COLLECTIVE REVIEWS
Complications and Results of Primary Minimally
Invasive Antireflux Procedures: A Review of 10,735
Reported Cases
Mark A Carlson,
MD
, Constantine T Frantzides,
MD
,
P
h
D
,
FACS
The number of antireflux procedures performed for gas-
troesophageal reflux disease in the United States has in-
creased in the past decade. In a sampling of US hospitals
by the National Center for Health Statistics, the number
of patients discharged with the International Classifica-
tion of Disease (ICD-9-CM) classification 44.66 (“Oth-
er procedures for creation of esophagogastric sphincteric
competence,” ie, fundoplication) in the years 1988,
1993, and 1998 was 13,000, 22,000, and 40,000, re-
spectively.
1
It would be safe to say that the majority of
these antireflux procedures are now minimally invasive.
The trend for more laparoscopic antireflux procedures
also has been seen in Europe.
2
The current approach of
choice for surgical treatment of gastroesophageal reflux
disease is a minimally invasive transabdominal antireflux
procedure.
3,4
During this evolution of operational ap-
proach there have been untoward events associated with
the minimally invasive antireflux operation. There is a
growing need to audit the results of minimally invasive
antireflux procedures because there has been (in the
medical literature) a question of its efficacy,
5-8
and also
because of the development of novel endoscopic proce-
dures to reproduce a sphincter mechanism in the lower
esophagus,
9,10
which potentially could compete with
laparoscopic antireflux surgery. In this review the results
of primary laparoscopic antireflux procedures will be
examined (international experience, English-language
literature) with an emphasis placed on the description
of perioperative complications and primary proce-
dure failures. Data on redo procedures also will be
analyzed to determine the causes for failure of pri-
mary minimally invasive procedures. Recommenda-
tions for avoiding the complications and failure of the
primary minimally invasive antireflux procedure will
be described.
REVIEW METHOD
A PubMed Medline (National Library of Medicine)
search was performed using various combinations of
these keywords: “gastroesophageal reflux disease,” “anti-
reflux procedure,” “Nissen,” “laparoscopic,” “minimally
invasive,” “reoperation,” and “redo.” A full copy of each
English-language article identified in this search was ob-
tained. Papers that had the primary intent of describing
a clinical series (primary or redo) or trial of antireflux
procedures were chosen for the databases (see subse-
quent text). If an article from a non-English language
journal contained sufficient data in its translated ab-
stract, then the abstract was included in the appropriate
database. In addition, six major surgery journals (Amer-
ican Journal of Surgery, Annals of Surgery, Archives of Sur-
gery, British Journal of Surgery, Journal of the American
College of Surgeons, and Surgery) from 1995 onward were
searched manually for relevant articles not found by the
electronic search.
Two databases of relevant papers were constructed
using Microsoft Excel (Microsoft Corp, Redmond,
WA). Database 1 contained data on primary laparo-
scopic antireflux procedures, and database 2 contained
data from redo operations after a primary minimally
invasive procedure. The tables of data contained in this
review are derived from these two databases. Statistical
analysis was performed within the Excel program.
GENERAL CHARACTERISTICS OF THE
PAPERS REVIEWED
Database 1
More than 400 papers were identified by electronic and
manual searching; ultimately 41 papers, published from
1993 to 2000, were entered into database 1 (primary
procedures), as listed in Table 1. The main criteria for a
paper to be included in database 1 was that the article
No competing interests declared.
Received January 24, 2001; Revised March 6, 2001; Accepted April 5, 2001.
From the Department of Surgery, University of Nebraska Medical Center,
Omaha, NE (Carlson) and the Department of Surgery, Rush University,
Chicago, IL (Frantzides).
Correspondence address: Constantine T Frantzides, MD, PhD, Department
of Surgery, Rush Presbyterian St Lukes Medical Center, Rush Professional
Building, Suite 818, 1725 West Harrison Ave, Chicago, IL 60612.
428
© 2001 by the American College of Surgeons ISSN 1072-7515/01/$21.00
Published by Elsevier Science Inc. PII S1072-7515(01)00992-9