Laparoscopic fundoplication: the alternative to long-term medical therapy for severe gastroesophageal reflux disease

Gastroesophageal reflux disease is common. Fundoplication is very effective for those patients who fail medical therapy, particularly those with an incompetent lower esophageal sphincter. Open surgery is reported to achieve cure rates in excess of 90 percent. Laparoscopic fundoplication has been performed since 1991. The early experience with this procedure is reviewed. 1992 cases were reported in the literature. The mortality rate was 0.1 percent. Operative complications occurred as follows: 0.9 percent esophagogastric perforation rate; 0.6 percent bleeding rate (requiring transfusion); and 0.6 percent pneumothorax rate. No splenectomies were reported. 4.8 percent of patients required conversion to the open procedure. As experience with the procedure is gained this conversion rate decreases. Recurrent reflux postoperatively is 3.4 percent, but follow-up is short (range: 0 to 36 months; mean: two years). Dysphagia requiring dilatation occurs in 3.5 percent of patients. Gas bloat occurs in 0 to 24 percent of patients. These results compare favorably with the published results of medical therapy and the open fundoplication. The early experience with laparoscopic fundoplication appears promising and provides an attractive alternative to long-term medical therapy and to open surgery in appropriate patients. Long-term follow-up is awaited.