title: Impact of anatomical wrap position on the outcome of Nissen fundoplication.
abstract: BACKGROUND
  The importance of anatomical reposition and fixation of the type I hiatal hernia during antireflux surgery has often been emphasized. It is not known whether the initial anatomical repair withstands the test of time and whether this repair is necessary for a successful outcome.
  
  
  METHODS
  The relationship between the objective anatomical and subjective symptomatic outcome of Nissen fundoplication was investigated prospectively in 57 patients. Findings of herniation, telescoping and obstruction at the level of the lower oesophageal sphincter on barium swallow were scored 2 years after operation by investigators who were unaware of the symptoms, and were related to symptoms and patient satisfaction evaluated by a standard questionnaire.
  
  
  RESULTS
  According to strict criteria, some 55 per cent of patients had some degree of anatomical failure; if only complete herniation, significant telescoping and signs of obstruction were scored as abnormal, 27 per cent had anatomical failure. There was no relation to subjective outcome; relief was reported by 48 of 49 patients, 25 of whom were cured and 23 significantly improved.
  
  
  CONCLUSIONS
  Anatomical repair during antireflux surgery does not stand the test of time. Although this has no demonstrable influence on the subjective outcome, the authors do not recommend deviating from well designed surgical guidelines. Current theories on the mechanism of antireflux surgery require further evaluation.
authors.affiliation: Department of Surgery, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
authors.forename: S C
authors.initials: SC
authors.lastname: Donkervoort
authors.forename: J E
authors.initials: JE
authors.lastname: Bais
authors.forename: H
authors.initials: H
authors.lastname: Rijnhart-de Jong
authors.forename: H G
authors.initials: HG
authors.lastname: Gooszen
mesh_terms: D001466:Barium Sulfate; D003287:Contrast Media; D004733:Enema / Q000379:methods; D005260:Female; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006547:Hernia / Q000209:etiology; D006801:Humans; D010535:Laparoscopy; D008297:Male; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D012008:Recurrence; D017211:Treatment Failure
chemical_list: D003287:Contrast Media; D001466:Barium Sulfate