Post-Nissen Dysphagia and Bloating Syndrome: Outcomes After Conversion to Toupet Fundoplication

Experience With an Innovative Surgical Treatment Option for Gastroesophageal Reflux Disease: Results of 28 Patients in a Retrospective Analysis

Introduction: Standard-of-care gastroesophageal reflux disease (GERD) procedures are associated with adverse events (AEs) (i.e., dysphagia, gas-bloating). RefluxStop has been developed to circumvent these outcomes. This study presents the results of 28 patients managed with RefluxStop in Germany. Methods: Between July 2021 and November 2023, 28 patients with GERD underwent RefluxStop surgery, a novel laparoscopic antireflux procedure. Retrospective chart analysis with patient-informed consent was conducted to determine clinical outcomes, such as GERD Health-Related Quality of Life (GERD-HRQL) score, proton pump inhibitors (PPI) use, symptomatology, patient satisfaction, and perioperative AEs. Results: Baseline characteristics (n = 28): age 47 ± 13.1 years; 67.9% female; body mass index (BMI) 27.3 ± 4.1 kg/m2; 93% PPI use for 5.6 ± 2.7 years; and hiatal hernia in 100% of cases of mean (standard deviation [SD]) size 3.4 (0.8) cm, whereof 35.7% were large hiatal hernia (4-6 cm). At a mean (SD) follow-up of 14.1 (4.7) months, patients experienced 88.6% improvement in median (IQR) total GERD-HRQL score from a baseline of 35 (7.7) to 4 (4.2) at follow-up (P < .05). Preoperative dysphagia (35.7%) resolved completely in all patients (P < .001). The mean (SD) GERD-HRQL heartburn subdomain decreased by 90.6% from a baseline of 18.1 (6.1) to 1.7 (1.2) at follow-up and all patients (100%) had scores <5. Similarly, the mean (SD) regurgitation subdomain decreased from a baseline of 13.2 (4.7) to 2 (1.6) at follow-up and all patients (100%) had scores <5. Patient satisfaction was achieved in 96.4% of patients with no PPI use required in 93% of patients (P < .001); only one patient required PPIs for persistent GERD symptoms. No cases of reoperation or esophageal dilatation were performed. Minor intraoperative AEs occurred in seven patients (i.e., neck emphysema). Conclusion: RefluxStop provides excellent safety and effectiveness outcomes for GERD treatment. Dysphagia completely resolved (0%) with 88.6% improvement in median GERD-HRQL score and satisfaction achieved in 96.4% of patients. These promising results reproduced the outcomes noted in the RefluxStop CE trial in real-world settings.

One-year outcomes of biological mesh in hiatal hernia repair: a real-world study

PURPOSE

The placement of synthetic mesh during laparoscopic hiatal hernia repair has been verified to reduce postoperative recurrence, but mesh erosion and other related complications may occur to synthetic mesh, and our aim was to verify the safety and efficacy of biological mesh in hiatal hernia repair.

METHODS

Patients with hiatal hernia who were treated at a tertiary teaching university hospital from December 2020 to May 2023 were prospectively included in this study. General clinical data, hernia-related data, and intraoperative data were collected, and the patients were followed up at 1, 3, 6, and 12 months after surgery, after 12 months, follow-up as needed for primary outcome until September 2024. The following parameters were recorded during follow-up visit: gastroesophageal reflux symptoms, Gastroesophageal reflux disease-Health related quality of life (GERD-HRQL) questionnaire, postoperative recurrence, mesh-related complications and patients' overall satisfaction.

RESULTS

A total of 82 patients with hiatal hernia were included in this study. The mean age of the patients was 62.68 ± 15.93 years, mean BMI 24.81 ± 4.05 kg/m2, the average operation time was 128.21 ± 39.20 min. There was statistically significant improvement of GERD symptom postoperative (p<0.05). 72 cases (93.5%) were rated as "Great" on the GERD-HRQL at the 12 months after surgery; 65 cases (84.4%) were rated as "very satisfactory" on the overall satisfaction scale at the 12 months after surgery. 6 patients (7.3%) experienced recurrences, with no mesh-related complications reported during the follow-up.

