Achalasia at the Crossroads Between Specialties

Background: Achalasia is a condition that can be treated either by surgery, such as Heller myotomy associated with an antireflux procedure, or by pneumatic dilation, the choice of type of treatment being a widely debated topic nowadays. Methods: We selected patients with the diagnosis of achalasia, calculating the Eckardt score on admission and they were treated by pneumatic dilation, respectively by myotomy associated with fundoplication. Therapeutic success at the end of treatment was analyzed, as well as that in subsequent follow-ups. At the same time, other important aspects of the study were quality of life and complications. Results: Forty-eight patients were included, 20 in the group of those treated by pneumatic dilation, and 28 treated by surgery. The results of the therapeutic success were to the advantage of the surgery, both after the completion of the treatment, and in the follow-ups from one year to 2 years (96.4% vs 90%, respectively 92.9% vs. 85%). The quality of life was better in patients with pneumatic dilation throughout the period. Conclusions: Surgical treatment of achalasia has a higher success rate than pneumatic dilation, but the latter is associated with a better quality of life.

Evaluation of post-operative dysphagia following anti-reflux surgery

BACKGROUND

Anti-reflux surgery (ARS) has known long-term complications, including dysphagia, bloat, and flatulence, among others. The factors affecting the development of post-operative dysphagia are poorly understood. We investigated the correlation of intra-operative esophagogastric junction (EGJ) characteristics and procedure type with post-operative dysphagia following ARS.

METHODS

Robotic ARS was performed on 197 consecutive patients with pathologic reflux utilizing EndoFLIP™ technology. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and high-pressure zone (HPZ) length were collected. Dysphagia was assessed pre-operatively and at 3 months post-operatively.

RESULTS

The median pre-operative DI for all procedures was 2.6 (IQR 1.6-4.5) mm²/mmHg. There was no difference in post-operative DI between procedures [Hill: 0.9 (IQR 0.7-1.1) mm²/mmHg, Nissen: 1.0 (IQR 0.7-1.4) mm²/mmHg, Toupet: 1.2 (IQR 0.8-1.5) mm²/mmHg, Linx: 1.0 (IQR 0.7-1.2) mm²/mmHg, p = 0.24], whereas post-operative HPZ length differed by augmentation type [Hill: 3 (IQR 2.8-3) cm, Nissen: 3.5 (IQR 3-3.5) cm, Toupet: 3 (IQR 2.5-3.5) cm, Linx: 2.5 (IQR 2.5-3) cm, p = 0.032]. Eighty-nine patients (45.2%) had pre-operative dysphagia. Thirty-two patients (27.6%) reported any dysphagia at their 3-month post-operative visit and 12 (10.3%) developed new or worsening post-operative dysphagia [Hill: 2/18 (11.1%), Nissen: 2/35 (5.7%), Toupet: 4/54 (7.4%), Linx: 4/9 (44.4%), p = 0.006]. The median pre-operative and post-operative DI of patients who developed new or worsening dysphagia was 2.0 (IQR 0.9-3.8) mm²/mmHg and 1.2 (IQR 1.0-1.8) mm²/mmHg, respectively, and that of those who did not was 2.5 (IQR 1.6-4.0) mm²/mmHg and 1.0 (IQR 0.7-1.4) mm²/mmHg (p = 0.21 and 0.16, respectively).

CONCLUSIONS

Post-operative DI was similar between procedures, and there was no correlation with new or worsening post-operative dysphagia. Linx placement was associated with higher rates of new or worsening post-operative dysphagia despite a shorter post-procedure HPZ length and similar post-operative DI when compared to other methods of LES augmentation.

[Laparoscopic transhiatal resection of the lower third of the esophagus for late recurrence of achalasia cardia after laparoscopic esophagocardiomyotomy: a 12-year follow-up]

The choice of treatment for recurrence after esophagocardiomyotomy is individual. Repeated esophagocardiomyotomy is appropriate in patients without malignancy and significant deposition of food masses in distal esophagus followed by severe pulmonary complications. Esophagectomy is desirable in case of unadvisable or failed repeated esophagocardiomyotomy. The authors presents laparoscopic transhiatal resection of the lower third of the esophagus (2019) in a patient with recurrent achalasia of the cardia stage 3-4 and cicatricial peptic stricture of the lower third of the esophagus after previous laparoscopic esophagocardiomyotomy with fundoplication (2009). The immediate results of redo surgery and physical status of the patient after 3 years (12-year follow-up) are described.

[Effectiveness of laparoscopic esophagocardiomyotomy combined with various modifications of fundoplication in the treatment of achalasia cardia]

OBJECTIVE

To analyze the results of laparoscopic esophagocardiomyotomy with original fundoplication and Dor fundoplication.

MATERIAL AND METHODS

Laparoscopic esophagocardiomyotomy with fundoplication was performed in 196 patients with achalasia cardia. Patients with achalasia stage 2 comprised 48.5% (95/196), stage 3 - 51.5% (101/196). Two groups were distinguished depending on surgery: Dor fundoplication (group 1, n=53) and Allakhverdyan fundoplication (group 2, n=143). Statistical analysis of data was carried out.

RESULTS

Surgery time in the first group was longer by 35 minutes (p=0.000), blood loss - by 30 ml (p=0.000), postoperative hospital-stay - by 3 days. Pulmonary complications occurred in 34% and 2% of patients, respectively (p=0.002). In the first group, reflux esophagitis in 3 months after surgery was found in 62% of patients, after 6 months - 72%, after a year - in 74% of patients. In the second group, these values were 24%, 8% and 3%, respectively. Dysphagia developed in 2% and 1% of cases, respectively (p=0.767).

CONCLUSION

Dor fundoplication demonstrates unsatisfactory long-term results and should be currently considered as historical stage in surgical treatment of achalasia cardia.

Expanded Indication for Magnetic Sphincter Augmentation: Outcomes in Weakly Acidic Reflux Compared to Standard GERD Patients

BACKGROUND

Magnetic sphincter augmentation (MSA) is a modern surgical anti-reflux technique with proven efficacy and low postoperative morbidity in patients with acidic reflux. The aim of this retrospective review study was to evaluate the symptomatic outcome of MSA in patients with weakly acidic reflux.

METHODS

From a prospectively collected clinical database, comprising all 327 patients that underwent MSA at our institution, a total of 67 patients with preoperative weakly acidic reflux measured in the 24-h impedance-pH-metry were identified. Postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD Health-Related Quality-of-Life (GERD-HRQL), alimentary satisfaction (AS), and patients' overall satisfaction were evaluated within highly standardized follow-up appointments. Furthermore, outcome of these patients was compared to the postoperative outcome of a comparable group of patients with a preoperative acidic reflux.

RESULTS

At a median follow-up of 24 months, none of the patients with weakly acidic reflux presented with persistent dysphagia, or underwent endoscopic dilatation or reoperation. The postoperative GERD-HRQL score was significantly reduced (2 vs. 20; p = 0.001) and the median AS was 9/10. Preoperative daily heartburn, regurgitations, and respiratory complaints were improved in 95%, 95%, and 96% of patients, respectively. A total of 10% of the patients continued to use PPIs postoperatively. No significant difference was observed in terms of postoperative outcome or quality of life when comparing weakly acidic reflux patients with those diagnosed with preoperative acidic reflux.

CONCLUSION

Magnetic sphincter augmentation significantly improves GERD-related symptoms and quality of life in patients with weakly acidic reflux with very low postoperative morbidity.

Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation

BACKGROUND

Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons.

METHODS

Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated.

RESULTS

There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf's alpha <0.30), indicating low to no agreement between providers.

CONCLUSION

In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.

Identification of Lung Transplant Recipients with a Survival Benefit after Fundoplication

BACKGROUND

Gastroesophageal reflux disease (GERD) and aspiration of enteric contents is associated with worse outcomes after lung transplant. The purpose of this study is to elucidate populations that benefit the most from fundoplication after lung transplant.

METHODS

Lung transplants from 2001-2019 (n=971) were retrospectively reviewed and stratified by a fundoplication before (n=128) or after (n=24) chronic lung allograft dysfunction (CLAD) development vs those who didn't. Patients with a fundoplication prior to CLAD were propensity-matched to those without a fundoplication. The primary outcome of interest was post-transplant survival. Time-to-event rates were calculated using a multivariable Cox proportional hazards model and Kaplan-Meier functions.

RESULTS

A fundoplication prior to CLAD improved post-transplant survival before and after propensity-matching, and remained a significant predictor after adjusting for baseline characteristics (HR:0.57, 95% CI:0.4-0.8, P=0.001). Recipients with a restrictive disorder (HR: 0.46, 95% CI:0.3-0.73, P=0.001), age <65 (HR:0.48, 95% CI:0.32-0.71, P<0.001), and both single (HR:0.47, 95% CI:0.28-0.79, P=0.005) or double (HR:0.55, 95% CI:0.32-0.93, P=0.027) lung transplants had a significant decrease in mortality after fundoplication. The effect was present after excluding early deaths and/or CLAD diagnoses. GERD diagnosed by pH, impedance or EGD was not associated with worse outcomes. Among patients with CLAD, a fundoplication was an independent predictor of post-CLAD survival (HR:0.27, 95% CI:0.12-0.61, P=0.002).

CONCLUSIONS

A fundoplication before or after CLAD development is an independent predictor of survival. Younger patients with restrictive disease, independent of the type of transplant, have a survival benefit. GERD diagnosed by conventional methods was not associated with worse survival.

Redo fundoplication and early Roux-en-Y diversion for failed fundoplication: a 3-year single-center experience

BACKGROUND

Redo fundoplication (RF) and Roux-en-Y diversion (RNY) are both accepted surgical treatments after failed fundoplication. However, due to higher reported morbidity, RNY is more commonly performed only after several surgical failures. In our experience, RNY at an earlier point of the disease progression seems to be related with better outcomes. The aim of this study was to investigate this aspect by comparing the results between RF and RNY performed by a single surgeon over 3 years at our institution.

METHODS

A prospectively maintained database was reviewed to identify patients who underwent RF or RNY at our institution between 2016 and 2019 by a single surgeon (author SKM). Patients with previous bariatric surgery were excluded.

RESULTS

Of 43 patients, 28 underwent RF and 15 underwent RNY (mean body mass index 28.6 and 32.7 kg/m², respectively, p = 0.01). The number of previous antireflux surgeries for the RF and RNY groups was 1 (82% vs 80%, p > 0.99), 2 (18% vs 7%, p = 0.4), and more than 2 (0% vs 13%, p = 0.1). RNY took longer than RF (median, 165 vs 137 min, p = 0.02), but both groups had a median estimated blood loss of 50 ml (p = 0.82). There was no difference in intraoperative complications (25% vs 20% for RF and RYN, respectively, p > 0.99). Postoperative complications were more common in the RF than in the RYN group (21% vs 7%, p = 0.39). Median hospital stay was 3 days for both groups (p = 0.78). At short-term follow-up, the mean quality of life score was similar for the RF and RYN groups (11.5 vs 12.2, p = 0.8).

CONCLUSIONS

RNY diversion, if performed by experienced hands and at an earlier point of disease progression, has comparable perioperative morbidity to RF and should be considered as a feasible and safe option for definitive treatment of failed antireflux surgery.

Long-term outcome and efficiency of symptom-selective approach to assess gastroesophageal reflux prior to gastrostomy in neurologically impaired children

PURPOSE

To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children.

METHODS

Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared.

RESULTS

There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods.

CONCLUSION

Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term.

Preferential performance of Thal fundoplication for gastroesophageal reflux disease: a single institution experience

PURPOSE

Nissen fundoplication (NF) is the most commonly used surgical treatment for persistent gastroesophageal reflux disease (GERD). We introduced to the alternative Thal fundoplication (TF) (partial anterior wrapping) in 1998. The purpose of this paper is to review and report on the effectiveness of TF in our department.

METHODS

We retrospectively analyzed cases of 281 patients who underwent TF for GERD at our hospital from 1998 to 2019.

RESULTS

Average age, 16.3 ± 18.1 years; average body weight, 21.0 ± 16.0 kg; average operative time, 89.1 ± 43.0 min; average volume of bleeding, 11.6 ± 29.2 g; enteral feeding commenced after an average of 3.4 ± 1.3 postoperative days (PODs), and average postoperative full enteral feeding was 6.3 ± 1.4 PODs. Five patients (1.8%) had Clavien-Dindo classification III or higher; average hospital stay duration was 10.3 ± 6.0 days, with symptom recurrence affecting 17 patients (6.1%).

CONCLUSION

TF may be an effective and simple treatment for GERD that has few recurrences and avoids complications common to NF, but further studies to compare it with other techniques are needed.

Surgical myotomy and anterior fundoplication for achalasia disease. Short-term outcomes

AIM

Achalasia is a well-known disease among esophageal motility disorders, and all treatments for this disease are aimed at relaxing the lower esophageal sphincter (LES). Recently, endoscopic and surgical myotomy techniques are used more frequently because they give better results than other conservative techniques. In this study, we aimed to present the early results of surgical myotomy and anterior fundoplication techniques in the treatment of achalasia-related dysphagia.

METHODS

Our study enrolled patients who operated with laparoscopic myotomy and anterior fundoplication for achalasia between 2014 and 2019. Patients' demographic and clinical properties, operative details, and postoperative shortterm outcomes were retrospectively analyzed.

RESULTS

A total of 25 patients (11 women, 14 men) were enrolled. The mean age was 40.72±13.6 (range 18-66) years. The mean LES pressure was 26.6±11.2 (range 16-50) mmHg. The mean esophageal myotomy length was 7.83±1.88 (range 7-12 cm). Esophagus perforation developed in one patient during myotomy. The mean time to start oral feeding was 2.56±0.76 (range 2-4) days, and the mean length of hospital stay was 4.96±1.17 (range 3-8) days. During the follow-up, symptom regression was observed in 92 % of patients at the end of a 1-year.

CONCLUSION

According to our results and available literature, myotomy with Dor fundoplication is an effective technique that can be used to treat achalasia disease.

KEY WORDS

Achalasia, Dor fundoplication, Heller myotomy.

Congenital diaphragmatic hernias: Severe defect grade predicts the need for fundoplication

Over one-third of infants with congenital diaphragmatic hernia (CDH) eventually require a Nissen fundoplication (NF). We examined pre- and intraoperative predictors for need of a NF in children undergoing CDH repair to elucidate, which patients will need a later NF.A retrospective analysis of all consecutive patients undergoing CDH repair at our institution from 2008 to 2018 was performed. Patients who underwent a NF were compared to those who did not (noNissen). Logistic regression analysis was performed to find independent predictors for NF in patients undergoing CDH repair. Severe Defect Grade was defined as defect >50% of the hemidiaphragm and intrathoracic liver.One hundred twenty-six patients were included, 42 (33%) underwent NF at a median of 61 days after CDH repair. Intrathoracic liver was more frequent in the NF (71%) versus noNissen (45%) group (P = .008). Absence of >50% of the hemidiaphragm was more frequent in the NF group (76% vs 31%, P < .001). Severe Defect Grade emerged as independent predictor for NF (odds ratio 7, 95% confidence interval 3-16, P < .001).Severe Defect Grade emerged as independent predictor for NF after CDH repair.

Tension-free mesh versus suture-alone cruroplasty in antireflux surgery: a randomized, double-blind clinical trial

BACKGROUND

Antireflux surgery is effective for the treatment of gastro-oesophageal reflux disease (GORD) but recurrence of hiatal hernia remains a challenge. In other types of hernia repair, use of mesh is associated with reduced recurrence rates. The aim of this study was to compare the use of mesh versus sutures alone for the repair of hiatal hernia in laparoscopic antireflux surgery.

METHODS

Patients undergoing laparoscopic Nissen fundoplication for GORD between January 2006 and December 2010 were allocated randomly to closure of the diaphragmatic hiatus with crural sutures or non-absorbable polytetrafluoroethylene mesh (CruraSoft®). The primary outcome was recurrence of hiatal hernia, as determined by barium swallow study 12 months after surgery. Secondary outcomes were: intraoperative and postoperative complications, use of antireflux medication, postoperative oesophageal acid exposure, quality of life, dysphagia and duration of hospital stay.

RESULTS

Some 77 patients were randomized to the suture technique and 82 patients underwent mesh repair. At 1 year, the hiatal hernia had recurred in six of 64 patients (9 per cent) in the mesh group and two of 64 (3 per cent) in the suture group (P = 0·144). Reflux symptoms, use of proton pump inhibitors and oesophageal acid exposure did not differ between the groups. At 3 years, recurrence rates were 13 and 10 per cent in the mesh and suture groups respectively (P = 0·692). Dysphagia scores decreased in both groups, but more patients had dysphagia for solid food after mesh closure (P = 0·013). Quality-of-life scores were comparable between the groups.

CONCLUSION

Tension-free crural repair with non-absorbable mesh does not reduce the incidence of recurrent hiatal hernia compared with use of sutures alone in patients undergoing laparoscopic fundoplication. NCT03730233 ( http://www.clinicaltrials.gov).

[Current status of anti-reflux surgery of proximal gastrectomy for esophagogastric junction tumor]

In recent years, the overall incidence of gastric cancer has been decreasing worldwide, while the incidence of the esophagogastric junction tumor is increasing year by year. With the progress of the diagnostic technology of upper gastrointestinal tumors and the gradual popularization of early cancer screening, the detection rate of early esophagogastric junction tumor keeps increasing. Therefore, in recent years, the clinical application of gastric function preserving surgery is gradually increasing. As an important part of the surgical treatment strategy of esophagogastric junction tumors, proximal gastrectomy has attracted more and more attention with the confirmation of oncological safety. Compared with total gastrectomy, patients after proximal gastrectomy have better nutritional status and quality of life. However, the high incidence of reflux esophagitis after traditional proximal gastrectomy has seriously affected the quality of life of patients, and also hindered the application of proximal gastrectomy in esophagogastric junction tumors. How to reduce the occurrence of reflux esophagitis after proximal gastrectomy by optimizing the method of digestive tract reconstruction has been a big challenge in clinical practice. This article reviews the current methods of anti-reflux surgery for proximal gastrectomy for esophagogastric junction tumors, aiming to provide a reference for choosing a reasonable anti-reflux surgery.

Short-term parent reported recovery following open and laparoscopic fundoplication

BACKGROUND

It is assumed that children recover faster after laparoscopic (LF) than after open fundoplication (OF). As this has not been confirmed in any randomized study (RCT), we have in a subsection of a larger RCT compared parent reported recovery of children after LF and OF.

METHODS

Postoperative symptoms, use of analgesics, overall well-being, and time to return to school/day-care were recorded in a subsection of children enrolled in a RCT comparing LF and OF. Ethical approval and parental consent were obtained.

RESULTS

Fifty-five children (LF: n = 27, OF: n = 28) of the 88 enrolled in the RCT, were included in the short term follow up on parent reported recovery. Caregivers were interviewed median 28 days [interquartile range (IQR) 22-36] postoperatively. There was no significant difference regarding improvement in overall well-being (LF: 63%, OF: 68%, p = 0.70), new-onset dysphagia (LF: 30%, OF: 18%, p = 0.08), use of analgesics (LF: 15%, OF: 14%, p = 1.00), or time to return to school/day-care (LF: median 7 days [IQR 5-14] vs. OF: 12 days [IQR 7-15], p = 0.35).

CONCLUSION

We could not demonstrate faster recovery after LF than after OF. Most children had returned to school/day-care after 2 weeks and had improved overall well-being 1 month after surgery.

TYPE OF STUDY

Randomized controlled trial.

LEVEL OF EVIDENCE

Level II.

Long-term patient satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort: study protocol for a retrospective cohort study with development of a novel scoring system for patient selection

INTRODUCTION

Laparoscopic anti-reflux surgery is standard of care in surgical treatment of gastro-oesophageal reflux disease and is not without risks of adverse effects, including disruption of the fundoplication and postfundoplication dysphagia, in some cases leading to reoperation. Non-surgical factors such as pre-existing anxiety or depression influence postoperative satisfaction and symptom relief. Previous studies have focused on a short-term follow-up or only certain aspects of disease, such as reoperation or postoperative quality of life. The aim of this study is to evaluate long-term patient-satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort using a comprehensive multimodal follow-up, and to develop a clinically applicable scoring system usable in selecting patients for anti-reflux surgery.

METHODS AND ANALYSIS

The study is a retrospective cohort study utilising data from patient records and follow-up with patient-reported quality of life as well as registry-based data. The study population consists of all adult patients having undergone laparoscopic anti-reflux surgery at The Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital Denmark in an 11-year period. From electronic records; patient characteristics, preoperative endoscopic findings, reflux disease characteristics and details on type of surgery, will be identified. Disease-specific quality of life and dysphagia will be collected from a patient-reported follow-up. From Danish national registries, data on comorbidity, reoperative surgery, use of pharmacological anti-reflux treatment, mortality and socioeconomic factors will be included. Primary outcome of this study is treatment success at follow-up.

ETHICS AND DISSEMINATION

Study approval has been obtained from The Danish Patient Safety Agency, The Danish Health Data Authority and Statistics Denmark, complying to Danish and EU legislation. Inclusion in the study will require informed consent from participating subjects. The results of the study will be published in peer-reviewed medical journals regardless of whether these are positive, negative or inconclusive.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03959020).

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repair in regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m² at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.

Use of Impedance Planimetry (Endoflip) in Foregut Surgery Practice: Experience of More than 400 Cases

BACKGROUND

We provide a comprehensive report of our institution's experience with the endoluminal functional lumen imaging probe (Endoflip) impedance planimetry system, a device that can be used intraoperatively to objectively evaluate the distensibility of any sphincter of the gastrointestinal tract. We aim to describe the variety of ways in which the Endoflip can be used in a foregut surgeon's practice.

STUDY DESIGN

This is a retrospective review of a prospectively maintained quality database of all patients in which the functional lumen imaging probe (FLIP) system was used between February 2013 and June 2019.

RESULTS

During the study period, 402 FLIP cases were performed: 226 fundoplications, 94 peroral endoscopic myotomies, 15 peroral pyloromyotomies, 12 antireflux mucosectomies, 11 magnetic sphincter augmentations, 9 laparoscopic Heller myotomies, 8 pre-esophagectomy esophagogastroduodenoscopies (EGDs), 4 diagnostic EGDs, 8 endoscopic Zenker's diverticulotomies, 5 post-peroral endoscopic myotomy EGDs, 8 EGDs with dilations, and 2 transoral incisional fundoplications.

CONCLUSIONS

Within a foregut surgeon's practice, the FLIP can be used to measure the upper esophageal sphincter, lower esophageal sphincter, and pylorus in a variety of clinical scenarios and settings.

Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis

BACKGROUND

Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease.

METHODS

Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease.

RESULTS

Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270°, 360°, anterior 180° and anterior 90°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 270° (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180°, and anterior 90° were equally effective as 360° for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270° (OR 0.38, 95%, CI 0.24-0.60), anterior 90° (moderate quality evidence), and anterior 180° (low-quality evidence) compared to 360°. The odds for gas-bloat were lower after 270° (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90° compared to 360° (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence.

CONCLUSION

Laparoscopic 270° fundoplication achieves a better outcome than 360° total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective.

REGISTRATION NO

CRD42017074783.

Update on the Durability and Performance of Collis Gastroplasty For Chronic GERD and Hiatal Hernia Repair At 4-Year Post-Intervention

BACKGROUND

Collis gastroplasty (CG) remains an important procedure to lengthen the esophagus when indicated in patients undergoing fundoplication for longstanding refractory gastroesophageal reflux disease (GERD) or large hiatal hernias. Concerns over potential sequelae of CG such as dysphagia and worsening heartburn as well as questions regarding the durability of the procedure remain a subject of debate. In this study, 3 and 4-year postoperative data is presented assessing patient quality of life (QOL) measures for those undergoing laparoscopic antireflux surgery (LARS) with and without CG.

METHODS

Comparative review of a prospectively maintained GERD patient database was conducted between patients undergoing LARS with CG versus non-CG (NC) at two institutions between October 2004 and February 2019. Patient demographic, perioperative, and QOL data was analyzed at 3 and 4 years postoperatively using four validated instruments: the Reflux Symptom Index (RSI), Laryngopharyngeal Reflux QOL (LPR-QOL), Swallowing QOL (SWAL), and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQOL) surveys.

RESULTS

A total of 214 CG and 798 NC patients were included in this study. The CG group was older (66.1 ± 12.9 vs. 59.0 ± 14.1, p < 0.001), had a higher frequency of ASA class 3 patients (39.7% vs. 29.7%), and had greater proportion of comorbid disease compared to NG. The groups were parallel in BMI (Collis 28.4 ± 5.2 kg/m² vs. non-Collis 28.6 ± 5.3 kg/m², p = 0.673). Subset analysis revealed persistent benefits through 4 years reflected by survey results in both groups. There were no statistically significant differences in QOL outcomes between CG and NC. A majority of patients in both groups reported discontinuation of antireflux medications and satisfaction with surgical outcomes and symptom control.

CONCLUSION

Long-term QOL outcomes after laparoscopic CG are comparable to patients treated with fundoplication alone in cases of long-standing GERD and hiatal hernias. Furthermore, CG patients enjoyed equivalent durability of the procedure without risk of subsequent dysphagia. Collis gastroplasty remains an important tool in the armamentarium of foregut surgeons.

Congenital intrathoracic stomach can be safely managed laparoscopically

PURPOSE

Congenital intrathoracic stomach (CIS) is an uncommon pediatric surgical diagnosis where > 2/3rd of the stomach lies within the chest through a hiatus defect. We reviewed our recent experience with this condition.

METHODS

A retrospective single-center review of children with a diagnosis of CIS (2007-2018) was performed. Patient demographics, presentation, imaging and management were assessed. Results are expressed as median (range).

RESULTS

Eleven patients (6 girls) were identified with onset of symptoms at 2 (0-26) months of age. Presenting symptoms were vomiting (8/11), respiratory symptoms (4/11) and failure to thrive (2/11). Two patients had Marfan's syndrome. An upper gastrointestinal contrast study demonstrated gastric herniation in all. All were corrected laparoscopically with hiatus repair and fundoplication [age at surgery 10.5 (1.5-34.5) months]. A concurrent gastrostomy was done in children ≤ 6 months (n = 5). Enteral feeds were commenced on post-operative day one in 9 and second post-operative day in 2. At 7 (0-95) months follow-up, all were on full enteral feeds. One patient had a recurrence 6 months post-operatively, which was re-operated laparoscopically without any further recurrence.

CONCLUSION

This is the largest reported series of children with CIS. All could be managed laparoscopically with no conversions and a low recurrence.

Congenital mixed giant hiatal hernia in a four-month-old infant

INTRODUCTION

Congenital hiatal hernia is a rare pathology, presenting at 28 months of age on average. Paraesophageal/mixed hernias cause recurrent respiratory infections, vomiting, anemia, and growth failure.

CLINICAL CASE

Four-month-old infant, with irritability since birth and partial feeding intolerance in the last 24 hours. A partial intrathoracic stomach was evidenced in the esophago-gastro-duodenal contrast study. A thoraco-abdominal CT scan was carried out, with giant mixed hiatal hernia, right posterolateral diaphragmatic hernia, and congenital short esophagus being considered as potential diagnoses. A giant mixed hiatal hernia was noted during surgery. Laparoscopic herniorrhaphy and Nissen fundoplication were performed.

DISCUSSION

In the pediatric population, Bochdalek's hernia and Morgagni's hernia are the most frequent congenital diaphragmatic hernias. Hiatal hernia is rare and causes gastrointestinal symptoms more frequently. Surgery is the treatment of choice, with the objective of preventing or minimizing these symptoms as well as gastric volvulus.

Wrap choice during fundoplication

Gastro-oesphageal reflux disease is an increasing health burden. The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication. The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications. These complications include “gas bloat” and dysphagia and can occur relatively frequently. Various modifications have been described to the original operation and some of these have been described. In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use. This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique. The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms. The advantages and disadvantages of an anterior wrap are discussed. The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.