Journal Club P.O.W. Hospital

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Journal ClubP.O.W. Hospital

• Monday 12th May 2003
• Wendell Neilson
• Bryan Yeo

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Division of Short Gastric Vessels at
Laparoscopic Nissen Fundoplication.A prospective
Double-Blind Randomized Trial with 5 year
Follow-Up.

• OBoyle, Watson, Jamieson, Myers, Game, Devitt
• University of Adelaide, Royal Adelaide Hospital,
  South Australia
• Annals of Surgery, 2002
• Vol 235, No. 2, pp 165-170

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Aim

• To determine whether division of the short
  gastric vessels at laproscopic Nissen
  fundoplication confers any long term clinical
  benefit to patients.

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Method

• Patients recruited between May 1994 and October
  1995, and allocated to either the division or
  non-division group.
• If conversion to an open procedure, then the
  patient remained within their allocated group.
• 5 year follow-up occurred between July and
  October 2000, via a telephone interview with a
  structured questionnaire.

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Method

• Questionnaire inquired about the presence of
  preoperative symptoms
• Heartburn
• Epigastric pain
• Regurgitation
• Dysphagia/anorexia
• Nausea and vomiting
• Also inquired about
• Heartburn control
• Bloating, and ability to relieve this with
  belching
• Excessive flatus
• Rate outcome of surgery

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Results

• 102 patients entered into trial 50 N-D, 52 D.
• Short term re-operation (lt6 months)
• N-D 2 lap. para-oesophageal hernia repairs
• D 1 laparotomy for bleeding at 6 hours from SGV
• 1 release of tight hiatal repair at day 5
• 1 open revision of hiatal scaring at 12 weeks
• Long term re-operation (gt6 months)
• N-D 1 revision for slipped fundoplication,
  11/12
• D open revision for hiatal stenosis 9/12
• 1 revision for slipped fundoplication, 6
  years

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Results

• At 6 month follow-up no significant difference in
  symptoms noted on questionnaire
• Trend to increased bloating in the D group
• Significantly greater operating time SGV division
  group.
• SGV ND 70.6 min mean, 35-170 min range
• SGV D 107.9 min mean, 59-215 min range
• No significant difference in hospital stay
  duration.

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Results

• 5 year follow-up with 99 patients (2 deaths and 1
  CVA) 49 N-D, 50 D.
• No significant difference for (plt0.05)
• Epigastric pain
• Regurgitation
• Anorexia
• Nausea and vomiting
• Early satiety
• Ability to belch

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Results

• Significant difference for (plt0.05)
• Increased flatus production p0.03
• Increased incidence of epigastric bloating p0.02
• Decreased ability to relieve bloating by belching
  p0.04
• Decreased satisfaction in outcome of surgery
• In the SGV division group

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Discussion

• Results similar to other prospective trials
• Luostarinen et al (n50) 3 years follow-up
• Open procedure
• Increased sliding H.H., and defective wraps with
  SGV div.
• Blomquist et al (n99) 1 year follow-up
• No significant clinical difference
• Division limb took longer operative time.

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Discussion

• Surprised by the difference in wind problems
• SGV division allows a mobile fundus and an
  application of a floppy wrap. Thus less
  bloating and flatus.
• Theorized that afferent nerves that control belch
  reflex from the stretch in the fundus travel
  partly with the SGV.

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Conclusion

• Division of short gastric vessels not necessary
  in laparoscopic Nissen fundoplication, and is
  associated with a longer operating time and a
  increased incidence of post-operative bloating
  and flatus

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Critique

• Positive
• Allocation to trail arms by blinded, independent
  person
• Same standardized questionnaire for all follow-up
  interviews.
• 5 year follow-up performed by a person not
  involved in the initial operation/allocation
• Close-to 100 patient follow-up

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Critique

• Negative
• Use of visual analog scale for measuring
  dysphagia, satisfaction with surgery etc. on a
  telephone interview.
• Use of telephone interview rather than face to
  face questioning
• No objective measurement of post-op improvement.
  E.g. pH monitoring or oesophageal manometry.