CONCLUSION

At a mean follow-up of 25.43 ± 10.38 months, the present study showed that laparoscopic hiatal hernia repair with biologic mesh results in low rates of 1-year recurrence and complications and increased patient satisfaction.

Acid Reflux Management with the RefluxStop Implant: A Prospective Multicenter Trial with 3-Year Outcomes

BACKGROUND

RefluxStop is a unique implant for laparoscopic treatment of gastroesophageal reflux disease (GERD). It restores normal function of the gastroesophageal junction without the unwanted effects of encircling the esophagus, circumventing adverse events (AEs) associated with conventional anti-reflux surgeries.

METHODS

Three-year follow-up of 50 patients with chronic GERD treated by RefluxStop was achieved in a prospective, single-arm, multicentric clinical trial analyzing safety and effectiveness of the procedure.

RESULTS

The 3-year results included 47 of 50 patients. No cases of device-related AEs, erosion, device migration, or explantation occurred during the entire study period. Two AEs were reported between the 1- and 3-year results (1-year results previously published), including mild dysphagia (n = 1) and heartburn (n = 1). No subjects (n = 0/47) required regular daily proton pump inhibitor (PPI) therapy at 3-year follow-up. Subjects experienced a 93.1% reduction in median total GERD-HRQL score at 3 years (2.0) from baseline (29.5). One subject (n = 1) was dissatisfied with treatment but demonstrated normal 24-h pH monitoring results. Daily regurgitation improved by 97.9% from a baseline of 86% (n = 43/50) to 2.1% (n = 1/47) at follow-up. Dysphagia GERD-HRQL subscore of > 2 (i.e., bothersome everyday) decreased from 22% at baseline to 2% at 3 years. Baseline odynophagia (16%) completely resolved at 3 years.

CONCLUSION

RefluxStop surgery treats GERD without encircling and applying pressure on the esophagus. Three-year follow-up demonstrates that the device is safe and effective in treating GERD with substantial improvements in quality of life via GERD-HRQL (median improvement 93%), PPI usage (0%), and 98% without dysphagia.

Therapeutic Management of Gastroesophageal Reflux Disease (GERD)-Is There Something Between PPI and Fundoplication? An Overview

Gastroesophageal reflux disease (GERD) affects millions globally, with traditional treatments like proton pump inhibitors (PPIs) and surgical fundoplication presenting challenges such as long-term medication dependency and disturbing long term side effects following surgery. This review explores emerging, alternative therapies that offer less invasive, personalized alternatives for GERD management. Endoscopic approaches, including Stretta therapy, transoral incisionless fundoplication (TIF), and endoscopic full-thickness plication (EFTP), demonstrate promising but also controversial outcomes in symptom relief and reduced acid exposure. Laparoscopic electrical stimulation therapy (EndoStim®) and the LINX® magnetic sphincter augmentation system address LES dysfunction, while endoscopic anti-reflux mucosectomy and/or ablation techniques aim to construct a sufficient acid barrier. The RefluxStop™ device offers structural solutions to GERD pathophysiology with intriguing results in initial studies. Despite promising results, further research is required to establish long-term efficacy, safety, and optimal patient selection criteria for these novel interventions. This review underscores the importance of integrating emerging therapies into a tailored, multidisciplinary approach to GERD treatment.

Robotic versus laparoscopic revision to Toupet fundoplication for failed Nissen fundoplication: a single-center experience

Nissen fundoplication (NF) is a common surgical procedure to treat gastroesophageal reflux disease; however, a subset of patients may continue to experience symptoms or develop symptom recurrence despite a successful procedure. This study aims to compare laparoscopic and robotic approaches for treating failed NF and evaluate the outcomes after converting to Toupet fundoplication (TF). We conducted a retrospective analysis of patients who underwent robotic or laparoscopic revision to TF for failed NF between 2016 and 2023. The data collected included demographics, pre-operative workup, and peri- and post-operative outcomes. Symptom analysis and anti-reflux medication usage were collected using a patient questionnaire. Failed fundoplication was defined as the need for an additional operation due to unresolved GERD symptoms or the emergence of a new issue. Eighty-eight patients (56 laparoscopic, 32 robotic) were included. Mean operative time was 148.71 ± 53.64 min for the total cohort and was significantly longer in the robotic group (RG) 167.43 min vs 138.01 min in the Laparoscopic group (LG) (p value = 0.012). The LG had a length of hospital stay of 2.16 ± 1.69 days vs RG 2.21 ± 1.28 days (p value = 0.867). The LG had a higher number of early readmissions (5.4%, p value = 0.629) and both the LG and the RG had 1 patient that required an early reintervention. Symptoms of dysphagia and reflux decreased in both groups at last follow-up, but the reduction in PPI use was not significant. Surgical revision to TF for failed NF provides significant symptom improvement with low rates of complications and recurrences. Our study shows that both approaches are safe and feasible and have comparable surgical and symptom outcomes.

Regurgitation, eructation, and supragastric belch: retrograde esophageal motility, disorders, and treatment

PURPOSE OF REVIEW

This review describes pathologic conditions of retrograde flow into the esophagus along with recent therapeutic advances and treatment options.

RECENT FINDINGS

The esophagus facilitates anterograde and retrograde movement of contents, the latter of which is mediated by transient lower esophageal sphincter relaxations (TLESRs). Gastroesophageal reflux disease (GERD) often includes esophageal-specific symptoms such as heartburn or regurgitation. Volume regurgitation responds less frequently to acid suppression with proton pump inhibitors (PPIs) than heartburn, given its relationship with incompetence of the esophagogastric junction (EGJ) and increased frequency of TLESRs. Therefore, although the refluxate pH can be altered with PPIs, the frequency of reflux episodes is generally not reduced and surgical and endoscopic treatments may be favored. Other instances of abnormal retrograde esophageal flow respond better to medical therapy, or lifestyle interventions. Compared to gastric belching because of increased stomach distension, supragastric belching is caused by intake of air from pharynx into the esophagus followed by rapid expulsion of air. These conditions can be distinguished on esophageal tests such as high-resolution manometry and are likely to respond to behavioral modifications.

SUMMARY

Retrograde flow into the esophagus can be a normal occurrence, but diagnostic testing to distinguish causes can guide appropriate intervention.

Exploring the feasibility and safety of laparoscopic anti-reflux surgery with the new RefluxStop™ device: a retrospective cohort study of 40 patients

AIMS OF THE STUDY

Anti-reflux surgery aims to restore the anti-reflux barrier and reduce the retrograde flow of stomach contents. However, traditional surgical techniques generally involve some degree of encircling of the oesophagus, which can result in adverse effects such as dysphagia and the inability to belch or vomit. Based on the first published results, a novel surgical technique - with the RefluxStop™ device - appears promising for treating gastroesophageal reflux disease (GERD) with minimal postoperative dysphagia. This study describes the initial clinical experience with this procedure in a cohort of patients with chronic gastroesophageal reflux disease to evaluate its feasibility and safety in clinical practice.

METHODS

This retrospective cohort study examined the first 40 patients who underwent laparoscopic anti-reflux surgery with the RefluxStop™ device at a private hospital in Switzerland. The procedure involves implanting a nonactive device on the outside of the gastric fundus to stabilise a narrow oesophagogastric plication. Feasibility was assessed based on the proportion of patients in whom the device could be successfully implanted, with a discussion of the operative details. Intraoperative and postoperative complications, adverse effects, and changes in gastroesophageal reflux disease-related quality of life (GERD-HRQL questionnaire) are also reported.

RESULTS

Between May 2020 and April 2022, 40 patients underwent elective surgery for laparoscopic hiatal hernia repair and RefluxStop™ device implantation. All patients had typical symptoms of gastroesophageal reflux disease, such as heartburn and regurgitation; 20 (50%) had preoperative dysphagia. Laparoscopic surgery was feasible in all patients except one who required laparotomy due to adhesions and associated bleeding when accessing the abdomen. The median operating time was 57.5 minutes (interquartile range = 51.75-64.25 minutes) with no device-related intraoperative or postoperative complications. All patients were imaged one day and three months postoperative, confirming the correct placement of the device. Reflux symptoms (heartburn and acid regurgitation) were significantly improved in all patients at three months (p <0.0001).

CONCLUSION

These preliminary results support the feasibility and safety of introducing this novel laparoscopic anti-reflux surgical treatment option in clinical practice.

Laparoscopic Large Hiatal Hernia Repair With RefluxStop: Outcomes of Six Months Follow-up in Thirty Patients

OBJECTIVE

The antireflux surgical technique with the RefluxStop device is one of the latest approaches to treating patients with gastroesophageal reflux disease (GERD). The aim of this study was to assess the safety and feasibility of laparoscopic hiatal hernia (HH) repair with the RefluxStop device in patients with GERD and concurrent large HH (≥4 cm).

PATIENTS AND METHODS

A retrospective chart review was performed for the first 30 patients with a large HH who consented and underwent HH surgery with the RefluxStop device. The operative technique and outcomes were evaluated to assess safety and feasibility, HH recurrence, dysphagia, and patient satisfaction.

RESULTS

Between May 2020 and April 2022, 30 patients underwent laparoscopic HH repair with the RefluxStop device. All patients had typical symptoms of GERD, such as heartburn and regurgitation, and 15 patients (50%) had preoperative dysphagia. Median HH size was 5 cm (interquartile range, 4 to 5). Median operating time was 56 minutes (interquartile range, 52 to 63), with no intra and postoperative complications related to the device. One patient required laparotomy due to adhesions and associated bleeding when accessing the abdomen. All patients had postoperative imaging (video fluoroscopy) on postoperative day 1 and at 3 months, confirming the correct location of the RefluxStop device. One patient (3.3%) needed postoperative balloon dilatation due to severe dysphagia. Reflux symptoms (heartburn and acid regurgitation) resolved significantly in all patients ( P < 0.001) at 6 months. One episode of recurrence of HH (3.3%) occurred during the follow-up period of 6 months.

CONCLUSION

This study demonstrates the short-term safety and feasibility of laparoscopic HH repair with the RefluxStop device in patients with large HH, with a low rate of postoperative dysphagia and subsequent improvement or resolution of reflux symptoms in all patients.

Short-term results of laparoscopic anti-reflux surgery with the RefluxStop device in patients with gastro-esophageal reflux disease and ineffective esophageal motility

PURPOSE

In gastro-esophageal reflux disease (GERD) requiring surgical treatment, concomitant ineffective esophageal motility (IEM) is a decisive factor in surgical planning, due to concern regarding dysphagia. Anti-reflux surgery with the RefluxStop device is a promising technique. We assessed initial feasibility and clinical outcomes of RefluxStop surgery in patients with GERD and IEM.

METHODS

Retrospective analysis of patients with GERD, hiatal hernia (HH), and IEM, who underwent surgery with RefluxStop at our institution and achieved 12-month follow-up. Technique feasibility was assessed, in addition to symptom resolution (GERD-HRQL questionnaire), adverse events, HH recurrence, dysphagia, and patient satisfaction. Placement of the device was confirmed by video fluoroscopy on postoperative day 1, and at 3 and 12 months.

RESULTS

Between June 2020 and November 2022, 20 patients with IEM underwent surgery with RefluxStop and completed 12-month follow-up. All patients reported typical symptoms of GERD, and 12 had preoperative dysphagia. The median HH length was 4.5 cm (IQR, 3.75-5). The median operating time was 59.5 min (IQR, 50.25-64) with no implant-related intra- or postoperative complications. No HH recurrence was observed. One patient reported persistent left-sided thoracic pain at 11 months post-surgery, which required diagnostic laparoscopy and adhesiolysis. Three patients reported severe postoperative dysphagia: balloon dilatation was performed towards resolution. The mean GERD-HRQL scores improved (from 40.7 at baseline to 4.8 at 3 months and 5.7 at 12 months (p <0.001)).

