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Keywords:

  • esophagus;
  • laparoscopy;
  • minimally invasive;
  • stomach;
  • surgery

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

Fifty years have seen profound changes in treatment of conditions of the upper gut. The development of the proton pump inhibitors, and the recognition of the role of Helicobacter pylori in peptic ulcer disease rendered surgery for gastroesophageal reflux infrequent, and for peptic ulcer largely redundant. Yet the introduction of laparoscopic (minimally invasive) surgery 20 years ago triggered what can now be regarded as a true revolution in surgery for the gastrointestinal tract. The reduced physical impact of minimally invasive surgery has made operations far more accessible to patients, especially for the elderly and those with comorbidities. Australia has been at the forefront of this revolution, with a rapid uptake and development of techniques, as well as guidelines for safe practice, somewhat ahead of the United States and the United Kingdom. One reason for this has been the close cooperation between gastroenterologists and surgeons in Australia.

In diseases of the upper gut, Australians have led the way in evidence-based research. Australian clinical experience in laparoscopic antireflux surgery and minimally invasive esophagectomy are among the largest in the world. In this brief review, I will highlight some of the most significant achievements in laparoscopic upper gut surgery.

Laparoscopic antireflux and hiatal hernia surgery

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

The earliest laparoscopic fundoplication techniques were reported from Belgium1 and Scotland.2 Dr Les Nathanson, with Professor Alf Cushieri, reported eight patients where large hiatal hernias were laparoscopically repaired and Nissen fundoplication was added.2 The Australian experience began in both Adelaide and Brisbane with the first laparoscopic fundoplications being performed in 1991. In a short-time frame, laparoscopic fundoplications were being performed by groups in Adelaide, Sydney, Brisbane, and Melbourne.

Unlike the experience with laparoscopic cholecystectomy, which was rapidly acquiring a reputation for producing an increased rate of complications, laparoscopic fundoplication tended to be concentrated in large centers in the hands of special interest units. This was probably a reflection of traditional referral practices, where gastroesophageal reflux disease was referred by gastroenterologists and gall stones by general practitioners. There was thus a more cooperative and collegiate approach that ultimately provided a relatively safe environment for the development of technical skills and technology. These were also academic units. In Brisbane and Adelaide large animal preparatory work was carried out before the first operations were performed on humans. From these environments grew detailed prospective databases, peer review, randomized controlled trials and eventually national multicenter trials in laparoscopic antireflux surgery. This period of the 1990s saw fundoplication scrutinized like never before in its 40-year history, so that, over time, the operation was modified and evaluated in clinical trials in an attempt to produce better efficacy and durability with a lower rate of side-effects.

While the aim was to mimic the open procedure, there were initially no definitive published guides to the laparoscopic approach. With technical experimentation and primitive laparoscopic instruments, the first operations took 5–7 h, compared with 45–60 min today. At the time it seemed we were embarking on an operation where for the first time, the surgeon felt worse than the patient at the end of the procedure, and its future role was uncertain. In time, the laparoscopic approach to Nissen fundoplication was shown to be safe, efficacious, and with significantly reduced postoperative pain and hospital stay.3 Moreover, pre- and post-operative objective 24-h pH monitoring studies confirmed a consistent normalization of esophageal acid exposure, from a median 11% to 1%, respectively.4

Long-term efficacy of laparoscopic fundoplication

There has been a prevailing view over time that fundoplication for reflux generally provides only a short-term therapeutic option with a high recurrence rate in the medium and long-term, and a substantial number of patients suffer debilitating side-effects. Our long-term follow-up databases, for the first time, have been able to address these issues. After a minimum of 10 years follow up in 247 patients, the Adelaide group reports a 17% rate of revisional surgery (most operations successfully completed laparoscopically); 84% had good or excellent control of heartburn, and there was an 83% rate of being highly satisfied with the outcomes.5 In Brisbane, a long-term follow-up database was established in 1991 that continues today. Pre- and post-operative symptom scores, quality-of-life (QoL) assessment, and postoperative side-effects are documented by an independent assessor at 1, 3, 5, 10, and 15 years. Symptom recurrence rate is 10% at 5 years and 12% at 10 years (Table 1). Satisfaction rates are also high, at 88%. These results confirm that laparoscopic fundoplication for reflux, in appropriately selected patients, gives excellent short- and long-term results.

Table 1.  Long-term follow up after laparoscopic fundoplication (1991–2008; n = 3982)
  Heartburn (%)Regurgitation (%)Dysphagia (%)
  1. +0 or 1 ‘normal’; 2 or 3 ‘abnormal’.

  2. 10 year satisfaction rate: 88%.

DeMeester score+0/12/30/12/30/12/3
Pre op(n = 3982)138722788020
1 year(n = 3268)946946919
3 year(n = 2508)937937919
5 year(n = 1887)90109010928
10 year(n = 657)881288129010

Partial or full wrap? Division of short gastric vessels at fundoplication?

The long-standing debate about partial versus Nissen (360°) fundoplication was addressed by the Adelaide group. In a randomized controlled trial comparing laparoscopic Nissen versus anterior 180 degree fundoplication, the Adelaide group demonstrated equivalent control of reflux after 10 years, a high patient satisfaction rate, with a lower side-effect rate to 5 years.6–8 After preliminary studies in an animal model, they then pushed the boundaries further by conducting a similar randomized controlled trial of Nissen versus anterior 90° fundoplication9,10 Again, reflux control was similar but with fewer side-effects after the lesser fundoplication. The Adelaide group have now directed a multicenter national trial along similar lines, with early results paralleling their own study.11,12 They have established beyond doubt that partial fundoplication is a viable surgical option that provides equivalent reflux control and has potential for fewer side-effects.

There has been controversy regarding the necessity of dividing short gastric vessels in fundoplication surgery. Again, the Adelaide group has addressed this issue with a randomized controlled trial of division, or not, of short gastric vessels during fundoplication.13 This study definitively demonstrated that complications, reflux control, dysphagia, and patient satisfaction were equivalent, even after 10 years of follow up; this confirms that short gastric vessel division during fundoplication is not necessary.14

Does esophageal motility affect outcome after fundoplication?

Traditional wisdom has taught that fundoplication in patients with motility disturbances risks postoperative dysphagia, making pre-operative motility studies mandatory. Australian groups have again addressed these questions. Pre- and post-operative manometry studies in patients undergoing laparoscopic fundoplication were compared with clinical outcomes, including dysphagia.15 No correlations could be demonstrated. In another study, chronic dysphagia after laparoscopic fundoplication in 846 patients was found to be uncommon (2%).16 In fact, the rate of dysphagia overall was found to be reduced after fundoplication, with no differences in dysphagia rates between patients with non-specific motor disorder, low amplitude or even absent peristalsis. These and other Australian studies have obviated the necessity of mandatory pre-operative manometry, and demonstrate that the prevalence of clinically significant chronic dysphagia after fundoplication is very low.17

Revision laparoscopic fundoplication

Traditionally, revision fundoplication surgery for recurrent reflux has been associated with poor outcomes. In a group of 118 patients having laparoscopic revision fundoplication, 70 operations were performed for recurrent reflux.18 After 1 year, 84% and 87% were heartburn and regurgitation free, respectively. Similarly, in another study of revisional surgery, 86% of patients were satisfied or highly satisfied with the results after 1 year.19 These results demonstrate that laparoscopic revisional antireflux surgery is not only feasible in most cases of recurrent reflux, but that very good outcomes can be expected for the majority of patients.

For postoperative dysphagia, this is best divided into acute and chronic phases. Overall, the prevalence of dysphagia after fundoplication is reduced.20,21 But some patients experience severe dysphagia for the first time after their fundoplication.22 Acute severe dysphagia is experienced by 2% of patients after Nissen fundoplication, and is not predicted by any pre-operative clinical variables, including manometry.22 Early re-operation and conversion to a lesser fundoplication enables quicker return to normality than conservative measures, including serial dilatation.22 Although a ‘tight’ fundoplication or hiatal repair can be identified in some, the majority do not have an identifiable physical obstruction of this nature. The employment of an anterior partial fundoplication as the primary procedure obviates this problem.6

For chronic troublesome postoperative dysphagia, again there is no correlation with pre-operative motility disorders.16 Dysphagia tends to improve throughout the first year postoperatively. Revisional surgery for dysphagia is successful in the majority of cases, but less so than revisional surgery for recurrent reflux, with a satisfaction rate of 75%.18,22 Revision fundoplication for gas bloat has the highest satisfaction rate.18

Laparoscopic repair of para-esophageal or large mixed hiatal hernia

The most prominent contributions in this area have come from Falk and Smith. These hernias often occur in the older age group of patients, and the Sydney group has demonstrated that this surgery is safe in the elderly (no mortality in 35 patients), with acceptable morbidity (17%).23 Further, QoL is significantly improved in these patients. Important long-term objective data have been provided by this group; they document a symptomatic recurrence rate for laparoscopic para-esophageal hiatus hernia repair of 12%.24 Asymptomatic recurrence, documented by barium swallow, occurred in a further 21%. Such studies provide impetus to improve on current repair techniques, for example by employing mesh reinforcement.25 These approaches to clinical studies have been predicated on preliminary large animal studies, following a tradition of careful laboratory studies leading to clinical trials in upper gut laparoscopic surgery in Australia.

Cardiomyotomy for achalasia

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

Prior to the laparoscopic era, the most commonly used method for treatment of achalasia was endoscopic forced balloon dilatation. While achieving an almost universal success rate, the procedure carries a risk of acute esophageal rupture, and patients frequently require a repeat procedure. Shimi, Cushieri and Nathanson reported successful laparoscopic cardiomyotomy in a 30-year-old patient in 1991, demonstrating its feasibility.26 A series of 14 patients was reported by the Adelaide group in 1995, including symptom outcome and esophageal physiology.27 Twelve of 14 had complete resolution of dysphagia, the other two were improved. A low morbidity of the procedure, with an added anterior fundoplasty, was later reported in 82 procedures.28 But in a chronic disease it is longevity of the procedure that counts. After 5 years, 73% of patients were able to consume an unrestricted diet, and the early relief from dysphagia was found to be sustained. The satisfaction rate was 77%.

In an attempt to determine whether a thoracoscopic or laparoscopic approach was superior, Richard Cade in Melbourne compared groups of 17 and 19, respectively. There was no difference found in operating time, complications, length of stay nor efficacy after 2 years, indicating that either approach is valid.29 Given the palliative nature of the surgery and persisting aperistalsis, these are excellent results. Minimally invasive cardiomyotomy with fundoplasty is now the procedure of first choice for achalasia.30

Minimally invasive esophagectomy

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

In Australia, interest in a minimally invasive approach to esophagectomy was stimulated by a lecture from Professor Cushieri at the Royal Australasian College of Surgeons Annual Scientific Congress in Adelaide in 1993. At that meeting, he reported the Dundee experience of 10 cases of thoracoscopically assisted three-stage esophagectomy.31 At the time, we had been trialing and reporting the abdomino-cervical (‘blunt’) esophagectomy in order to avoid the morbidity of thoracotomy,32 which had the distinct disadvantage of lack of visualization of the thoracic structures being dissected. Any new approach needed to be shown to be feasible, safe, and oncologically sound.

In Brisbane, a pilot study was commenced using the Cushieri technique; the aim was to reproduce our standard esophagectomy dissection, but with the thoracoscopic approach. Feasibility and safety were reported in 162 patients, with an inhospital mortality rate of 5.3%.33 We then extended the procedure to combined thoracoscopic and laparoscopic esophagectomy, and included QoL assessment.34 In 25 patients, there were no deaths. Finally, a comparison between traditional open esophagectomy, thoracoscopically assisted and total minimally invasive esophagectomy was undertaken (Table 2).35 A total of 446 patients were included. Inhospital mortality was similar with the three approaches (2.6%, 2.3% and 0%, respectively) and stage-specific survival was no different, confirming oncological equivalence. Advantages of a minimally invasive approach were less blood loss, shorter ICU and hospital stay. These results confirmed that a minimally invasive approach to esophagectomy is acceptable, satisfying all pre-stated criteria of feasibility, safety, and oncological equivalence.

Table 2.  Outcomes comparison between open (O), thoracoscopic-assisted (T-A) and totally minimally invasive esophagectomy (MIE)
 Ivor Lewis (O)T-AMIEP
(154)(409)(25)
  1. ICU, intensive care unit; LOS, length of stay; NS, not significant.

Blood loss (mL)6004003000.017
ICU stay (h)2624190.03
LOS (days)1513110.03
Mortality (%)220NS
Survival, median (months)    
 Stage II A403326NS
 Stage II B232923NS
 Stage II C211619NS

Meanwhile, other centers in Australia have experimented with minimally invasive approaches to esophagectomy. This has included successful combined abdominal, hand-assisted and thoracoscopic Ivor Lewis esophagectomy.36 Later, a three-stage minimally invasive approach was developed with anastomosis in the neck.37,38 Fifty-six patients undergoing minimally invasive esophagectomy were then compared with 98 contemporary patients undergoing conventional open esophagectomy. Results were consistent with the findings of the Brisbane group, where there was less blood loss in the minimally invasive esophagectomy group, shorter ICU stay but with no difference in morbidity or mortality and similar oncologic outcomes.39

Together, the results have established minimally invasive esophagectomy as a comparable and viable option to traditional open resection in the surgical treatment of esophageal cancer.

Laparoscopic adjustable gastric banding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

Morbid obesity is a significant community health issue with a rising prevalence and a predilection to a raft of diseases (diabetes, sleep apnea, cardiovascular disease, cirrhosis) resulting in poor QoL, premature death, and substantial medical costs.40 Although surgical bypass and restrictive procedures historically have been shown to be effective to obtain sustained weight loss and reduction in medical complications of obesity, these operations were performed ‘open’ and carried high rates of morbidity.40 The introduction of the laparoscopic adjustable gastric band provided a new operation for morbid obesity that is minimally invasive, readily reversible and with the potential for reduced morbidity. Its introduction in Australia was overseen by Paul O'Brien and John Dixon in Melbourne and required training and accreditation by surgeons before its use. After medium term follow up (4 years), the operation was found to be effective in achieving 60% of excess weight loss, with short hospital stay and a low morbidity rate.41 The technique was also driven by a Brisbane group, producing similar preliminary results.42

Medical benefits of the laparoscopic adjustable gastric band have included improvement in asthma,43 metabolic syndrome44 (glucose tolerance, dyslipidemia, hypertension), sleep apnea, gastroesophageal reflux,45 diabetes,46 non-alcoholic liver disease,47 and overall QoL.48 A very significant contribution has been a randomized controlled trial of laparoscopic gastric banding versus best medical treatment for morbidly obese patients with diabetes.49 Remission of diabetes of 73% was achieved in the surgical group as opposed to 13% in the medically treated group. Further, the surgical approach was found to be more cost-effective.50 These findings are having a substantial effect on the allocation of medical resources toward the treatment of obesity and diabetes in the public sector.

Other innovations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

Australian surgeons have developed minimally invasive approaches to a range of other upper gut problems. These include laparoscopic gastrectomy for early gastric cancer,51 also applicable to the elderly and advanced gastric cancer for palliation. Laparoscopic resection of gastrointestinal stromal tumors,52 thoracoscopic resection of leiomyoma, diverticula, and long myotomy are also performed. In the case of emergencies, techniques for thoracoscopic repair of esophageal perforation53 and laparoscopic repair of perforated or bleeding peptic ulcer have all been developed.54 Finally, it should be noted that almost all laparoscopic upper gut operations are greatly facilitated by the invention of the Nathanson liver retractor, routinely used throughout the world.55

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References

In this brief review, a range of significant achievements (Table 3) by Australian groups in laparoscopic upper gut surgery have been outlined. Many of these have had international recognition for substantively advancing the field of laparoscopic surgery. There is much to be proud of, not the least being the orderly, safe progression and detailed published documentation of these revolutionary new surgical techniques. This has been achieved in an environment of collegiate cooperation between surgeons and their gastroenterological colleagues.

Table 3.  Chronology of landmark achievements in upper gut laparoscopic surgery in Australia
1990Animal laboratory preparation for laparoscopic fundoplication.
Laparoscopic fundoplication commenced in patients.
1993Thoracoscopic-assisted esophagectomy commenced.
Thoracoscopic repair of ruptured esophagus.
1994Randomized controlled trial—division short gastric vessels.
Single center report of 155 laparoscopic fundoplications.
First Lap Band procedure.
1995Animal studies commenced to refine fundoplication.
Laparoscopic gastric resection reported.
First report of a series of laparoscopic cardiomyotomy for achalasia.
1996Randomized controlled trial of Nissen versus anterior 180° fundoplication.
Report of normalization of acid exposure laparoscopic Nissen fundoplication.
1997Laparoscopic suture repair bleeding duodenal ulcer.
1998Randomized controlled trial of Nissen versus anterior fundoplication.
2004Documentation of natural history of laparoscopic repair large hiatus hernia.
2008Randomized controlled trial of Lap Band versus best medical therapy for diabetes.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic antireflux and hiatal hernia surgery
  5. Cardiomyotomy for achalasia
  6. Minimally invasive esophagectomy
  7. Laparoscopic adjustable gastric banding
  8. Other innovations
  9. Conclusions
  10. References