World J. Surg. 26, 1106 –1111, 2002 DOI: 10.1007/s00268-002-6247-2 WORLD Journal of SURGERY © 2002 by the Socie ´te ´ Internationale de Chirurgie Dysphagia and Clinical Outcome after Laparoscopic Nissen or Rossetti Fundoplication: Sequential Prospective Study Sandro Contini, M.D., 1 Roberto Zinicola, M.D., 1 Anna Bertelé, M.D., 2 Giorgio Nervi, M.D., 2 Patrizia Rubini, M.D., 1 Carmelo Scarpignato, M.D., D.Sc. 3 1 Department of General Surgery and Organ Transplantation, School of Medicine and Dentistry, University of Parma, Via Gramsci 14, 43100 Parma, Italy 2 Division of Gastroenterology and Digestive Endoscopy, Maggiore University Hospital, Via Gramsci 14, 43100 Parma, Italy 3 Laboratory of Clinical Pharmacology, School of Medicine and Dentistry, University of Parma, Via Gramsci 14, 43100 Parma, Italy Published Online: June 6, 2002 Abstract. Laparoscopic fundoplication represents the most widely used operation in the surgical treatment of gastroesophageal reflux disease (GERD). Besides being operator-dependent, the clinical outcome (efficacy and side-effects) seems also to be dependent on the specific surgical technique. In this prospective trial we compared the results of two groups of patients who were submitted sequentially to the Rossetti or Nissen fundoplication procedure. Dysphagia, other side effects, and clinical out- come were evaluated early after surgery and at 6 and 12 months after the operation. Although both procedures were clinically effective, there was a significant trend toward less postoperative dysphagia in the Nissen group. In these patients the incidence of early dysphagia was significantly lower than that observed in those submitted to the Rossetti fundoplication. In addition, Nissen patients experienced a significantly smaller number of days with dysphagia. One year after surgery, however, the two procedures proved equally successful without any significant difference in dysphagia incidence. Complete fundic mobilization should therefore be advised to reduce the incidence of early troublesome dysphagia. Laparoscopic surgery for gastroesophageal reflux disease (GERD) has replaced the open approach in most centers and is likely to become the standard surgical treatment of this disease, being much more accepted by surgeons and patients. This accep- tance is predicated largely on a shorter length of hospital stay, smaller incisions, and decreased postoperative pain. For surgeons, the advantages of videoendoscopic surgery are realized in the improved exposure to the esophagus through less destructive access while preserving the integrity of the operation [1]. Severe esophagitis, “complicated” Barrett’s esophagus, and incomplete resolution of symptoms or relapses while on medical therapy are indications for surgical intervention [2, 3]. In the past, failure of medical treatment was commonly listed as a reason to proceed with surgical therapy. This indication may no longer be valid in the era of proton pump inhibitors (PPIs) because their efficacy is much greater than that of the H 2 -blockers. In fact, when patients’ symptoms do not respond to PPI therapy, the diagnosis of GERD should be questioned, and a trial of high-dose therapy is war- ranted [4]. Conversely, when an individual is relatively young, has had reflux disease for a long time, and has a mechanically defec- tive esophageal sphincter (which predisposes to frequent recur- rences and predicts the need for continued therapy), surgery should be viewed as an alternative to medical therapy rather than as a “last resort” [2, 3]. There is little doubt that antireflux surgery is an excellent management option for the properly selected patient in the hands of the skilled and experienced esophageal surgeon [3, 5]. On the other hand, there is little doubt that, as practiced, there has been substantial morbidity associated with the suboptimal utilization of antireflux surgery [3, 5]. The risk of postoperative symptoms (especially dysphagia) creates considerable anxiety for surgeons, gastroenterologists, and patients alike [6]. As Fuchs et al. [7] emphasize in their review, experience does matter, especially in the arena of antireflux surgery. Whether or not you are likely to subject a patient to a Nissen or Rossetti fundoplication in the hands of an experienced surgeon, there is compelling evidence for not recommending that a patient be the “occasional case” of the nonspecialized surgeon. Results of surgical management are in- deed operator-dependent. In contrast, no particular expertise is required for prescribing a pill (i.e., a proton pump inhibitor) whose undesirable effects, if any, are trivial and reversible [5]. Besides being operator-dependent, the clinical outcome seems also to be dependent on the specific surgical technique [7, 8]. Most surgeons agree that the crural closure, an adequate posterior window, and a floppy 2-cm wrap are important aspects of the procedure [9], but there is still some controversy about the need for dividing the short gastric vessels (SGV). Some surgeons argue that division of the SGV is not needed to create a loose fundo- plication [10 –14], while others claim that not doing so can lead to a more restrictive wrap, thus increasing postoperative dysphagia [15–17]. This step of the standard Nissen fundoplication [18] has been omitted in the Rossetti modification [19]. Correspondence to: S. Contini, M.D., Department of General Surgery and Organ Transplantation, Maggiore University Hospital, Via Gramsci 14, 43100 Parma, Italy, e-mail: continis@unipr.it