CONCLUSION

RefluxStop surgery was feasible and offered effective treatment for this group of patients with GERD and IEM. All patients had complete resolution or significant improvement of GERD symptoms, and 90% of them were satisfied with their quality of life 1 year after surgery.

A Tailored Approach to Laparoscopic Fundoplication: Outcomes in Patients with Esophageal Dysmotility

BACKGROUND

Esophageal dysmotility is a common finding in patients being evaluated for antireflux surgery, although its implication remains unclear. We aimed to evaluate outcomes of patients with esophageal dysmotility after fundoplication.

METHODS

A retrospective review of a prospective quality-database was performed. All patients who underwent laparoscopic Nissen (NF) or Toupet (TF) fundoplication were included. Esophageal dysmotility was defined using the Chicago Classification v4.0 and conventional metrics, creating three sub-groups: ineffective esophageal motility (IEM), distal/diffuse esophageal spasm (DES), and hypercontractile esophagus (HE). Quality of life (QOL) outcomes were measured by the Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Scores.

RESULTS

Of 487 patients included, 99 (20.3%) had esophageal dysmotility (49 IEM, 40 DES, 10 HE). While a majority in the dysmotility group (81.8%) underwent TF, most patients in the normal group (76.5%) underwent NF (p < 0.001). On multivariable analysis controlling for sex, age, BMI, hiatal hernia, and surgery type, the normal group had higher Dysphagia Scores at 3 weeks (2.2 ± 0.9 vs. 1.7 ± 0.8, p < 0.001), but not at 6-month, 1-year, 2-year, or 5-year follow-up. There were no differences between normal and dysmotility groups in terms of RSI or GERD-HRQL scores at any time point. Patients with different sub-types of esophageal dysmotility had similar QOL outcomes at all time points.

CONCLUSION

Patients with esophageal dysmotility had similar outcomes compared to those with normal motility after fundoplication, suggesting the tailored approach favoring partial fundoplication for patients with dysmotility as part of an appropriate treatment algorithm.

A Rare Occurrence of Rotational Retro-Esophageal Gastric Body Herniation Through a Nissen Fundoplication

Anti-reflux procedures have become a mainstay in managing gastroesophageal reflux disease (GERD) and hiatal hernia. Unfortunately, post-operative events such as breakdown of the wrap, downward slippage, or transdiaphragmatic herniation of an intact wrap cause these procedures to fail and create complications such as recurrent hiatal hernia and reflux dysphagia, regurgitation, and obstruction requiring revision surgery. We discuss a case of a rotational retro-esophageal herniation of the gastric body through a Nissen fundoplication presenting as obstruction, dysphagia, and regurgitation, highlighting the peculiar nature of this presentation and the ease of misdiagnosis given its rarity.

OUP accepted manuscript

Background

Fundoplication is an essential step in para-oesophageal hernia (POH) repair, but which type minimizes postoperative mechanical complications is controversial.

Methods

This was a randomized, double-blind clinical trial conducted between May 2009 and October 2018. Patients with symptomatic POH were allocated to either a total (Nissen) or a posterior partial (Toupet) fundoplication after hernia reduction and crural repair. The primary outcome was dysphagia (Ogilvie dysphagia scores) at 6 months postoperatively. Secondary outcomes were peri- and postoperative complications, swallowing difficulties assessed by the Dakkak dysphagia score, gastro-oesophageal reflux, quality of life (QoL), and radiologically confirmed hernia recurrence.

