Laparoscopic antireflux surgery: five-year results and beyond in 1340 patients

Molecular and Functional Recovery of Esophageal Barrier Integrity After Laparoscopic Anti-reflux Surgery

BACKGROUND

Patients undergoing laparoscopic anti-reflux surgery (LARS) often experience improved quality of life and reduced gastroesophageal reflux disease (GERD) symptoms. This study aimed to assess the impact of LARS on epithelial remodeling and repair in the esophageal mucosa.

METHODS

Upper gastrointestinal (GI) endoscopy was performed once on healthy controls (HC) and twice on GERD patients before and approximately 6 month after surgery, with esophageal biopsies collected. The expressions of E-cadherin (ECAD), Occludin (OCLN), Claudin 1 (CLDN1), Claudin 4 (CLDN4), Zonula Occludens -1 (ZO-1), and ZO-2 were analyzed in the biopsies, and dilated intercellular spaces (DIS) were examined under light microscopy.

RESULTS

The study included 22 GERD patients who were underwent for LARS, and 20 HCs. All patients had pathological reflux episodes. In the Post-LARS group, TEER increased significantly compared to Pre-LARS and HC (p < 0.05), while mucosal permeability decreased (p < 0.05). A significant negative correlation was found between TEER and permeability (p = 0.0002). DIS remained dilated in both Pre- and Post-LARS patients compared to HC (p < 0.05). Gene expression analysis revealed significant increases in ZO-1, OCLN, and ZO-2 Post-LARS (p < 0.05).

CONCLUSION

LARS improves mucosal integrity by enhancing TEER and reducing permeability in GERD patients, although DIS remains unchanged. The upregulation of tight junction genes such as ZO-1 and OCLN Post-LARS suggests that surgical intervention may support epithelial barrier restoration. DIS remains dilated after LARS; this might be reason that it is not an early marker in GERD pathogenesis. These findings enhance our understanding of GERD nature and may inform future target therapeutic strategies.

Risk Factors for Recurrence of Gastroesophageal Reflux Disease After Laparoscopic Nissen Fundoplication in Patients With Severe Motor and Intellectual Disabilities

PURPOSE

Laparoscopic Nissen fundoplication (LNF) is the standard surgical treatment for gastroesophageal reflux disease (GERD) in patients with severe motor and intellectual disabilities (SMID). It is necessary to prevent the recurrence of GERD because it poses multiple clinical and surgical challenges for these patients. In Japan, the Endoscopic Surgical Skill Qualification System (ESSQS) has been established to ensure technical competency in laparoscopic surgery for pediatric patients. Our aim was to elucidate the risk factors for recurrence of GERD after LNF in pediatric patients with SMID.

METHODS

Fifty patients with SMID who underwent LNF with gastrostomy for GERD at our institution between January 2009 and April 2022 were retrospectively investigated. Recurrence rate and risk factors were examined in univariate and multivariate analyses.

RESULTS

GERD recurred in 5 of the 50 patients (10.0%). In univariate analysis, operation time was significantly longer in the recurrence group than in the non-recurrence group (333 vs. 254 min, p = 0.01). No operations in the recurrence group were performed by an ESSQS-qualified surgeon (p = 0.28). In multivariate analysis, operation time was an independent risk factor for recurrence.

CONCLUSION

Operation time was identified as a risk factor for recurrence of GERD after LNF in patients with SMID.

EVIDENCE

II.

Efficacy and safety of antireflux surgery in gastroesophageal-related cough: a systematic review and meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) is a prevalent condition that manifests a spectrum of symptoms, including gastroesophageal-related cough (GERC). Antireflux procedures have been employed to alleviate these symptoms, yet their efficacy varies. This systematic review and meta-analysis aim to evaluate the improvement in gastroesophageal-related cough and other reflux symptoms following antireflux procedures.

METHODS

A systematic review was performed by searching PubMed, Embase, and Cochrane Library. All observational studies reporting the improvement of GERC and other reflux symptoms after the antireflux procedures. Data were extracted and pooled using a random effects model to assess the overall effect size and heterogeneity between studies. The authors found that antireflux surgery has some clear benefits for common reflux-related symptoms.

RESULTS

Fifty-nine eligible studies with 7431 patients with GERD were included in this study. The pooled cough remission rate was 80.0% (95% CI: 75.4-84.2) and the mean time of follow-up was 35.8 months. Antireflux surgery significantly improved overall reflux-related symptom scores (all P <0.001). The authors also assessed the rate of remission of other reflux symptoms. The pooled heartburn remission rate was 87.7% (95% CI: 82.3-92.2) and the pooled regurgitation remission rate was 91.2% (95% CI: 87.8-94.1).

CONCLUSION

Antireflux procedures significantly improve gastroesophageal-related cough and other reflux symptoms. These findings support the use of antireflux procedures as a viable treatment option for patients with GERD symptoms. Further research is needed to identify predictors of success and to optimize patient selection for antireflux procedures.

Global Transcriptomic Analysis of Topical Sodium Alginate Protection against Peptic Damage in an In Vitro Model of Treatment-Resistant Gastroesophageal Reflux Disease

Breakthrough symptoms are thought to occur in roughly half of all gastroesophageal reflux disease (GERD) patients despite maximal acid suppression (proton pump inhibitor, PPI) therapy. Topical alginates have recently been shown to enhance mucosal defense against acid-pepsin insult during GERD. We aimed to examine potential alginate protection of transcriptomic changes in a cell culture model of PPI-recalcitrant GERD. Immortalized normal-derived human esophageal epithelial cells underwent pretreatment with commercial alginate-based anti-reflux medications (Gaviscon Advance or Gaviscon Double Action), a matched-viscosity placebo control, or pH 7.4 buffer (sham) alone for 1 min, followed by exposure to pH 6.0 + pepsin or buffer alone for 3 min. RNA sequencing was conducted, and Ingenuity Pathway Analysis was performed with a false discovery rate of ≤0.01 and absolute fold-change of ≥1.3. Pepsin-acid exposure disrupted gene expressions associated with epithelial barrier function, chromatin structure, carcinogenesis, and inflammation. Alginate formulations demonstrated protection by mitigating these changes and promoting extracellular matrix repair, downregulating proto-oncogenes, and enhancing tumor suppressor expression. These data suggest molecular mechanisms by which alginates provide topical protection against injury during weakly acidic reflux and support a potential role for alginates in the prevention of GERD-related carcinogenesis.

Medium term (> 12 months) outcomes after laparoscopic hiatal hernia repair without conventional fundoplication using PH4B-mesh implant (Phasix™) in 176 reflux patients: experience and technique

BACKGROUND

Hiatal mesh repair remains a controversial topic among anti-reflux surgeons. Biosynthetic mesh cruroplasty may prevent early recurrence while avoiding late esophageal erosion and strictures associated with non-resorbable materials. So far, medium-term results on hiatal PH4B (Poly-4-Hydroxybutyrate) mesh repair from high-volume centers are lacking.

METHODS

We analyzed the medium-term efficacy and safety of PH4B mesh cruroplasty in 176 consecutive patients (≥ 18 years) with symptomatic hiatal hernias. Treatment failure was defined as the clinical recurrence of reflux symptoms. Patients could choose between mesh augmented hiatal repair (combined with a modified anterior hemifundoplication and fundophrenicopexy), Nissen fundoplication, and magnetic sphincter augmentation at their discretion. We also describe the surgical approach to mesh augmented hiatal repair used at our center.

RESULTS

On average, patients were 55 (± 14) years old and followed up for 22 (± 7; sum: 3931) months. Treatment failed in 6/176 (3%, 95% CI: 2-7%) patients. The 24-month Kaplan-Meier failure estimate was 2.8% (95% CI: 0.4-5%). Each centimeter in hernia size increased the risk of failure by 52% (p = 0.02). Heavier patients (BMI > 27) had an 11% higher probability of clinical symptom recurrence (p = 0.03). The dysphagia and bloating/gas rate were 13/176 (7%), each. 8 (5%) patients required endoscopy due to dysphagia but without intervention. No serious complications, including mesh infection and erosion, or fatalities, occurred.

CONCLUSION

Augmented PH4B mesh cruroplasty without conventional fundoplication shows excellent intermediate-term results in patients with reflux disease due to hiatal hernia. Around one in thirty patients experience treatment failure within 2 years of surgery. Hernia size and overweight are key determinants of treatment failure.

Long-term results after laparoscopic revision fundoplication: a retrospective, single-center analysis in 194 patients with recurrent hiatal hernia

BACKGROUND

After laparoscopic fundoplication, 10-20% of patients experience symptom recurrence-often due to resurgence of the hiatal hernia. The standard surgical treatment for such cases remains laparoscopic revision fundoplication. However, there is little data on the time frame and anatomic patterns of failed fundoplications. Additionally, few large studies exist on the long-term efficacy and safety of laparoscopic revision fundoplication.

METHODS

In a single-center, retrospective analysis of 194 consecutive revision fundoplications for recurrent reflux disease due to hiatal hernia, we collected data on time to failure and patterns of failure of the primary operation, as well as on the efficacy and safety of the revision.

RESULTS

The median time to failure of the primary fundoplication was 3 years. Most hiatal defects were smaller than 5 cm and located anteriorly or concentric around the esophagus. Laparoscopic redo fundoplication was technically successful in all cases. The short-term complication rate was 9%, mainly dysphagia requiring endoscopic intervention. At a mean follow-up of 4.7 years, 77% of patients were symptom-free, 14% required daily PPI, and 9% underwent secondary revision. Cumulative failure rates were 9%, 23%, and 31% at 1, 5, and 10 years.

CONCLUSION

The majority of failed fundoplications occur within 3 years of primary surgery, with most patients exhibiting anterior or concentric defects. For these patients, laparoscopic revision fundoplication is a safe procedure with a low rate of short-term complications and satisfactory long-term results.

Secondary peristalsis and esophagogastric junction distensibility in symptomatic post-fundoplication patients

BACKGROUND

The impact of esophageal dysmotility among patients with post-fundoplication esophageal symptoms is not fully understood. This study aimed to investigate secondary peristalsis and esophagogastric junction (EGJ) opening biomechanics using functional lumen imaging probe (FLIP) panometry in symptomatic post-fundoplication patients.

METHODS

Eighty-seven adult patients post-fundoplication who completed FLIP for symptomatic esophageal evaluation were included. Secondary peristaltic contractile response (CR) patterns and EGJ opening metrics (EGJ distensibility index (EGJ-DI) and maximum EGJ diameter) were evaluated on FLIP panometry and analyzed against high-resolution manometry (HRM), patient-reported outcomes, and fundoplication condition seen on esophagram and/or endoscopy.

