title: Laparoscopic clam shell partial fundoplication achieves effective reflux control with reduced postoperative dysphagia and gas bloating.
abstract: 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.
authors.affiliation: The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Amgad E
authors.initials: AE
authors.lastname: el-Sherif
authors.forename: Prasad S
authors.initials: PS
authors.lastname: Adusumilli
authors.forename: Brian L
authors.initials: BL
authors.lastname: Pettiford
authors.forename: Thomas A
authors.initials: TA
authors.lastname: d'Amato
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Schuchert
authors.forename: Alicia
authors.initials: A
authors.lastname: Clark
authors.forename: Carmen
authors.initials: C
authors.lastname: DiRenzo
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Landreneau
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
authors.forename: Rodney J
authors.initials: RJ
authors.lastname: Landreneau
mesh_terms: D003680:Deglutition Disorders / Q000517:prevention & control*; D005260:Female; D005414:Flatulence / Q000517:prevention & control*; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D012189:Retrospective Studies