gastroesophageal reflux disease ( gerd ) represents various subclinical and clinical syndromes that with increasing gravity may require several therapeutic approaches for satisfactory management . in the overall management of gerd it offers all the possibilities of traditional surgical intervention that include partial fundopiication , anterior ( dor ) or posterior ( toupet ) and total ( nissen or nissen - rossetti ) fundoplication with crural reapproximation . in addition , the postoperative course is usually more benign with laparoscopic versus open access in both the near- and long - term . however , a reconsideration of surgical indications must be evaluated based on symptom resolution , the incidence of morbidity and mortality , together with local effects , such as dysphagia and the  gas bloat  syndrome . surgical therapy must be viewed in light of generally efficacious medical therapy utilizing antisecretory drugs ( ranitidine and proton pump inhibitors ) . the aim of this study was to reexamine the indications for videolaparoscopic treatment with fundoplication to treat gerd . from 1998 through 2000 , 12 of 58 patients affected by gerd were treated with laparoscopic surgical interventions . most patients were males ( 10 males and 2 females ) with a mean age of 52 years ( range , 45 to 67 ) . the clinical evaluation involved endoscopy , ph - manometry , and upper gastrointerstinal radiographic studies . , symptoms resumed after the suspension of medical therapy that was correctly continued for a prolonged period ( 6 months ) . fundamentally , medical therapy included dietary adjustments , weight loss , antisecretory drugs ( ranitidine , proton pump inhibitors ) , and prokinetic drugs ( table 1 ) . percent incidence of the principal signs and symptoms : retrospective evaluation of the antecedents in the preoperative assessment for possible surgical intervention , the presence of second- or third - degree esophagitis , manometric demonstration of low esophageal sphincter ( les ) pressure or incontinence , and overall the presence or absence of normal esophageal peristalsis were found to be important . moreover , in all cases , demonstrable reflux ( on 24-hour ph monitoring ) and sliding hiatal hernias were found ( table 2 ) . preoperative instrument evaluation the 12 patients selected based on clinical history and physical / laboratory findings underwent laparoscopic nissen fundoplication . in 3 cases , hiatal hernioplasty was also included . the immediate results of this series are characterized by the absence of conversions to laparotomy ; nevertheless , 2 cases of iatrogenic diaphragmatic arterial vessel bleeding occurred that required intraoperative hemostasis maneuvers . mean operative time was 180 minutes ; the mean postoperative stay was 6.2 days ( range , 4 to 11 ) . in our initial experience , we were careful to resume alimentation . the postoperative stay was prolonged for more than 10 days in 3 patients because of severe dysphagia in the postoperative phase that slowly resolved spontaneously within 2 months . worthy of attention is postoperative dysphagia that can be a significant problem as evidenced by its presence in 8 of our patients . it was mild in 5 patients and of short duration ( 41.6% ) but was more serious in 3 patients and took longer to resolve ( 25% ) ( table 3 ) . laparoscopic nissen - rossetti fundoplication : results of 12 patients results were evaluated 6 months postoperatively with instrument and clinical evaluation ( esophagogastroduodenumscopy , ph manometry ) . heartburn resolved entirely in 11 patients ( 91.6% ) ; in only 1 patient did the trouble diminish but not permit the suspension of medical therapy . the central point is represented by hypotonia ( incompetence ) of the lower esophageal sphincter ( les ) to which altered esophageal body motility or a delay of the gastric emptying , or both , can compound the problem . the sliding hiatal hernia is an anatomic alteration that often has little clinical relevance if it is not accompanied by reflux . the anatomicopathological lesions of esophageal mucosa ( esophagitis , columnar metaplasia , and others ) are effects of the prolonged action of acid reflux . all the surgical measures achieve anatomical correction of the esophagocardiac region , which must be followed by a functional result , either the abolition or at least the reduction of gerd . laparoscopic nissen - rossetti fundoplication : six months postoperative follow - up the surgical construction of a fundoplication can be efficacious only for the control of acid gastroesophageal reflux , ie , abolition of heartburn and improvement or healing of lesions directly related to the presence of acid secretions ( esophagitis , metaplasia ) . overall at the exordium , after demonstration of the feasibility and advantages of mini - invasive surgery , the surgical indications for gerd have been suggested but not precisely defined . should there be a wrap and if so , how much ? should a total 360-degree nissen fundoplication be used or perhaps a 270 ( toupet ) , a partial wrap , anterior or posterior fixation , or other ? if preoperative manometry shows normal motility of the esophageal body , a short , floppy nissen fundoplication ( 360 ) is indicated . if , at the level of the esophageal body , untidy contractions of 25% of the total or a mean pressure < 30 mm hg are present , a partial toupet fundoplication ( 270 or 180 ) should be considered because a high risk of dysphagia may exist if a 360-degree wrap is performed . furthermore , alterations of esophageal motility , with a high degree of reflux are not corrected by fundoplication of whatever type and do not alter the postoperative results . the feasibility and advantages of laparoscopic fundoplication in the treatment of gerd have been extensively demonstrated . the failure of surgical treatment