Results

A total of 70 patients were randomized to a Nissen (n = 32) or a Toupet (n = 38) fundoplication. Compared with baseline, Ogilvie dysphagia scores were stable at the 3- and 6-month follow-up in the Nissen group (P = 0.075 and 0.084 respectively) but significantly improved in the Toupet group (from baseline mean (s.d.): 1.4 (1.1) to 0.5 ( 0.8) at 3 months, and 0.5 (0.6) at 6 months; P = 0.003 and P = 0.001 respectively). At 6 months, Dakkak dysphagia scores were significantly higher in the Nissen group than in the Toupet group (mean (s.d.): 10.4 (7.9) versus 5.1 (7.2); P = 0.003). QoL scores improved throughout the follow-up. However, at 3 and 6 months postoperatively, the absolute median improvement (⍙) from preoperative values in the mental component scores of the Short Form-36 QoL questionnaire was significantly higher in the Toupet group (median (i.q.r.): 7.1 (−0.6 to 15.2) versus 1.0 (−5.4 to 3.3) at 3 months, and 11.2 (1.4 to 18.3) versus 0.4 (−9.4 to 7.5) at 6 months; (P = 0.010 and 0.003 respectively)). At 6 months, radiologically confirmed POH recurrence occurred in 11 of 24 patients (46 per cent) of the Nissen group and in 15 of 32 patients (47 per cent) of the Toupet group (P = 1.001).

Conclusions

A partial posterior wrap (Toupet fundoplication) showed reduced obstructive complications and improved QoL compared with a total (Nissen) fundoplication following POH repair.

Registration number: NCT04436159 (http://www.clinicaltrials.gov)

Magnetic Sphincter Augmentation Outcomes in Severe Gastroesophageal Reflux Disease

Introduction: Outcomes of laparoscopic procedures for gastroesophageal reflux disease (GERD) are variable depending on surgical expertise and/or patient-related factors. Some procedures may be inadequate in patients with severe disease. Effectiveness of laparoscopic magnetic sphincter augmentation (MSA) has not been extensively tested in patients with severe disease.

Methods: A prospectively collected database was analyzed to identify patients who underwent MSA at a single institution. Individuals who had previous esophago-gastric surgery were excluded. Severe GERD was defined as lower esophageal sphincter pressure <5 mmHg, distal esophageal amplitude <30 mmHg, Barrett's metaplasia, stricture or grade C-D esophagitis, and/or DeMeester score >50. Clinical characteristics and outcomes of patients with severe GERD were compared with those of patients with mild to moderate GERD who served as control group.

Results: Over the study period, a total of 336 patients met the inclusion criteria, and 102 (30.4%) had severe GERD. The median follow-up was 24 months (IQR = 75) in severe GERD patients and 32 months (IQR = 84) in those with non-severe GERD. Patients with severe GERD had a higher rate of dysphagia and higher GERD-HRQL scores. After the MSA procedure, symptoms, health-related quality of life scores, and proton-pump inhibitors consumption significantly decreased in both groups (p < 0.05). No difference between groups was found in the prevalence of severe post-operative dysphagia, the need for endoscopic dilation or device removal, and the DeMeester score.

Conclusion: Laparoscopic MSA is safe and effective in reducing symptoms, PPI use, and esophageal acid exposure also in patients with severe GERD.

Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter?

BACKGROUND

Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia.

METHODS

A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected.

RESULTS

The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit.

CONCLUSION

One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.

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.

Severe dysphagia after antireflux surgery: a rare case of esophageal hiatal stenosis

Severe and persistent dysphagia (PD) due to a stenosis of the esophageal hiatus is a serious and rare complication after antireflux procedures. In the case report presented here, the treatment of dysphagia, which arose eight weeks after surgery and progressively worsened, required a new laparoscopic approach. The re-intervention undertaken allowed us to identify the cause of the dysphagia, a tight hiatal stenosis, and to treat it successfully.

Efficacy of Magnetic Sphincter Augmentation Across the Spectrum of GERD Disease Severity

BACKGROUND

The performance and durability of various types of fundoplication are variable when stratified by disease severity. To date, magnetic sphincter augmentation (MSA) has not been evaluated in this context. We designed this study to determine the efficacy of MSA in the treatment of severe GERD.

STUDY DESIGN

Guided by previous studies, a DeMeester score (DMS) ≥ 50 was used as a cutoff point to define severe reflux disease. Subjects were divided into 2 groups using this cutoff, and outcomes of severe cases were compared with those with less severe disease (DMS < 50).

