0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery FREE

Frank a. Granderath, MD; Thomas Kamolz, PhD; Ursula m. Schweiger, MD; Rudolph Pointner, MD
[+] Author Affiliations

From the Division of Clinical Psychology (Dr Kamolz), and the Department of General Surgery (Drs Granderath, Schweiger, and Pointner), Hospital Zell am See, Zell am See, Austria.


Arch Surg. 2003;138(8):902-907. doi:10.1001/archsurg.138.8.902.
Text Size: A A A
Published online

Background  One of the most frequent complications after laparoscopic antireflux surgery is estimated to be the intrathoracic herniation of the wrap into the chest. therefore, in up to 5% of patients, revisional surgery is necessary.

Hypothesis  Patients who undergo laparoscopic refundoplication for postoperative intrathoracic wrap herniation using a circular polypropylene mesh for hiatal closure have a good to excellent functional outcome, during a complete follow-up of 1 year.

Design  Prospective nonrandomized trial of a consecutive sample.

Setting  University-affiliated community hospital.

Patients  Twenty-four patients undergoing laparoscopic refundoplication for persistent or recurrent symptoms of gastroesophageal reflux disease as a result of postoperative intrathoracic wrap migration.

Intervention  All patients underwent laparoscopic refundoplication with a circular polypropylene mesh for hiatal closure.

Main outcome measures  Recurrences, complications, postoperative lower esophageal sphincter pressure, demeester score, esophagogastroduodenoscopy results, and barium swallow results.

Results  All refundoplications were completed laparoscopically. there were no intraoperative complications. twenty-one patients underwent laparoscopic nissen fundoplication; in 3 patients, a laparoscopic toupet fundoplication was performed. previous antireflux procedures included an open nissen fundoplication (n = 5), a laparoscopic nissen fundoplication (n = 15), and a laparoscopic toupet fundoplication (n = 4). postoperatively, one patient had severe dysphagia and had to undergo pneumatic dilatation once. during a follow-up of 1 year after surgery, no patient developed a recurrent hiatal hernia, with or without intrathoracic wrap herniation. the mean lower esophageal sphincter pressure increased significantly (P<.01) at 3 months (12.2 mm hg) and 1 year (11.9 mm hg) after refundoplication. the mean demeester score decreased significantly (P<.01) from 50.5 points preoperatively to 16.0 points at 3 months and 14.7 points at 1 year after refundoplication.

Conclusion  Laparoscopic refundoplication with prosthetic hiatal closure is a safe and effective procedure for preventing recurrent intrathoracic wrap herniation, with good to excellent functional outcome for a complete follow-up of 1 year.

Figures in this Article

DUring the past decade, laparoscopic fundoplication has emerged as the most successful procedure in the surgical treatment of severe gastroesophageal reflux disease (gerd). thousands of laparoscopic antireflux operations have been performed since dallemagne et al1 first described the possibility of minimally invasive access in 1991, with good to excellent functional and symptomatic outcome and a significant improvement of patients' quality of life.25 However, some studies68 also have shown that there is a small group of patients in whom antireflux surgery fails and revisional surgery for persistent or recurrent gerd symptoms is required. one of the most frequent morphological reasons for refundoplication is estimated to be recurrent hiatal hernia, with or without migration of the wrap into the chest.9 Therefore, many researchers5 prefer a routine hiatal closure during laparoscopic fundoplication. some studies1012 have shown that it might be useful to use prosthetic materials for reinforcement of the hiatal crura to prevent postoperative hiatal disruption.

This prospective study presents the surgical outcome and functional results in patients who underwent laparoscopic revisional surgery with prosthetic hiatal closure using a circular polypropylene mesh for recurrent hiatal hernia as the cause of failure of primary antireflux surgery.

Until may 1, 2000, a group of 24 patients underwent laparoscopic refundoplication for persistent or recurrent gerd symptoms at our surgical department. in all patients, a postoperative intrathoracic wrap migration was the morphological reason for refundoplication (Figure 1). there were 6 female and 18 male patients (mean age, 55 years; range, 35-67 years). previous antireflux procedures were an open nissen fundoplication (n = 5), a laparoscopic nissen fundoplication (n = 15), and a laparoscopic toupet fundoplication (n = 4). crural closure was performed during primary surgery in every patient. the mean period between primary antireflux surgery and laparoscopic revisional surgery was 2.8 years (range, 4 months to 12 years).

