Abstracts
1998 Digestive Disease Week

#2328

LAPAROSCOPIC TOUPET IS AN INADEQUATE PROCEDURE FOR PATIENTS WITH SEVERE REFLUX DISEASE. K.D. Horvath, B.A. Jobe, L.L. Swanstrom, Oregon Health Sciences University and Legacy Health Systems, Portland, OR.

Recently, we have shown that laparoscopic Toupet fundoplication is associated with a high degree of late failure when employed as a primary treatment for GERD. This study defines preoperative patient risk factors that predispose to failure.

Data from 50 patients with objective follow up performed as part of a prospective long term outcomes project (24hr pH monitoring, manometry, EGD at 6 months, 3 years and 6 years) was analyzed. Preoperative studies of patients with documented postoperative failure (24hr pH <4, >5% of the time) were compared to preoperative studies of patients with normal 24hr pH studies. Outcomes were assessed at 27 months postop.

At late follow up, 22% (11/50) of patients had heartburn and 40% (18/46) had abnormal 24 hr pH testing. 61% of patients with abnormal objective testing are dependant upon medical therapy. Factors associated with severe reflux as listed in table 1 were significantly more prevalent in the failure group.

Table 1. Preoperative Risk Factors

p < .05 for all comparisons

Comparison of postoperative LES pressures showed lower pressures in the failure group compared to the non-failures (11 mm/Hg vs 15.3 mm/Hg). Additionally, total LES length was also significantly less in the failure group (1.4 cm vs 2.8 cm) p<0.5. Wrap herniation was the source of failure in two patients. There were no wrap disruptions documented by EGD.

Laparoscopic Toupet fundoplication is associated with a high rate of failure both clinically and by objective testing. Patients with severe GERD are more likely to fail surgery than patients with uncomplicated or mild disease. Failure is secondary to inadequacy of the anti-reflux barrier. Laparoscopic Toupet fundoplication should be reserved for patients with severe motility disorder and uncomplicated GERD.

Copyright 1996 - 1998, SSAT, Inc. Revised 29 June 1998.