KEY RESULTS

FLIP CR patterns included 14 (16%) normal CR, 30 (34%) borderline CR, 28 (32%) impaired/disordered CR, 13 (15%) absent CR, and 2 (2%) spastic reactive CR. Compared with normal and borderline CRs (i.e., CR patterns with distinct, antegrade peristalsis), patients with impaired/disordered and absent CRs demonstrated significantly greater time since fundoplication (2.4 (0.6-6.8) vs. 8.9 (2.6-14.5) years; p = 0.002), greater esophageal body width on esophagram (n = 50; 2.3 (2.0-2.8) vs. 2.9 (2.4-3.6) cm; p = 0.013), and lower EGJ-DI (4.3 (2.7-5.4) vs. 2.6 (1.7-3.7) mm2/mmHg; p = 0.001). Intact fundoplications had significantly higher rates of normal CRs compared to anatomically abnormal (i.e., tight, disrupted, slipped, herniated) fundoplications (9 (28%) vs. 5 (9%); p = 0.032), but there were no differences in EGJ-DI or EGJ maximum diameter.

CONCLUSIONS & INFERENCES

Symptomatic post-fundoplication patients were characterized by frequent abnormal secondary peristalsis after fundoplication, potentially worsening with time after fundoplication or related to EGJ outflow resistance.

Inflammatory responses in esophageal mucosa before and after laparoscopic antireflux surgery

BACKGROUND

Currently, the primary treatment for gastroesophageal reflux is acid suppression with proton pump inhibitors, but they are not a cure, and some patients don't respond well or refuse long-term use. Therefore, alternative therapies are needed to understand the disease and develop better treatments. Laparoscopic anti-reflux surgery (LARS) can resolve symptoms of these patients and plays a significant role in evaluating esophageal healing after preventing harmful effects. Successful LARS improves typical gastroesophageal reflux symptoms in most patients, mainly by reducing the exposure time to gastric contents in the esophagus. Amelioration of the inflammatory response and a recovery response in the esophageal epithelium is expected following the cessation of the noxious attack.

AIM

To explore the role of inflammatory biomolecules in LARS and assess the time required for esophageal epithelial recovery.

METHODS

Of 22 patients with LARS (pre- and post/5.8 ± 3.8 months after LARS) and 25 healthy controls (HCs) were included. All subjects underwent 24-h multichannel intraluminal impedance-pH monitoring and upper gastrointestinal endoscopy, during which esophageal biopsy samples were collected using endoscopic techniques. Inflammatory molecules in esophageal biopsies were investigated by reverse transcription-polymerase chain reaction and multiplex-enzyme-linked immunosorbent assay.

RESULTS

Post-LARS samples showed significant increases in proinflammatory cytokines [interleukin (IL)-1β, interferon-γ, C-X-C chemokine ligand 2 (CXCL2)], anti-inflammatory cytokines [CC chemokine ligand (CCL) 11, CCL13, CCL17, CCL26, CCL1, CCL7, CCL8, CCL24, IL-4, IL-10], and homeostatic cytokines (CCL27, CCL20, CCL19, CCL23, CCL25, CXCL12, migration inhibitory factor) compared to both HCs and pre-LARS samples. CCL17 and CCL21 levels were higher in pre-LARS than in HCs (P < 0.05). The mRNA expression levels of AKT1, fibroblast growth factor 2, HRAS, and mitogen-activated protein kinase 4 were significantly decreased post-LARS vs pre-LARS. CCL2 and epidermal growth factor gene levels were significantly increased in the pre-LARS compared to the HCs (P < 0.05).

CONCLUSION

The presence of proinflammatory proteins post-LARS suggests ongoing inflammation in the epithelium. Elevated homeostatic cytokine levels indicate cell balance is maintained for about 6 months after LARS. The anti-inflammatory response post-LARS shows suppression of inflammatory damage and ongoing postoperative recovery.

Esophageal Motility Patterns in Paraesophageal Hernia Patients Compared to Sliding Hiatal Hernia: Bigger Is Not Better

BACKGROUND

In patients with paraesophageal hernias (PEH), the course of the esophagus is often altered, which may affect esophageal motility. High-resolution manometry (HRM) is frequently used to evaluate esophageal motor function prior to PEH repair. This study was performed to characterize esophageal motility disorders in patients with PEH as compared to sliding hiatal hernia and to determine how these findings affect operative decision-making.

METHODS

Patients referred for HRM to a single institution from 2015 to 2019 were included in a prospectively maintained database. HRM studies were analyzed for the appearance of any esophageal motility disorder using the Chicago classification. PEH patients had confirmation of their diagnosis at the time of surgery, and the type of fundoplication performed was recorded. They were case-matched based on sex, age, and BMI to patients with sliding hiatal hernia who were referred for HRM in the same period.

RESULTS

There were 306 patients diagnosed with a PEH who underwent repair. When compared to case-matched sliding hiatal hernia patients, PEH patients had higher rates of ineffective esophageal motility (IEM) (p<.001) and lower rates of absent peristalsis (p=.048). Of those with ineffective motility (n=70), 41 (59%) had a partial or no fundoplication performed during PEH repair.

CONCLUSION

PEH patients had higher rates of IEM compared to controls, possibly due to a chronically distorted esophageal lumen. Offering the appropriate operation hinges on understanding the involved anatomy and esophageal function of each individual. HRM is important to obtain preoperatively for optimizing patient and procedure selection in PEH repair.

Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication

BACKGROUND

Currently, the reported parameters that predict the resolution of symptoms after surgery are largely subjective and unreliable. Considering that fundoplication rebuilds the structural integrity of the lower esophageal sphincter (LES), the authors focused on searching for objective and quantitative predictors for the resolution of symptoms based on the anatomical issues and whether an antireflux barrier can be well established or not.

MATERIALS AND METHODS

The authors reviewed the prospectively collected data of 266 patients with gastroesophageal reflux disease (GERD) who had undergone laparoscopic Nissen fundoplication (LNF). All patients were diagnosed with GERD using preoperative esophagogastroduodenoscopy, 24-h ambulatory esophageal pH monitoring, and high-resolution esophageal manometry. The patients received GERD symptom surveys using the validated Korean Antireflux Surgery Group questionnaire twice: preoperatively and 3 months after the surgery.

RESULTS

After excluding patients with insufficient follow-up data, 152 patients were included in the analysis. Multivariate logistic regression analyses revealed that a longer length of the LES and lower BMI determined better resolution of typical symptoms after LNF (all P <0.05). Regarding atypical symptoms, higher resting pressure of LES and DeMeester score greater than or equal to 14.7 were associated with better resolution after the surgery (all P <0.05). After LNF, typical symptoms improved in 34 out of 37 patients (91.9%) with a length of LES >greater than .05 cm, BMI less than 23.67 kg/m 2 , and atypical symptoms were resolved in 16 out of 19 patients (84.2%) with resting pressure of LES greater than or equal to 19.65 mm Hg, DeMeester score greater than or equal to 14.7.

CONCLUSION

These results show that the preoperative length and resting pressure of LES is important in the objective prediction of symptom improvement after LNF.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.

METHODS

Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

RESULTS

The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.

CONCLUSION

Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

The Nissen-Hill Hybrid Repair: Experience with the First 500

INTRODUCTION

A new repair for gastroesophageal reflux and hiatal hernia, the Nissen-Hill hybrid repair (HYB), was developed to combine the relative strengths of its component repairs with the aim of improved durability. In several small series' it has been shown to be safe, effective and durable for paraesophageal hernia (PEH) , Barrett's esophagus (BE) and gastroesophageal reflux disease (GERD). This study represents our experience with the first 500 consecutive repairs for all indications .

METHODS

Retrospective study of prospectively collected data for the first 500 consecutive HYB repairs from March 2006 to December 2016 including all indications for surgery. Three quality of life metrics, manometry, radiographic imaging, and pH testing were administered before and at defined intervals after repair.

RESULTS

500 patients with median follow up of 6.1 years. Indications for surgery were GERD in 231 (46.2%), PEH in 202 (40.4%), and re-operative repair in 67 (13.4%). The mean age was 59, with BMI of 30 and 63% female. A minimally invasive approach was used in 492 (98%). Thirty-day operative mortality was 1 (0.2%), with a 4% major complication rate and a median length of stay of 2 days. Preoperative to postoperative pH testing was available for 390 patients at a median follow-up of 7.3 months, with median DeMeester score improving from 45.9 to 2.7. At long-term follow-up (229 responses) all median quality of life scores improved: QOLRAD 4 to 6.9, GERD-HRQL 22 to 3 and Swallowing 37.5 to 45 and proton pump inhibitor use dropped from 460 (92%) to 50 (10%) Fourteen (2.8%) underwent re-operation for failure.

CONCLUSION

The combined Nissen-Hill hybrid repair is safe and effective in achieving excellent symptomatic and objective outcomes and low recurrence rates beyond 5 years.

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.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF).

SUMMARY OF BACKGROUND DATA

Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair.

METHODS

A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%).

CONCLUSIONS

LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up

Background

Various technical modifications of Nissen fundoplication (NF) that aim to improve patients’ outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF.

Methods

283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed.

Results

Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively.

Conclusion

Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF.

Surgical treatment of GERD: systematic review and meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.

METHODS

PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.

RESULTS

From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference =  - 0.51, 95%CI  - 0.63, - 0.40, I² = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I² = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I² = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I² = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I² = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).

CONCLUSIONS

The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.

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).

Esophageal Clearance in Laryngopharyngeal Reflux Disease: Correlation of Reflux Scintigraphy and 24-hour Impedance/pH in a Cohort of Refractory Symptomatic Patients

Objectives

The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (LPR) is poorly understood and remains a controversial issue. The 24-hour impedance monitoring has shown promise in the evaluation of LPR but is problematic in pharyngeal recording. We have shown the utility of scintigraphic studies in the detection of LPR and lung aspiration of refluxate. Correlative studies were obtained in patients with a strong history of LPR and severe GERD.

Methods

A highly selected sequential cohort of patients with a high pre-test probability of LPR/severe GERD who had failed maximal medical therapy were evaluated with 24-hour impedance/pH, manometry and scintigraphic reflux studies.

Results

The study group comprised 34 patients (15 M, 19 F) with a mean age of 56 years (range: 28-80 years). The majority had LPR symptoms (mainly cough) in 31 and severe GERD in 3. Impedance bolus clearance and pH studies were abnormal in all patients in the upright and supine position. A high rate of non-acid GERD was detected by impedance monitoring. LOS tone and ineffective oesophageal clearance were found in the majority of patients. Scintigraphic studies showed strong correlations with impedance, pH and manometric abnormalities, with 10 patients showing pulmonary aspiration.

Conclusion

Scintigraphic studies appear to be a good screening test for LPR and pulmonary aspiration as there is direct visualisation of tracer at these sites. Impedance studies highlight the importance of non-acidic reflux and bolus clearance in the causation of cough and may allow the development of a risk profile for pulmonary aspiration of refluxate.

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.

Management of Recurrent Paraesophageal Hernia

Recurrent symptomatic paraesophageal hernias (PEHs) can lead to significant morbidity if untreated. Surgical treatment of recurrent PEH can pose a great challenge. Several different surgical options are available and need to be considered on an individual basis. Before embarking on the repair of a recurrent hernia, a thorough work-up needs to be completed. Although recurrent PEHs have traditionally been repaired through an open approach, a minimally invasive approach can be performed by surgeons with extensive experience in minimally invasive esophageal surgery. Repair of recurrent PEH provides excellent patient satisfaction and symptoms resolution. Routine follow-up with surveillance imaging can assist in treating recurrent symptoms.

Persistent dysphagia is a rare problem after laparoscopic Nissen fundoplication

BACKGROUND

Although around 30% of patients with gastroesophageal reflux disease (GERD) are insufficiently treated with medical therapy, only 1% opt for surgical therapy. One of the reasons behind this multifactorial phenomenon is the described adverse effect of long-term dysphagia or gastric bloating syndrome after surgical treatment. Aim of this study was to evaluate the most common side effects associated with anti-reflux surgery, as well as long-term outcomes in a large cohort of highly surgically standardized patients after laparoscopic Nissen fundoplication (LNF).

METHODS

Out of a prospective patients' database including all patients that underwent anti-reflux surgery between 01/2003 and 01/2017 at our institution, 350 consecutive patients after highly standardized LNF were included in this study. A standardized interview was performed by one physician assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD-Health-Related-Quality-of-Life (GERD-HRQL), Alimentary Satisfaction (AS), and patients' overall satisfaction.

RESULTS

After a median follow-up of 4 years, persistent dysphagia (PD) after LNF was observed in 8 (2%) patients, while postoperative gas-bloat syndrome in 45 (12.7%) cases. Endoscopic dilatation was needed in 7 (2%) patients due to dysphagia, and 19 (5%) patients underwent revision surgery due to recurrence of GERD. The postoperative GERD-HRQL total score was significantly reduced (2 (IQR 0-4.3) vs. 19 (IQR 17-32); p < 0.000) and the median AS was 9/10. Heartburn relief was achieved in 83% of patients. Eighty-three percent of patients were free of PPI intake after follow-up, whereas 13% and 4% of the patients reported daily and irregular PPI use, respectively.

CONCLUSION

LNF is a safe and effective surgical procedure with low postoperative morbidity rates and efficient GERD-related symptom relief. PD does not represent a relevant clinical issue when LNF is performed in a surgical standardized way. These results should be the benchmark to which long-term outcomes of new surgical anti-reflux procedures are compared.

Anti-reflux procedures: complications, radiologic findings, and surgical and gastroenterologic perspectives

This article provides an overview of the current surgical anti-reflux procedures and their imaging findings, as well as the surgical complications. Accurate and timely clinical assessment requires an engaged radiologist fluoroscopist who understands the perspectives of their interdisciplinary colleagues, including the surgeon and gastroenterologist. The complex pathophysiology calls for an interdisciplinary approach, and the radiologist needs to tailor their evaluation to answer the specific questions posed by their clinical colleagues and by the presenting symptomatology.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

A Modified Technique to Create a Standardized Floppy Nissen Fundoplication Without a Bougie

INTRODUCTION

Nissen fundoplication is frequently applied in the surgical treatment of patients with gastroesophageal reflux disease (GERD). When the gastroesophageal junction remains too large or becomes too narrow, persistent GERD or dysphagia may occur. To assure a correct size of the gastroesophageal junction, the fundoplication can be created over a bougie. However, this increases the risk of esophageal perforation. Therefore, we have modified a previously described technique to create a standardized fundoplication without the use of a bougie. In this article, we describe this technique and demonstrate the initial results.

MATERIALS AND METHODS

We describe a technique to create a standardized Nissen fundoplication. After suture repair of the hiatal hernia, three marking sutures were placed on the gastric fundus, based on an equilateral triangle. The size of this triangle determines the final diameter of the fundoplication. With these measurements, we assure sufficient patency, minimize rotation, and create a more reproducible fundoplication that may reduce postoperative dysphagia.

RESULTS

We have operated 15 patients according to this technique. Mean operative time was 69.5 (SD 8.4) minutes, no complications occurred. There was no early dysphagia and the mean length of stay was 1.3 days (1-2). Quality of life after 1 year was excellent.

CONCLUSIONS

This modified method for standardized Nissen fundoplication is safe and might reduce postoperative dysphagia. Quality of life after 1 year is excellent. The effect on postoperative dysphagia and the reproducibility of this technique should be established in a large prospective study.

Risk factors for delayed gastric emptying following laparoscopic repair of very large hiatus hernias

Background

Delayed gastric emptying can complicate surgery for hiatus hernia. The aim of this study was to quantify its incidence following laparoscopic repair of very large hiatus hernias, identify key risk factors for its occurrence and determine its impact on clinical outcomes.

Methods

Data collected from a randomized trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (more than 50 per cent of stomach in chest) were analysed retrospectively. Delayed gastric emptying was defined as endoscopic evidence of solid food in the stomach after fasting for 6 h at 6 months after surgery.

Results

Delayed gastric emptying occurred in 19 of 102 patients (18·6 per cent). In univariable analysis, type 2 paraoesophageal hernia (relative risk (RR) 3·15, 95 per cent c.i. 1·41 to 7·06), concurrent anterior and posterior hiatal repair (RR 2·66, 1·14 to 6·18), hernia sac excision (RR 4·85, 1·65 to 14·24), 270°/360° fundoplication (RR 3·64, 1·72 to 7·68), division of short gastric vessels (RR 6·82, 2·12 to 21·90) and revisional surgery (RR 3·69, 1·73 to 7·87) correlated with delayed gastric emptying. In multivariable analysis, division of short gastric vessels (RR 6·27, 1·85 to 21·26) and revisional surgery (RR 6·19, 1·32 to 28·96) were independently associated with delayed gastric emptying. Delayed gastric emptying correlated with adverse gastrointestinal symptomatology, including higher rates of bloating, nausea, vomiting and anorexia, as well as reduced patient satisfaction with the operation and recovery.

Conclusion

Delayed gastric emptying following large hiatus hernia repair is common and associated with adverse symptoms and reduced patient satisfaction. Division of short gastric vessels and revisional surgery were independently associated with its occurrence.

Review of antireflux procedures for proton pump inhibitor nonresponsive gastroesophageal reflux disease

Up to 40% of patients with gastroesophageal reflux disease (GERD) report persistent symptoms despite proton pump inhibitor (PPI) therapy. This review outlines the evidence for surgical and endoscopic therapies for the treatment of PPI nonresponsive GERD. A literature search for GERD therapies from 2005 to 2015 in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 2928 unique citations. Of those, 45 unique articles specific to surgical and endoscopic therapies for PPI nonresponsive GERD were reviewed. Laparoscopic fundoplication (n = 19) provides symptomatic and physiologic relief out to 10 years, though efficacy wanes with time. Magnetic sphincter augmentation (n = 6) and transoral incisionless fundoplication (n = 9) improve symptoms in PPI nonresponders and may offer fewer side effects than fundoplication, though long-term follow-up is lacking. Radiofrequency energy delivery (n = 8) has insufficient evidence for routine use in treating PPI nonresponsive GERD. Electrical stimulator implantation (n = 1) and endoscopic mucosal surgery (n = 2) are newer therapies under evaluation for the treatment of GERD. Laparoscopic fundoplication remains the most proven therapeutic approach. Newer antireflux procedures such as magnetic sphincter augmentation and transoral incisionless fundoplication offer alternatives with varying degrees of success, durability, and side effect profiles that may better suit individual patients. Larger head-to-head comparison trials are needed to better characterize the difference in symptom response and side effect profiles.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

Use of acid-suppressive therapy before anti-reflux surgery in 2922 patients: a nationwide register-based study in Denmark

BACKGROUND

Guidelines recommend that patients with gastro-oesophageal reflux disease are adequately treated with acid-suppressive therapy before undergoing anti-reflux surgery. Little is known of the use of acid-suppressive drugs before anti-reflux surgery.

AIM

To determine the use of proton pump inhibitors and H2 -receptor antagonists in the year before anti-reflux surgery.

METHODS

A nationwide retrospective study of all patients aged ≥18 undergoing first-time anti-reflux surgery in Denmark during 2000-2012 using data from three different sources: the Danish National Register of Patients, the Danish National Prescription Register, and the Danish Person Register.

RESULTS

The study population thus included 2922 patients (median age: 48 years, 55.7% male). The annual proportion of patients redeeming ≥180 DDD of acid-suppressive therapy increased from 17.0% 5 years before anti-reflux surgery to 64.9% 1 year before. The probability for inadequate dosing 1 year before surgery (<180 DDD) was significantly increased for younger patients, patients operated in the period 2000-2003, patients who had not undergone pre-surgical manometry, pH- or impedance monitoring, and patients who had not redeemed prescriptions on NSAID or anti-platelet drugs.

CONCLUSION

Compliance with medical therapy should be evaluated thoroughly before planning anti-reflux surgery, as a high proportion of patients receive inadequate dosing of acid-suppressive therapy prior to the operation.

Reoperative antireflux surgery

Patient satisfaction with primary antireflux surgery is high, but a small percentage of patients experience recurrent reflux and dysphagia, requiring reoperation. The major anatomic causes of failed fundoplication are slipped fundoplication, failure to identify a short esophagus, and problems with the wrap. Minimally invasive surgery has become more common for these procedures. Options for surgery include redo fundoplication with hiatal hernia repair if needed, conversion to Roux-en-Y anatomy, or, as a last resort, esophagectomy. Conversion to Roux-en-Y anatomy has a high rate of success, making this approach an important option in the properly selected patient.

Evaluation and management of patients with symptoms after anti-reflux surgery

Over the past two decades, there has been an increase in the number of anti-reflux operations being performed. This is mostly due to the use of laparoscopic techniques, the increasing prevalence of gastroesophageal reflux disease (GERD) in the population, and the increasing unwillingness of patients to take acid suppressive medications for life. Laparoscopic fundoplication is now widely available in both academic and community hospitals, has a limited length of stay and postoperative recovery time, and is associated with excellent outcomes in carefully selected patients. Although the operation has low mortality and postoperative morbidity, it is associated with late postoperative complications, such as gas bloat syndrome, dysphagia, diarrhea, and recurrent GERD symptoms. This review summarizes the diagnostic evaluation and appropriate management of such postoperative complications. If a reoperation is needed, it should be performed by experienced foregut surgeons.

Improvement in quality-of-life after laparoscopic Nissen fundoplication

CONTEXT

Evaluating quality of life after surgery for gastroesophageal reflux is fundamental, since improvement of symptoms is the main goal of treatment.

OBJECTIVE

To compare the satisfaction of patients operated for GERD, interviewed at the office, with patients interviewed by telephone.

METHODS

One hundred and seventy-eight patients were submitted to laparoscopic Nissen fundoplication. Ninety patients were found, and 45 agreed to come to the hospital's office. The other 45 patients were interviewed by telephone. Quality of life was evaluated using three methods: The GERD-HRQL questionnaire, translated to Portuguese; question "If you could choose it today, would you do surgery again?"; and question "If you could classify your symptom improvement between 0 and 10, which grade would you give?" Patients were divided in group A (office interview) and B (telephone interview). Statistical analysis was performed.

RESULTS

The average GERD-HRQL score in group A was 6.29, while in group B was 14.09(P = 0.002). There was no statistical difference between groups A and B regarding patients choice of doing the surgery again(P = 0.714) and their grade of postoperative symptom improvement (P = 0.642).

CONCLUSION

The overall postoperative satisfaction was high. The GERD-HRQL questionnaire might not be suitable for application by telephone in our population, and based on other analyzes, the satisfaction and quality of life of patients interviewed at the office or by telephone was similar.

Laparoscopic repair for failed antireflux procedures

BACKGROUND

Minimally invasive procedures have become common, and more reoperations for failed antireflux procedures are performed laparoscopically. We wanted to study the outcomes of laparoscopic reoperations for reflux.

METHODS

Medical records of all patients who underwent reoperation without esophageal resection after previous antireflux procedures between January 2000 and October 2012 were reviewed.

RESULTS

Seventy-five patients were included in this report: 56 (77%) women and 19 (23%) men. Median age was 58 years. The previous operation was laparoscopic antireflux procedures in 65 (87%) patients. The median interval between the last antireflux procedure and laparoscopic reoperation was 42 months. The median body mass index (BMI) was 28.7. All patients were symptomatic. Intraoperative findings included recurrent hiatal hernia in 47 (63%) patients, incompetent fundoplication in 14 (19%) patients, tight fundoplication in 8 (11%) patients, and tight crura in 2 (3%) patients. Laparoscopic Nissen fundoplication was performed in 57 (76%) patients, partial posterior fundoplication was performed in 12 (16%) patients, partial anterior fundoplication was performed in 3 (4%) patients, removal of crural stitches was performed in 2 patients, and a combination of partial posterior fundoplication and removal of crural stiches was performed in 1 patient. Complications occurred in 13 (15%) patients. Improvement in symptoms was observed in 70 (93%) patients in early postoperative follow-up and in 59 (78%) patients in long-term follow-up. Functional results were classified as excellent in 59 (78%) patients, good in 6 (7%) patients, fair in 7 (8%) patients, and poor in 3 (4%) patients.

CONCLUSIONS

Laparoscopic reoperation for failed antireflux operations is a complex procedure, but it is safe and effective in selected patients. Reoperation after a failed antireflux repair results in excellent or good functional status in a majority of patients, but these results may deteriorate over time.

Short- and long-term results of laparoscopic versus open anti-reflux surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

There is an ongoing debate about whether laparoscopic anti-reflux surgery (LARS) or open anti-reflux surgery (OARS) is the better option for the surgical treatment of gastroesophageal reflux disease (GERD). This study was aimed to evaluate and compare the short- and long-term results of both surgical strategies by means of a systematic review and meta-analysis.

METHODS

A systematic search of electronic databases (PubMed, Embase, The Cochrane Library) for studies published from 1970 to 2013 was performed. All randomized controlled trials (RCTs) that compared LARS with OARS were included. We analyzed the outcomes of each type of surgery over short- and long-term periods.

RESULTS

Twelve studies met final inclusion criteria (total n = 1,067). A total of 510 patients underwent OARS and 557 had LARS. The pooled analyses showed, despite of longer operation time, the hospital stay and sick leave were significantly reduced in the LARS group. Significant reductions were also observed in complication rates for the LARS group in both short (odds ratio (OR) 0.31, 95 % CI 0.17 to 0.56) and long-term periods (OR 0.24, 95 % CI 0.07 to 0.80). Although complaints of reflux symptoms were more frequent among LARS patients in the short-term follow-up, LARS achieved better control of reflux symptoms in the long-term period (P < 0.05). Reoperation rate, patient's satisfaction, and 24-h pH monitoring were all comparable between the two groups (all P > 0.05).

CONCLUSIONS

LARS is an effective and safe alternative of OARS for the surgical treatment of GERD, which enables a faster convalescence, better control of long-term reflux symptoms, and with reduced risk of complications.

Systematic review: Laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors

AIM: To assess laparoscopic fundoplication (LF) in partial responders to proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD).

METHODS: We systematically searched PubMed and Embase (1966-Dec 2011) for articles reporting data on LF efficacy in partial responders. Due to a lack of randomized controlled trials, observational studies were included. Of 558 articles screened, 17 were eligible for inclusion. Prevalence data for individual symptoms were collated across studies according to mutually compatible time points (before and/or after LF). Where suitable, prevalence data were presented as percentage of patients reporting symptoms of any frequency or severity.

RESULTS: Due to a lack of standardized reporting of symptoms, the proportion of patients experiencing symptoms was recorded across studies where possible. After LF, the proportion of partial responders with heartburn was reduced from 93.1% (5 studies) to 3.8% (5 studies), with similar results observed for regurgitation [from 78.4% (4 studies) to 1.9% (4 studies)]. However, 10 years after LF, 35.8% (2 studies) of partial responders reported heartburn and 29.1% (1 study) reported regurgitation. The proportion using acid-suppressive medication also increased, from 8.8% (4 studies) in the year after LF to 18.2% (2 studies) at 10 years. In the only study comparing partial responders to PPI therapy with complete responders, higher symptom scores and more frequent acid-suppressive medication use were seen in partial responders after LF.

CONCLUSION: GERD symptoms improve after LF, but subsequently recur, and acid-suppressive medication use increases. LF may be less effective in partial responders than in complete responders.

Esophageal Calibration with Soft Orogasrtric Tube During Laparoscopic Nissen Fundoplication may Reduce Postoperative Transient Dysphagia

Gastroesophageal reflux is the most common benign disorder of the esophagus and laparoscopic Nissen fundoplication has become the standard surgical treatment for its treatment. In our area, where the use of bougie calibration is debatable, postoperative dysphagia is encountered often after this surgery although it is usually not permanent. The aim of this study was to investigate the effect of using a soft silicone tube 39 F in diameter for esophageal calibration during laparoscopic Nissen fundoplication on the incidence of postoperative dysphagia. We divided cases scheduled to undergo laparoscopic Nissen fundoplication between January 2009 and November 2010 into two groups, each consisting 25 patients. Esophageal calibration with a 39 F silicone orogastric tube was used for the first group while there was no operative calibration in the second group. The surgical duration was recorded; the presence and severity of the postoperative dysphagia was calculated by using a dysphagia severity scoring system during the 1-year postoperative follow-up. The dysphagia severity scores were significantly lower in group 1 than group 2 on the postoperative second day and at the end of the first week and first month. We did not find a significant difference at the end of the 6-month and first year. There was also no significant difference regarding surgery duration. The use of a soft orogastric tube 39 F in diameter for esophagus calibration during laparoscopic Nissen fundoplication has significantly decreased the incidence of postoperative transient dysphagia without affecting the duration of surgery. Although dysphagia gradually resolves in the majority of patients, a safe and easy calibration method for its prevention is worth developing, and we believe that the use of our method in larger series could be beneficial.

Long-term outcomes of reintervention for failed fundoplication: redo fundoplication versus Roux-en-Y reconstruction

BACKGROUND

Redo fundoplication (RF) is the mainstay of treatment for failed fundoplication. A subset of patients with failed fundoplication requires Roux-en-Y reconstruction (RNY) for symptom relief. The aim of this study was to compare the long-term subjective outcomes between RF and RNY in patients with failed fundoplication.

METHODS

After Institutional Board Review approval, retrospective review of a prospective database identified 119 RF (mean = 54.1 years, 78 women) and 64 RNY (mean = 54.8 years, 35 women) patients who underwent reoperative surgery between December 2003 and September 2009. Data variables analyzed included demographics, esophageal manometry, 24-h pH study, type of procedure, perioperative findings, complications, pre- and postoperative symptom (heartburn, regurgitation, dysphagia, and chest pain) scores (scale 0-3), and patient satisfaction score (scale 1-10). Patients with grade 2 and 3 scores were considered to have significant symptoms.

RESULTS

Patients who underwent RNY had a significantly higher body mass index, higher mean number of risk factors, and higher preoperative severity of heartburn and regurgitation compared to the RF group. Of the 183 patients, long-term (>3 years) follow-up was available for 132 (89 RF and 43 RNY) patients. Symptom severity significantly improved after both procedures, with the exception of dysphagia in the RNY group. Overall, there was no significant difference in patients' satisfaction between the RF and RNY groups. In subset analysis, patients with morbid obesity, esophageal dysmotility, or ≥4 risk factors have better satisfaction with RNY compared to RF (p = 0.027, 0.031, and 0.045, respectively).

CONCLUSIONS

RF and RNY have equally good patient satisfaction at 3 years follow-up. RNY may have improved outcomes in patients who are morbid obese, have esophageal dysmotility, or have four or more risk factors.

Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis

PURPOSE

Studies of endoscopic application of radiofrequency energy to the lower esophageal sphincter for gastroesophageal reflux control have produced conflicting reports of its effectiveness. This study aimed to conduct a meta-analysis of randomized controlled trials and cohort studies to assess the impact of this treatment.

METHODS

Twenty studies were included. Outcomes analyzed included gastroesophageal reflux disease (GERD) symptom assessment, quality of life, esophageal pH, and esophageal manometry.

RESULTS

A total of 1441 patients from 18 studies were included. Radiofrequency treatment improved heartburn scores (P=0.001), and produced improvements in quality of life as measured by GERD-health-related quality-of-life scale (P=0.001) and quality of life in reflux and dyspepsia score (P=0.001). Esophageal acid exposure decreased from a preprocedure Johnson-DeMeester score of 44.4 to 28.5 (P=0.007).

CONCLUSIONS

Radiofrequency ablation of the lower esophageal sphincter produces significant improvement in reflux symptoms and may represent an alternative to medical treatment and surgical fundoplication in select patients.

Fundoplication in chronic intractable cough

Background

Airway reflux is a common cause of chronic cough and this is often refractory to medical therapy. Surgery in the form of Nissen fundoplication has been highly successful in the treatment of the classic reflux symptoms of heartburn and dyspepsia. There is a paucity of data regarding response to fundoplication in patients presenting with chronic cough.

Methods

We retrospectively reviewed the case notes of patients from the Hull Cough Clinic who had undergone Nissen fundoplication over the past 6 years. Demographic details, duration of symptoms, presence of other symptoms, results of oesophageal studies, outcome and complications were recorded. Patients were contacted by post and asked to complete a questionnaire detailing current symptoms. In a subgroup with continued troublesome cough 24 hour pharyngeal pH measurements were undertaken.

Results

Forty seven patients underwent fundoplication. The average duration of pre-operative cough was 8 years. Gastro intestinal symptoms were present in the majority. In 30 (64%) patients a positive response to treatment was recorded. Mild dysphagia or bloating was seen in 18 patients following surgery. Four patients needed repeat surgical intervention for modification of fundoplication. One patient developed aspiration pneumonia eight weeks following surgery and died of a myocardial infarction. Two thirds of patients with persisting cough had evidence of airway reflux on pharyngeal pH monitoring.

Conclusion

In these patients with intractable cough a long term response rate of 63% represents a useful therapeutic option. Treatment failure is more frequent than for classic peptic symptoms and may be related to persistent gaseous reflux.