Place holder to copy figure label and caption
Figure 1.

Cinematographic x-ray film showing a "slipped" nissen fundoplication.

Graphic Jump Location

The preoperative workup in all patients included esophagogastroduodenoscopy (egd) and a barium swallow test (resulting in a cinematographic x-ray film) for visualization of the anatomical-morphological reason for failure. in addition, esophageal manometry and 24-hour ph monitoring were performed routinely in every patient preoperatively. the type of refundoplication was tailored to the results of esophageal manometry. laparoscopic 360° nissen fundoplication was performed in all patients with normal esophageal motility, whereas patients with poor esophageal motility (a pressure of <30 mm hg in the lower esophageal segments in response to wet swallows) or disordered peristalsis (>40% simultaneous contractions in wet swallows) underwent laparoscopic 270° toupet fundoplication.

SUrgical technique

The beginning of laparoscopic refundoplication is performed in accord with standard procedure using a 5-port system with 11-mm trocars, as described previously.13 After establishing the pneumoperitoneum with a maximum pressure of 12 to 14 mm hg, the operation starts with an extended adhesiolysis. after mobilizing the left liver lobe, a liver retractor is placed through the rightmost port for elevation of the liver off the hiatal region. by careful dissection with the harmonic scalpel (ultracision; ethicon endo-surgery, vienna, austria), the herniated fundoplication is identified and brought back intra-abdominally using an atraumatic babcock grasper. the distal esophagus and the gastroesophageal junction are dissected carefully by blunt dissection, and the right and left crura are identified. after complete mobilization, the old wrap is taken down in every patient (Figure 2). after breakdown of the wrap, the esophagus is mobilized posteriorly and the retroesophageal window is created. the right and left crura and the crural commissure are dissected exactly (Figure 3). after exact identification of the hiatal crura, crural closure is performed using interrupted 2-0 polysorb sutures (Figure 4). after closing the crura posteriorly, the esophagus has to be lying loose in the hiatus. an oval sheet will be cut out of a 10 × 15-cm polypropylene mesh (tyco healthcare, vienna), which we normally use for transabdominal preperitoneal hernia repair. for the esophageal body, a 3- to 4-cm keyhole in the center of the oval mesh is cut out. after bringing the mesh intra-abdominally, it is placed around the esophagus at the gastroesophageal junction, so that the esophageal body is lying through the keyhole of the mesh (Figure 5). the circular mesh is fixed onto the diaphragm using a hernia stapler (ethicon endo-surgery) (Figure 6). then, the 360° floppy nissen fundoplication is fashioned as described previously (Figure 7 and Figure 8).13

Place holder to copy figure label and caption
Figure 2.

Breakdown of the old wrap.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Preparation of the hiatus.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Crural closure.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Placement of the circular mesh.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Fixation with a hernia stapler.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

Creation of the new wrap.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

Completed 360° nissen fundoplication.

Graphic Jump Location
FOllow-up

Follow-up was obtained completely for all 24 patients. six weeks after surgery, patients were seen at our surgical department for egd surveillance. at 3 months and 1 year postoperatively, esophageal manometry and 24-hour ph monitoring were performed routinely in every patient.

STatistical analysis

Statistical analysis was performed using the statistical product and service solutions computer program (spss inc, chicago, ill). the data for esophageal manometry and 24-hour ph monitoring are presented as mean ± sd. treatment results were analyzed with a t test as appropriate and a P<.05 was considered significant. in some cases, descriptive statistics were used.

All procedures could be completed successfully laparoscopically. there were no intraoperative complications. twenty-one patients underwent laparoscopic nissen fundoplication; in 3 patients, a laparoscopic toupet fundoplication was performed. postoperatively, one patient had severe dysphagia and had to undergo pneumatic dilatation. after pneumatic dilatation, the patient was free of symptoms at follow-up. the mean operating time was 145 minutes (range, 105-235 minutes).

EGd results

Six weeks postoperatively, 21 patients underwent egd surveillance at our surgical department; the remaining 3 patients underwent egd at their local gastroenterologist. all patients showed no endoscopic signs of recurrent hiatal hernia or intrathoracic wrap migration.

