title: Impact of surgeon experience on 5-year outcome of laparoscopic Nissen fundoplication.
abstract: OBJECTIVE
  To investigate the 5-year effect of surgeon experience with laparoscopic Nissen fundoplication (LNF). In 2000, a randomized controlled trial (RCT) was prematurely terminated because LNF for gastroesophageal reflux disease was associated with a higher risk to develop dysphagia than conventional Nissen fundoplication (CNF). Criticism focused on alleged bias caused by the relative lack of experience with the laparoscopic approach of the participating surgeons.
  
  
  METHODS
  Multicenter RCT and prospective cohort study.
  
  
  METHODS
  University medical centers and tertiary teaching hospitals.
  
  
  METHODS
  In the RCT, 74 patients underwent CNF and 93 patients underwent LNF (LNFI). The complete setup of the cohort study (LNFII) (n = 121) mirrored the RCT, except that surgeon experience increased from more than 5 to more than 30 LNFs per surgeon.
  
  
  METHODS
  Conventional Nissen fundoplication, LNFI, and LNFII.
  
  
  METHODS
  Intraoperative and in-hospital characteristics, objective reflux control, and clinical outcome.
  
  
  RESULTS
  In LNFII, operating time (110 vs 165 minutes; P < .001), dysphagia (2.5% vs 12.3%; P = .008), dilatations for dysphagia (0.8% vs 7.0%; P = .02), and conversions (3.5% vs 7.7%; P = .19) were reduced compared with LNFI. Moreover, in LNFII, hospitalization (4.2 vs 5.6 days; P = .07 and 4.2 vs 7.6 days; P < .001) and in-hospital complications (5.1% vs 13.5%; P = .046 and 5.1% vs 19.3%; P = .005) were reduced compared with LNFI and CNF, respectively. In LNFII, the 6-month reintervention rate was reduced compared with LNFI (0.8% vs 10.1%; P = .002). Esophagitis and esophageal acid exposure at 3 months and reflux symptoms, proton-pump inhibitor use, and quality of life at 5 years improved similarly.
  
  
  CONCLUSIONS
  Operating time, complications, hospitalization, early dysphagia, dilatations for dysphagia, and reintervention rate after LNF improve significantly when surgeon experience increases from more than 5 to more than 30 LNFs. In contrast, short-term objective reflux control and 5-year clinical outcome do not improve with experience. In experienced hands, LNF reduces in-hospital complications and hospitalization compared with CNF, with similar 5-year effectiveness and reoperation rate.
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Joris A J L
authors.initials: JA
authors.lastname: Broeders
authors.forename: Werner A
authors.initials: WA
authors.lastname: Draaisma
authors.forename: Hilda G
authors.initials: HG
authors.lastname: Rijnhart-de Jong
authors.forename: André J P M
authors.initials: AJ
authors.lastname: Smout
authors.forename: Jan J B
authors.initials: JJ
authors.lastname: van Lanschot
authors.forename: Ivo A M J
authors.initials: IA
authors.lastname: Broeders
authors.forename: Hein G
authors.initials: HG
authors.lastname: Gooszen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000639:trends; D012008:Recurrence; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult