Laparoscopic or Open Antireflux Surgery - A Comparative Study with Special Reference to the Patient's Perspective

Abstract: The overall aim of this thesis was to compare the effects of laparoscopic versus open antireflux surgery in a randomized clinical trial focusing the patients' subjective and objective outcome postoperatively, from a short-term and a long-term perspective. A further aim was to describe GORD patients' experiences of illness and surgical treatment and if possible to find striking characteristics relating to laparoscopic or open surgery. Sixty patients with Gastro Oesophageal Reflux Disease (GORD) were randomized to laparoscopic or open 360º fundoplication. Subjective evaluations according to disease-specific and generic questionnaires, postoperative protocol, structured interviews, questionnaire and narratives as well as objective evaluations according to endoscopy, oesophageal manometry and 24-h pH monitoring were performed preoperatively, postoperatively, 1 month, 6 months and 5 years after surgery. Five patients were converted to open surgery. Two patients in the laparoscopic group were reoperated on because of hiatal strictures, one patient in the open group was reoperated on because of an incisional hernia and one patient in each group was operated on for having an intestinal obstruction. Operating time was longer for laparoscopic surgery 148 versus 109 minutes for open surgery (P<0.001), analgesics was less 33.9 versus 67.5 mg per total hospital stay for open surgery (P<0.001). Respiratory function was better in the laparoscopic group, FEV 2.6 versus 2.0 litres (P=0.008) and FVC 3.2 versus 2.2 litres (P=0.004); postoperative hospital stay was shorter 3 (2-6) versus 3 (2-10) days (P=0.021) for open surgery. No difference was found in sick leave between the groups. No differences were found in short- or long-term subjective outcomes in diet, sleep, medication, patient satisfaction and symptoms of GORD. Nor were there any differences found in short- or long-term objective outcomes from endoscopy, manometry or 24-h pH monitoring. Dysphagia, flatulence and difficulties to belch were new side-effects independent of type of surgery. Reasons for having surgery were a wish to avoid medication and to rid themselves of troubles and symptoms. All patients suffered from decreased well-being preoperatively that after surgery independent of invasiveness was restored back to or above norm values. Seven patients (25%) in the open group had complaints regarding the scar. The experts, the GORD patients themselves, described human responses to illness, surgical treatment and the outcome. No matter the type of invasiveness; elimination of the GORD symptoms led to increased well-being and for the majority of patients no need for daily acid-suppression medication. These results appeared one month after the operation and were still valid, five years after surgery.