title: An analysis of operations for gastroesophageal reflux disease: identifying the important technical elements.
abstract: BACKGROUND
  Better understanding of the pathogenesis of gastroesophageal reflux disease in recent years has not been accompanied by appreciable advances in the design of antireflux operations. In many cases, operations are still being performed just as they were described 30 years ago. It is important now to go beyond the eponymous procedures traditionally associated with antireflux operations and to identify the technical elements that contribute to effective and durable fundoplications.
  
  
  OBJECTIVE
  To compare antireflux operations and identify the important technical elements.
  
  
  METHODS
  Retrospective study in a university-based tertiary care center.
  
  
  METHODS
  Two hundred one patients had laparoscopic fundoplications for gastroesophageal reflux disease. The first 22 patients underwent Nissen-Rossetti procedures (360 degree wrap; no division of short gastric vessels). Subsequently, 82 patients had a total (360 degree Nissen wrap) fundoplication and 97 patients had a partial (240 degree Guarner wrap) fundoplication (both with the short gastric vessels divided), with the choice between them based on the quality of esophageal peristalsis. The 3 groups of patients were similar in age, duration of symptoms, incidence of hiatal hernia, and incidence of esophagitis.
  
  
  METHODS
  Resolution of heartburn, incidence of postoperative dysphagia, and stability of the reconstruction.
  
  
  RESULTS
  The resolution of heartburn was achieved for 15 patients (68%) who had the Nissen-Rossetti procedure, 73 patients (89%) who had a 360 degrees Nissen wrap, and 88 patients (91%) who had a 240 degree Guarner wrap. Postoperative dysphagia occurred in 3 patients (14%) having the Nissen-Rossetti procedure, 5 patients (6%) having a 360 degree wrap, and 2 patients (2%) having a 240 degree wrap. Herniation or disruption of the wrap occurred postoperatively in 9 patients (4.5%). Review of the videotapes of these 9 operations showed that important technical elements had been omitted in 8. Seven patients required a second operation.
  
  
  CONCLUSIONS
  Laparoscopic antireflux operations control symptoms without producing adverse effects if the following technical elements are included: the hernia is repaired and the hiatus reduced to a normal size, the short gastric vessels are divided, a total or partial wrap is used based on the quality of esophageal peristalsis, and the wrap is anchored in the abdomen.
authors.affiliation: Department of Surgery, University of California, San Francisco, School of Medicine, 94143-0788, USA.
authors.forename: M G
authors.initials: MG
authors.lastname: Patti
authors.forename: M
authors.initials: M
authors.lastname: Arcerito
authors.forename: C V
authors.initials: CV
authors.lastname: Feo
authors.forename: M
authors.initials: M
authors.lastname: De Pinto
authors.forename: J
authors.initials: J
authors.lastname: Tong
authors.forename: W
authors.initials: W
authors.lastname: Gantert
authors.forename: D
authors.initials: D
authors.lastname: Tyrrell
authors.forename: L W
authors.initials: LW
authors.lastname: Way
mesh_terms: D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D018662:Fundoplication / Q000379:methods; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome