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Journal Club P.O.W. Hospital

?Division of Short Gastric Vessels at Laparoscopic Nissen Fundoplication. A prospective Double-Blind Randomized Trial with 5 year Follow-Up.". O'Boyle, Watson, Jamieson, Myers, Game,

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Journal Club P.O.W. Hospital

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    1. Journal Club P.O.W. Hospital Monday 12th May 2003 Wendell Neilson Bryan Yeo

    2. Division of Short Gastric Vessels at Laparoscopic Nissen Fundoplication. A prospective Double-Blind Randomized Trial with 5 year Follow-Up. OBoyle, Watson, Jamieson, Myers, Game, & Devitt University of Adelaide, Royal Adelaide Hospital, South Australia Annals of Surgery, 2002 Vol 235, No. 2, pp 165-170

    3. Aim To determine whether division of the short gastric vessels at laproscopic Nissen fundoplication confers any long term clinical benefit to patients.

    4. Method Patients recruited between May 1994 and October 1995, and allocated to either the division or non-division group. If conversion to an open procedure, then the patient remained within their allocated group. 5 year follow-up occurred between July and October 2000, via a telephone interview with a structured questionnaire.

    5. Method Questionnaire inquired about the presence of preoperative symptoms: Heartburn* Epigastric pain Regurgitation Dysphagia/anorexia* Nausea and vomiting Also inquired about: Heartburn control Bloating, and ability to relieve this with belching Excessive flatus Rate outcome of surgery*

    6. Results 102 patients entered into trial: 50 N-D, 52 D. Short term re-operation (<6 months) N-D: 2 lap. para-oesophageal hernia repairs D: 1 laparotomy for bleeding at 6 hours from SGV 1 release of tight hiatal repair at day 5 1 open revision of hiatal scaring at 12 weeks Long term re-operation (>6 months) N-D: 1 revision for slipped fundoplication, 11/12 D: open revision for hiatal stenosis 9/12 1 revision for slipped fundoplication, 6 years

    7. Results At 6 month follow-up no significant difference in symptoms noted on questionnaire Trend to increased bloating in the D group Significantly greater operating time SGV division group. SGV ND: 70.6 min mean, 35-170 min range SGV D: 107.9 min mean, 59-215 min range No significant difference in hospital stay duration.

    8. Results 5 year follow-up with 99 patients (2 deaths and 1 CVA) 49 N-D, 50 D. No significant difference for (p<0.05): Epigastric pain Regurgitation Anorexia Nausea and vomiting Early satiety Ability to belch

    9. Results Significant difference for (p<0.05): Increased flatus production p=0.03 Increased incidence of epigastric bloating p=0.02 Decreased ability to relieve bloating by belching p=0.04 Decreased satisfaction in outcome of surgery In the SGV division group

    10. Discussion Results similar to other prospective trials: Luostarinen et al (n=50) 3 years follow-up Open procedure Increased sliding H.H., and defective wraps with SGV div. Blomquist et al (n=99) 1 year follow-up No significant clinical difference Division limb took longer operative time.

    11. Discussion Surprised by the difference in wind problems SGV division allows a mobile fundus and an application of a floppy wrap. Thus less bloating and flatus. Theorized that afferent nerves that control belch reflex from the stretch in the fundus travel partly with the SGV.

    12. Conclusion Division of short gastric vessels not necessary in laparoscopic Nissen fundoplication, and is associated with a longer operating time and a increased incidence of post-operative bloating and flatus

    13. Critique Positive Allocation to trail arms by blinded, independent person Same standardized questionnaire for all follow-up interviews. 5 year follow-up performed by a person not involved in the initial operation/allocation Close-to 100% patient follow-up

    14. Critique Negative Use of visual analog scale for measuring dysphagia, satisfaction with surgery etc. on a telephone interview. Use of telephone interview rather than face to face questioning No objective measurement of post-op improvement. E.g. pH monitoring or oesophageal manometry.

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