for gerd is indicated by the resumption of reflux symptoms along with dysphagia and gas bloat syndrome . a persistence of symptoms related to altered esophageal motility or to a delay in gastric emptying may exist.a mild transitory dysphagia very often follows fundoplication , but it goes on to a spontaneous resolution within 4 to 6 weeks ( 17% to 34% ) . persistent dysphagia ( 4% ) and the gas bloat syndrome are almost always due to a technical error in the construction of the fundoplication ( usually too long and/or too tight or insufficient mobilization of the esophagus and fundus of the stomach . the migration of the wrap , a paraesophageal hernia , or a tight hiatus hernioplasty can also be involved . a surgical approach considered less invasive must not be used unless the appropriate preoperative indications have been established . generally , the persistence of reflux ( and of its symptoms ) , or of often nonspecific symptoms related to abnormal esophageal motility are instead ascribed to an erroneous surgical indication . in fact , some techniques , such as the anterior fundoplication , do not offer sufficient guarantees of success in the treatment of a clinically relevant gerd , but they remain efficacious in some particular situations , such as completion of myotomy or vagotomy . in case of trouble from altered esophageal motility associated with the reflux , we can recognize 2 points of reference : the use of a posterior partial fundoplication and the conviction that the surgical measure , whatever it is ( total fundoplication or posterior partial ) , will only partially modify the clinical scenario . so the condition remains a fundamental point that determines the success of the surgical indication of the gerd . clinical and instrumental data allow the clinician to recognize those patients who will benefit from laparoscopic fundoplication , ie , the presence of gerd with third - degree esophagitis , age < 50 years , presence of typical symptoms , esophageal heartburn with demonstration of a failure of the les , complete resolution of the symptoms with antiacid therapy ( proton pump inhibitors ) . the first with altered motility and esophageal sphincter mechanism requires control of symptoms , and the second merits surgical therapy ( patients with complications of reflux esophagitis , such as intestinal metaplasia with eventual dysplasia and esophageal stenosis ) . the other group , as we indicated above , includes patients with manometric alteration of the esophageal body motility who must be considered separately because fundoplication can provide only partial symptom resolution . today , medical therapy has been shown to be efficacious in the control of gerd , so that the failures of medical therapy are difficult to define and are very few . the fact that the response to medical therapy is satisfactory , for the most numerous group of patients with reflux esophagitis , indicates the success of a surgical procedure because we can assume that all the symptoms are to be attributed only to acid reflux and not , for example , to esophageal body alterations . surgical intervention can be indicated in those intolerant to therapy with proton pump inhibitors , from an incomplete response to medical therapy , or from a desire of the patient to definitively resolve reflux symptoms , to escape from the necessity of chronic drug administration . laparoscopic fundoplication , total or partial posterior , represents in general the best treatment of gerd in select patients . the advantages of a minimally invasive approach ( more rapid and comfortable postoperative course , with less morbidity ) are evident and unanimously accepted ; the local complications remain fixed , and they are the same in both laparoscopy and laparotomy . the efficacy of antisecretory medical therapy ( proton pump inhibitors ) and the limiting criteria of the same , are evident , ie , young age , local side effects , very long administration of the drugs . the success of medical therapy can be used as a predictive criterion of the success of laparoscopic antireflux plasty . among the preoperative instrumental investigations , manometry can identify those patients with les hypotonia along with alterations in esophageal body motility . in this way , a determination can be made of the efficacy of partial antireflux plasties ( toupet ) or a complete 360-degree wrap , the nissen procedure .
background : the aim of the study was to evaluate the indications and surgical techniques for the treatment of gastroesophageal reflux disease.methods:from 1998 through 2000 , we performed gastroesophageal reflux surgery on 12 patients . 
 preoperative studies revealed third - degree esophagitis in most patients with no functional alterations of the esophagus itself . 
 the patients underwent a laparoscopic nissen - rossetti fundoplication . 
 no conversions to open laparotomy were necessary . 
 the mean operative time was 180 minutes.results:no intraoperative or immediate postoperative complications occurred . 
 the mean postoperative stay was 6.2 days . 
 transitory postoperative dysphagia was noted in 8 patients . in 5 patients 
 , it was mild and regressed after 2 weeks ; in 3 cases , it was severe and regressed over 2 months.conclusion:a laparoscopic surgical approach is a satisfactory method for correcting gastroesophageal reflux disease . 
 the efficacy of medical therapy has been well established . however , in the young person who may be required to take medication for many years or in those persons who are intolerant of standard medical therapy for gastroesophageal reflux disease , a surgical intervention is a satisfactory option . the success of medical therapy can be used as a predictive criterion of the success of laparoscopic nissen - rosetti fundoplication when normal motility of the esophageal corpus is present .