LOwer esophageal sphincter pressure

Preoperatively, the lower esophageal sphincter pressure was 2.9 ± 1.6 mm hg, and increased significantly (P<.01) to 12.2 ± 4.2 mm hg at 3 months after surgery and remained stable (11.9 ± 4.5 mm hg) at 1 year after surgery. data are shown in Figure 9.

Place holder to copy figure label and caption
Figure 9.

Mean lower esophageal sphincter (les) pressure.

Graphic Jump Location
Demeester score

The demeester score decreased significantly (P<.01), from 50.5 ± 15.3 preoperatively to 16.0 ± 10.4 at 3 months postoperatively and 14.7 ± 9.9 at 1 year after surgery. as these data show, some patients (n = 4) showed pathologic values during 24-hour ph monitoring, but did not report any kind of recurrent symptoms at follow-up. data are shown in Figure 10.

Place holder to copy figure label and caption
Figure 10.

Mean demeester score.

Graphic Jump Location
CInematographic x-ray film

An esophageal barium swallow test (resulting in a cinematographic x-ray film) was performed in 19 patients 1 year postoperatively. it showed a correct subdiaphragmatic position of the fundoplication, with no signs of anatomical or morphological complications in all these patients. an x-ray film was not obtained for the remaining 5 patients who showed normal functional values and were free of symptoms at follow-up.

Generally, laparoscopic antireflux surgery (lars) has become the most successful surgical treatment option for patients with severe gerd, and has emerged as an established procedure in centers worldwide. numerous large studies35,14 have proved lars to be safe and effective, with excellent symptomatic and functional outcomes for long-term follow-up periods. however, there have been some reports in the literature describing some complications unique to the laparoscopic technique. the most common technical failure seems to be in relation to the crural closure. therefore, the most common morphological reason for recurrent symptoms after primary laparoscopic fundoplication is the intrathoracic migration of the intact wrap.7,9,15 The intrathoracic wrap migration is a result of inadequate closure of the hiatal crura or postoperative disruption of the crural closure. other reasons are estimated to be inadequate mobilization of the esophagus or a so-called short esophagus. resulting symptoms are postoperative dysphagia, recurrent reflux, or a combination of both. in most patients with recurrent symptoms after primary antireflux surgery, refundoplication becomes necessary because of this anatomical failure.16,17 In a study by horgan et al,18 48 patients underwent a subsequent laparoscopic operation for primary failed open antireflux surgery or lars. in this group, postoperative wrap herniation was the most common reason for the subsequent operation.18 Laparoscopic refundoplication can be a safe procedure in patients in whom a primary intervention failed, with results inferior to those after initial surgery; nevertheless, there is good symptomatic and morphological outcome for short-term and midterm follow-up.19,20 The main challenge of laparoscopic refundoplication in patients with intrathoracic wrap migration seems to be closure of the hiatal crura. in a few patients who underwent laparoscopic refundoplication for that failure, the procedure failed again and the patients had to undergo revisional surgery twice or more.16 The problem of postoperative breakdown of the crura has led us to use a polypropylene mesh for reinforcement of the hiatal crura during laparoscopic refundoplication.

The underlying morphological reason for fundoplication failure and, therefore, indication for refundoplication in all 24 patients of the present study was an intrathoracic wrap migration. all patients underwent laparoscopic refundoplication with a circular polypropylene mesh that was fixed on the hiatus for crural reinforcement. during a complete follow-up of 1 year after surgery, none of these patients developed a recurrent crural disruption, with or without intrathoracic wrap migration. in addition, we saw no mesh-related complications, such as esophageal erosion, or other events related to the mesh implantation. the postoperative controls by cinematographic x-ray film showed a correct subdiaphragmatic position of the fundoplication in all patients. during follow-up, no patient had clinical or symptomatic recurrence of gerd. functional variables, such as lower esophageal sphincter pressure and demeester score, showed normal values at 3 months and 1 year after refundoplication.

There have been few studies reporting about the use of a mesh prosthesis in laparoscopic refundoplication, but there are some reports dealing with the use of prosthetic materials during primary lars for gerd and/or hiatal hernia. prosthetic reinforcement of the hiatal crura has been successfully described by basso et al.12 A group of 65 patients who underwent lars with simple interrupted sutures for hiatal closure were compared with 67 patients who underwent lars with a 3 × 4-cm polypropylene mesh for crural closure. for a mean follow-up of 22.5 months, no patient in the mesh group developed a recurrent hiatal hernia, whereas 13.8% of the patients in the nonmesh group developed a recurrence within the first 4 months after surgery.

Similar experiences have been shown in a recently published large nonrandomized series.10 Of 531 patients who underwent primary lars at our surgical unit, 170 underwent hiatal closure using a 1 × 3-cm polypropylene mesh supporting the reinforcement of the hiatal crura. in this group, in 1 patient (0.6%), a postoperative wrap herniation occurred during 1 year of follow-up, whereas 22 patients (6.1%) developed a wrap herniation in the group with simple interrupted sutures used for crural closure.

Carlson et al21 described 31 patients with gerd and a hiatal hernia (>8 cm) who were randomized to nissen fundoplication with either simple posterior cruroplasty or cruroplasty using a polytetrafluorethylene onlay mesh. as a result, 3 patients (18.8%) in the nonmesh group developed a recurrence, whereas no patient in the mesh group developed a recurrent hiatal hernia for a follow-up from 12 to 36 months.

In a recently published prospective randomized trial, frantzides et al22 presented 72 patients who underwent laparoscopic nissen fundoplication for large hiatal hernia repair. thirty-six patients underwent fundoplication using posterior cruroplasty and simple interrupted sutures, whereas the remaining 36 patients underwent posterior cruroplasty with onlay of a polytetrafluoroethylene mesh. besides the fact that the operation was longer in the polytetrafluoroethylene group, patients had similar complications and duration of postoperative hospital stay in both groups. a significant difference in recurrence of hiatal hernia could be evaluated: in the primary repair group, 8 recurrent hiatal hernias occurred postoperatively, in contrast to no recurrence in the polytetrafluoroethylene group.

It might be a case of discussion to use prosthetic material intra-abdominally in terms of the possibility for foreign body erosion into the esophagus or transmural migration of suture material into the esophagus after fundoplication23; however, in our experience, erosion of a foreign body or migration of a prosthetic mesh into the esophagus or stomach is a rare complication and, along with other researchers, we have not seen this complication after prosthetic placement of a mesh in the hiatal region in our patients.

Like data from other groups that had proved prosthetic hiatal closure during hiatal hernia repair or primary lars to be a protective factor regarding recurring hiatal hernia, our present study shows the efficacy of crural closure using a circular polypropylene mesh in laparoscopic refundoplication. for a complete follow-up of 1 year postoperatively, this procedure seems to be a safe and effective treatment option to prevent recurrent intrathoracic wrap migration, with symptomatic and functional results comparable to those for patients who underwent primary lars. however, a longer follow-up is needed to evaluate certain long-term complications.

Corresponding author and reprints: frank a. granderath, md, department of general surgery, hospital zell am see, a-5700 zell am see, austria (e-mail: fagzellamsee@yahoo.com).

Box Section Ref ID

Accepted for publication february 8, 2003.

This study was presented as a poster at the sages eighth world congress of the society of american gastrointestinal endoscopic surgeons (sages); march 13-16, 2002; new york, ny; at the 43rd annual meeting of the society for surgery of the alimentary tract, digestive disease week 2002; may 19-22, 2002; san francisco, calif; and at the world congress of the society of laparoendoscopic surgeons, endo expo 2002; september 12, 2002; new orleans, la.

We thank andreas schweiger, gce, for his support in manufacturing the intraoperative pictures.

Dallemagne  BWeerts  JMJehaes  CMarkiewicz  SLombard  R Laparoscopic nissen fundoplication: preliminary report. Surg laparosc endosc. 1991;1138- 143
PubMed
Arnaud  JPPessaux  PGhavami  B  et al.  Laparoscopic fundoplication for gastro-esophageal reflux: multicenter study of 1470 cases [in french]. Chirurgie. 1999;124516- 522
PubMed Link to Article
Granderath  FAKamolz  TSchweiger  UM  et al.  Long-term results of laparoscopic antireflux surgery: surgical outcome and analysis of failure after 500 laparoscopic antireflux procedures. Surg endosc. 2002;16753- 757
PubMed Link to Article
Lafullarde  TWatson  DIJamieson  GGMyers  JCGame  PADevitt  PG Laparoscopic nissen fundoplication: five-year result and beyond. Arch surg. 2001;136180- 184
PubMed Link to Article
Terry  MSmith  CDBranum  GDGalloway  KWaring  JPHunter  JG Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia. Surg endosc. 2001;15691- 699
PubMed Link to Article
Watson  DIDebeaux  AC Complications of laparoscopic antireflux surgery. Surg endosc. 2001;15344- 352
PubMed Link to Article
Hunter  JGSmith  CDBranum  GD  et al.  Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann surg. 1999;230595- 604
PubMed Link to Article
Hinder  RAKlingler  PJPerdikis  GSmith  SL Management of the failed antireflux operation: surgery of the esophagus. Surg clin north am. 1997;771083- 1098
PubMed Link to Article
Soper  NJDunnegan  D Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann surg. 1999;229669- 676
PubMed Link to Article
Granderath  FASchweiger  UMKamolz  T  et al.  Laparoscopic antireflux surgery with routine mesh-hiatoplasty in the treatment of gastroesophageal reflux disease. J gastrointest surg. 2002;6347- 353
PubMed Link to Article
Huntington  TR Laparoscopic mesh repair of the esophageal hiatus. J am coll surg. 1997;184399- 400
PubMed
Basso  NDe leo  AGenco  A  et al.  360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease. Surg endosc. 2000;14164- 169
PubMed Link to Article
Pointner  RBammer  TThen  PKamolz  T Laparoscopic refundoplications after failed antireflux surgery. Am j surg. 1999;178541- 544
PubMed Link to Article
Hinder  RAFilipi  CJWetscher  GNeary  PDemeester  TRPerdikis  G Laparoscopic nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann surg. 1994;220472- 481
PubMed Link to Article
Cadiere  GBBruyns  JHimpens  JVertruyen  M Intrathoracic migration of the wrap after laparoscopic nissen fundoplication. Surg endosc. 1996;10187
Link to Article
Granderath  FAKamolz  TSchweiger  UM  et al.  Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery? Surg endosc. 2002;16381- 385
PubMed Link to Article
Floch  NRHinder  RAKlingler  PJ  et al.  Is laparoscopic reoperation for failed antireflux surgery feasible? Arch surg. 1999;134733- 737
PubMed Link to Article
Horgan  SPohl  DBogetti  DEubanks  TPellegrini  C Failed antireflux surgery: what have we learned from reoperations? Arch surg. 1999;134809- 817
PubMed Link to Article
Granderath  FAKamolz  TSchweiger  UMPointner  R Failed antireflux surgery: quality of life and surgical outcome after laparoscopic refundoplication. Int j colorectal dis. 2003;18248- 253
PubMed Link to Article
Granderath  FAKamolz  TSchweiger  UMPointner  R Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: quality of life, symptomatic outcome, and patient satisfaction. J gastrointest surg. 2002;6812- 818
PubMed Link to Article
Carlson  MARichards  CGFrantzides  CT Laparoscopic prosthetic reinforcement of hiatal herniorrhaphy. Dig surg. 1999;16407- 410
PubMed Link to Article
Frantzides  CTMadan  AKCarlson  MAStavropoulos  GP A prospective, randomized trial of laparoscopic polytetraflouroethylene (ptfe) patch repair vs simple cruroplasty for large hiatal hernia. Arch surg. 2002;137649- 653
PubMed Link to Article
Arendt  TStuber  EMonig  HFölsch  URKatsoulis  S Dysphagia due to transmural migration of surgical material into the esophagus nine years after nissen fundoplication. Gastrointest endosc. 2000;51607- 610
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Cinematographic x-ray film showing a "slipped" nissen fundoplication.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Breakdown of the old wrap.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Preparation of the hiatus.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Crural closure.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Placement of the circular mesh.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Fixation with a hernia stapler.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

Creation of the new wrap.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

Completed 360° nissen fundoplication.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 9.

Mean lower esophageal sphincter (les) pressure.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 10.

Mean demeester score.

