The effect of the learning curve on the outcome of laparoscopic treatment for gastroesophageal reflux.

The laparoscopic treatment for gastroesophageal reflux (GR) by partial (PF) or total (TF) fundoplication is the current surgical treatment of choice after failure of appropriate medical treatment. The overall results with fundoplication include the initial learning period, during which the rate of complications, conversions, and duration of surgery and hospitalization are assumed to be greater. The aim of this study was to compare the results of laparoscopic treatment for GR in three groups of consecutive patients to determine the effect of the learning period on outcome. One hundred and fifty-six patients (88 men and 68 women) with an average age of 52.3 years (range, 18-78) were included. Surgery was indicated for failure or early relapse after the end of medical treatment or a symptomatic sliding hernia. The preoperative workup (endoscopy, barium meal, or esophageal pH monitoring) was governed by the clinical picture. The choice between TF and PF was based on the results of pH monitoring. Three groups of patients were chronologically defined. The parameters that were examined were the type of preoperative exploration, the type of fundoplication, the operative technique, the conversion rate, the mortality and morbidity rates, the duration of surgery and hospitalization, and the results at short- and medium-term follow-up. The three groups were comparable with respect to patient characteristics and the nature of their GR. All patients had an endoscopy, 91% had a barium meal, 77.5% underwent esophageal manometry, and 67% had pH monitoring. One hundred and thirty-six patients had a TF and 20 had a PF. Rossetti type TF became the reference procedure (67% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between groups I and groups II and III (140, 100, 80 minutes, respectively). The rate of conversion, due to a variety of causes, decreased from 9.8% to 3.8%, and then to 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 15% to 3.8%, and then to 0%. There were seven cases of relapse (4.6%), five in group I (10%) and two in group II (4%), with no cases in group III, although the follow-up in group III was shorter. There is an effect of the learning curve on the outcome of treatment for GR, and this must be taken into account in the training of surgeons (training within experienced departments and guidance during their initial interventions) and also in publications to allow a more accurate comparison of this technique with other treatments for GR.