Quality of Life and Surgical Outcome after Laparoscopic Nissen and Toupet Fundoplication: One-Year Follow-Up

Background and Study Aims: Quality of life data are becoming widely accepted as a measure of surgical outcome, but the multifaceted symptoms in patients with gastrointestinal disorders are a challenge for this type of evaluation. The aim of the present study was to determine any potential differences in quality of life, specifically in patients undergoing either laparoscopic „floppy” Nissen fundoplication or Toupet fundoplication.

Patients and Methods: Using the Gastrointestinal Quality of Life Index (GIQLI), the quality of life data for 175 consecutive patients undergoing laparoscopic „floppy” Nissen (n = 107) or Toupet (n = 68) fundoplication at our department of surgery over a period of 30 months were evaluated prospectively. The patients included 97 men and 78 women, with a mean age of 52 years. The GIQLI creates a general score for quality of life by classifying five different subscales: gastrointestinal symptoms, emotional status, physical and social functions, and stress of medical treatment. This questionnaire was given to the patients preoperatively, and on three occasions after surgery - at six weeks, three months, and one year.

Results: The analysis showed that the patients had a low GIQLI preoperatively in comparison with healthy individuals (mean 90.4 vs. 122.6 points), with all subscales being affected. The general score improved significantly six weeks postoperatively (mean: 118.2 points; P < 0.05), showed further improvement at three months (mean: 124.2 points), and remained stable at one year (mean: 123.1 points; P < 0.01) postoperatively. There were no differences in the quality of life or side effects between patients with a Nissen or Toupet fundoplication, except regarding the frequency of mild, transient dysphagia.

Conclusions: Patients with gastroesophageal reflux disease suffer from a poor quality of life. After laparoscopic fundoplication, the quality of life improves and becomes comparable to that of healthy individuals. In our view, quality of life data should be evaluated as a major factor in determining the role of surgical interventions. Patients should receive consultation and advice regarding quality of life questions prior to surgery.

References

• 1 McLeod RS. Gastrointestinal surgery. In: Spilker B (ed). Quality of life assessments in clinical trials.  New York; Raven Press, 1990: 333
• 2 Dimenäs E. Methodological aspects of evaluation of quality of life in gastrointestinal diseases.  Scand J Gastroenterol. 1993;  28 18-21
• 3 Kamolz T, Pointner R. Lebensqualität. Ein Beurteilungskriterium in der Chirurgie.  Acta Chir Austriaca. 1998;  30 355-358
• 4 Armstrong D. Reflux disease and Barrett's oesophagus.  Endoscopy. 1994;  26 9-19
• 5 Burhol PG. Prevalences of endoscopic and histological findings in subjects with and without dyspepsia.  Br Med J. 1991;  302 749-752
• 6 Paterson WG. Extraesophageal complications of gastroesophageal reflux disease.  Can J Gastroenterol. 1997;  11 45
• 7 Kahrilas PJ. Gastroesophageal reflux disease.  JAMA. 1996;  276 983-988
• 8 Fuchs KH. Pathophysiologie. In: Fuchs KH, Stein HJ, Thiede A (eds). Gastrointestinale Funktionsstörungen.  Berlin; Springer, 1997: 495-513
• 9 Sivri B, McCallum RW. What has the surgeon to know about pathophysiology of reflux disease?.  World J Surg. 1992;  16 294-299
• 10 Fuchs KH, Feussner H, Bonavina L, et al. Current status and trends in laparoscopic antireflux surgery: results of a consensus meeting.  Endoscopy. 1997;  29 298-308
• 11 Stein HJ, DeMeester TR. Who benefits from antireflux surgery?.  World J Surg. 1992;  16 313-319
• 12 Hinder RA. Gastroesophageal reflux disease: surgical options, choice of operations and outcomes. In: Katz PO, DeVault KR, Hinder RA (eds). GI in the next century - AGA postgraduate course.  Bethesda, MA; American Gastroenterological Association, 1999: 29-32
• 13 Pointner R, Bammer T, Kamolz T. Laparoskopische Sanierung der Refluxkrankheit.  Acta Chir Austriaca. 1999;  31 133-137
• 14 DeMeester TR, Wang CI, Wernly JA, et al. Technique, indications and clinical use of 24-hour esophageal pH monitoring.  J Thorac Cardiovasc Surg. 1980;  79 656-670
• 15 Bammer T, Pointner R, Hinder RA. Standard technique for laparoscopic Nissen and Toupet fundoplication.  Acta Chir Austriaca. 2000;  32
• 16 Lund RL, Wetscher GJ, Raiser F, et al. Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility.  J Gastrointest Surg. 1997;  1 301-308
• 17 Kauer WK, Peters JH, DeMeester TR, et al. A tailored approach to antireflux surgery.  J Thorac Cardiovasc Surg. 1995;  110 141-146
• 18 Hinder RA, Libbey JS, Gorecki P, et al. Antireflux surgery: indication, preoperative evaluation, and outcome.  Gastroenterol Clin North Am. 1999;  28
• 19 Zanninotto G, DeMeester TR, Schwitzer W, et al. The lower esophageal sphincter in health and disease.  Am J Surg. 1988;  155 104-110
• 20 Eypasch E, Wood-Dauphinée S, Williams JI, et al. Der Gastrointestinale Lebensqualitätsindex (GLQI).  Chirurg. 1993;  64 264-274
• 21 Eypasch E, Williams JI, Wood-Dauphinée S, et al. Gastrointestinal Quality of Life Index: development, validation and application of a new instrument.  Br J Surg. 1995;  82 216-222
• 22 Velanovich V, Karmy-Jones R. Measurement gastroesophageal reflux disease: relationship between the health-related quality of life score and physiologic parameters.  Am Surg. 1998;  64 649-653
• 23 Perdikis G, Hinder RA, Wetscher GJ, et al. Nissen fundoplication for gastroesophageal reflux disease: laparoscopic Nissen fundoplication - technique and results.  Dis Esophagus. 1996;  9 272-277
• 24 Wetscher GJ, Glaser K, Hinder RA, et al. Respiratory symptoms in patients with gastroesophageal reflux disease following medical therapy and following antireflux surgery.  Am J Surg. 1997;  174 639-643
• 25 Lundell LR. The knife or the pill in the long-term treatment of gastroesophageal reflux disease?.  Yale J Biol Med. 1995;  67 233-246
• 26 Dent J, Yeomans ND, MacKinnon M, et al. Omeprazole vs. ranitidine for prevention of relapse in reflux esophagitis: a controlled double-blind trial of their efficacy and safety.  Gut. 1994;  35 590-598
• 27 Lundell LR. Long-term treatment of gastro-oesophageal reflux disease with omeprazole.  Scand J Gastroenterol. 1994;  29 74-78
• 28 Glise H, Hallerbäck B, Johansson B. Quality-of-life assessments in evaluation of laparoscopic Rosetti fundoplication.  Surg Endosc. 1995;  9 183-189
• 29 Glise H, Hallerbäck B. Assessment of outcome after antireflux surgery.  Semin Laparosc Surg. 1995;  2 60-65
• 30 Kamolz T, Bammer T, Wykypiel H Jr, et al. Predictability of dysphagia after laparoscopic Nissen fundoplication.  Am J Gastroenterol. 2000;  95 408-414
• 31 Kamolz T, Bammer T, Wykypiel H Jr, et al. Stressverarbeitung und Persönlichkeitsstruktur bei Patienten mit und ohne stressassoziierter Symptomatik der gastrooesophagealen Refluxkrankheit.  Z Gastroenterol. 1999;  37 265-270
• 32 Bammer T, Kamolz T, Pointner R. Side effects of laparoscopic antireflux surgery: a one year follow-up. (SWSC 51st Annual Meeting).  San Diego; Southwestern Surgical Congress, 1999 [in press]
• 33 Pointner R, Bammer T, Then P, et al. Laparoscopic refundoplication after failed antireflux surgery.  Am J Surg. 1999;  178 541-544
• 34 Glise H, Wiklund K. Measurement of the impact of heartburn and dyspepsia on quality of life.  Aliment Pharmacol Ther. 1997;  11 73-77
• 35 Watson RGP, Tham TCK, Johnston BT, et al. Double-blind cross-over placebo-controlled study of omeprazole in the treatment of patients with reflux symptoms and physiological levels of acid reflux: the “sensitive oesophagus”.  Gut. 1997;  40 487-490