Graphic Jump Location

Tables

References

Dallemagne  BWeerts  JMJehaes  CMarkiewicz  SLombard  R Laparoscopic nissen fundoplication: preliminary report. Surg laparosc endosc. 1991;1138- 143
PubMed
Arnaud  JPPessaux  PGhavami  B  et al.  Laparoscopic fundoplication for gastro-esophageal reflux: multicenter study of 1470 cases [in french]. Chirurgie. 1999;124516- 522
PubMed Link to Article
Granderath  FAKamolz  TSchweiger  UM  et al.  Long-term results of laparoscopic antireflux surgery: surgical outcome and analysis of failure after 500 laparoscopic antireflux procedures. Surg endosc. 2002;16753- 757
PubMed Link to Article
Lafullarde  TWatson  DIJamieson  GGMyers  JCGame  PADevitt  PG Laparoscopic nissen fundoplication: five-year result and beyond. Arch surg. 2001;136180- 184
PubMed Link to Article
Terry  MSmith  CDBranum  GDGalloway  KWaring  JPHunter  JG Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia. Surg endosc. 2001;15691- 699
PubMed Link to Article
Watson  DIDebeaux  AC Complications of laparoscopic antireflux surgery. Surg endosc. 2001;15344- 352
PubMed Link to Article
Hunter  JGSmith  CDBranum  GD  et al.  Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann surg. 1999;230595- 604
PubMed Link to Article
Hinder  RAKlingler  PJPerdikis  GSmith  SL Management of the failed antireflux operation: surgery of the esophagus. Surg clin north am. 1997;771083- 1098
PubMed Link to Article
Soper  NJDunnegan  D Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann surg. 1999;229669- 676
PubMed Link to Article
Granderath  FASchweiger  UMKamolz  T  et al.  Laparoscopic antireflux surgery with routine mesh-hiatoplasty in the treatment of gastroesophageal reflux disease. J gastrointest surg. 2002;6347- 353
PubMed Link to Article
Huntington  TR Laparoscopic mesh repair of the esophageal hiatus. J am coll surg. 1997;184399- 400
PubMed
Basso  NDe leo  AGenco  A  et al.  360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease. Surg endosc. 2000;14164- 169
PubMed Link to Article
Pointner  RBammer  TThen  PKamolz  T Laparoscopic refundoplications after failed antireflux surgery. Am j surg. 1999;178541- 544
PubMed Link to Article
Hinder  RAFilipi  CJWetscher  GNeary  PDemeester  TRPerdikis  G Laparoscopic nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann surg. 1994;220472- 481
PubMed Link to Article
Cadiere  GBBruyns  JHimpens  JVertruyen  M Intrathoracic migration of the wrap after laparoscopic nissen fundoplication. Surg endosc. 1996;10187
Link to Article
Granderath  FAKamolz  TSchweiger  UM  et al.  Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery? Surg endosc. 2002;16381- 385
PubMed Link to Article
Floch  NRHinder  RAKlingler  PJ  et al.  Is laparoscopic reoperation for failed antireflux surgery feasible? Arch surg. 1999;134733- 737
PubMed Link to Article
Horgan  SPohl  DBogetti  DEubanks  TPellegrini  C Failed antireflux surgery: what have we learned from reoperations? Arch surg. 1999;134809- 817
PubMed Link to Article
Granderath  FAKamolz  TSchweiger  UMPointner  R Failed antireflux surgery: quality of life and surgical outcome after laparoscopic refundoplication. Int j colorectal dis. 2003;18248- 253
PubMed Link to Article
Granderath  FAKamolz  TSchweiger  UMPointner  R Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: quality of life, symptomatic outcome, and patient satisfaction. J gastrointest surg. 2002;6812- 818
PubMed Link to Article
Carlson  MARichards  CGFrantzides  CT Laparoscopic prosthetic reinforcement of hiatal herniorrhaphy. Dig surg. 1999;16407- 410
PubMed Link to Article
Frantzides  CTMadan  AKCarlson  MAStavropoulos  GP A prospective, randomized trial of laparoscopic polytetraflouroethylene (ptfe) patch repair vs simple cruroplasty for large hiatal hernia. Arch surg. 2002;137649- 653
PubMed Link to Article
Arendt  TStuber  EMonig  HFölsch  URKatsoulis  S Dysphagia due to transmural migration of surgical material into the esophagus nine years after nissen fundoplication. Gastrointest endosc. 2000;51607- 610
PubMed Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 32

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections