from patients with follow-up ranging from 5 to 40 months postoperation. Overall, 102/142 (72%) reported a good or excellent outcome. Patients who underwent LA had a higher rate of antacid medication use (LN 17.4% versus LA 34.2%, P = 0.036) but there was a higher score for inability to belch following LN (LN 2.03 versus LA 1.53, P = 0.034). When comparing the chronologically divided cohorts, LN was associated with a significantly longer hospital stay than LA (P < 0.001, Mann-Whitney U test). There was a significant decrease in hospital stay from the first to second group of 51 LNs (P < 0.001, Mann-Whitney U test) and a further significant reduction in hospital stay from the first 51 to second 51 LAs (P < 0.001, Mann-Whitney U test). In conclusion, both procedures provide good symptom control. Increased requirement for acid suppression following LA and inability to belch following LN, may suggest more long-term durability of the LN wrap. The decrease in the number of nights spent in hospital may be related to the procedure performed but seems more likely to be an effect of increasing volume of surgical experience.