RESULTS

A total of 334 patients underwent MSA. Patients with severe disease had a higher mean preoperative DMS compared with those with mild to moderate GERD (79.2 [53.2] vs 22.8 [13.7], p < 0.0001). At a mean postoperative follow-up of 13.6 (10.4) months, there was no difference between the mean GERD Health-Related Quality of Life (HRQL) total scores in patients with severe disease compared with those with less severe GERD (8.8 [10] vs 9.2 [10.8], p = 0.9204). Postoperative mean DMS was not different between groups (17.3[23.0] vs 14.1[33.9], p = 0.71), and there was no difference in the prevalence of esophagitis (p = 0.52). Patients with severe disease were less likely to be free from use of proton pump inhibitors after surgery (85% vs 93.1%, p = 0.041). There were similar rates of postoperative dysphagia (10% vs 14%, p = 0.42) and need for device removal (3% vs 5%, p = 0.7463).

CONCLUSIONS

MSA is an effective treatment in patients with severe GERD and leads to significant clinical improvement across the spectrum of disease severity, with few objective outcomes being superior in patients with mild-to-moderate reflux disease.

Ineffective Esophageal Motility in Patients with GERD is no Contraindication for Nissen Fundoplication

BACKGROUND

Patients with preoperative ineffective esophageal motility (IEM) are thought to be at increased risk for postoperative dysphagia leading to the recommendations for tailoring or avoiding anti-reflux surgery in these patients. The aim of this study was to evaluate if IEM has an influence on postoperative outcome after laparoscopic Nissen fundoplication (LNF).

METHODS

Seventy-two consecutive patients with IEM underwent LNF and were case-matched with 72 patients without IEM based on sex, age, BMI, HH size, total pH percentage time, total number of reflux episodes and the presence of BE. Standardized interview assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake, GERD-health-related-quality-of-life (GERD-HRQL), alimentary satisfaction and patients' overall satisfaction was evaluated.

RESULTS

Although a higher rate of preoperative dysphagia was observed in patients with IEM (29% IEM vs. 11% no IEM, p = 0.007), there was no significant difference in rates of dysphagia postoperatively (2 IEM vs. 1 no IEM, p = 0.559). Furthermore, no distinction was found in the postoperative outcome regarding symptom relief, quality of life, gas bloating syndrome, ability to belch and/or vomit or revision surgery between the two groups.

CONCLUSION

Although preoperative IEM has an influence on GERD presentation, it has no effect on postoperative outcome after LNF. IEM should not be a cause for avoiding LNF, as is has been shown as the most effective and safe anti-reflux treatment.

Postoperative Gastrointestinal Complaints After Laparoscopic Nissen Fundoplication

PURPOSE

To investigate the postoperative gastrointestinal complaints and their effects on the satisfaction level of patients after laparoscopic Nissen fundoplication (LNF).

MATERIALS AND METHODS

Over a 7-year period, 553 patients who underwent "floppy" LNF were evaluated for preoperative and postoperative complaints. For this purpose, a set of questions derived from gastroesophageal reflux disease-health-related quality-of-life questionnaire (GERD-HRQL) was used. A P-value of <0.05 was considered to show a statistically significant result.

RESULTS

The present study included 215 patients with a mean follow-up of 60 months. Reflux-related symptoms [regurgitation (17.7%), heartburn (17.2%), and vomiting (3.7%)] and nonspecific symptoms [bloating (50.2%), abdominal pain (15.3%), and belching (27%)] showed a significant decrease (P<0.001) after the surgery. Inability to belch (25.1%) and early satiety (29.3%) were the newly emerged symptoms. The percentage of patients with flatulence increased from 23.3% to 38.1% after LNF. There was no significant difference for dysphagia (25.6%) and diarrhea (15.3%) in the postoperative period. Of the patients, 15.3% had recurrent preoperative complaints and 9.8% were using drugs for that condition. Satisfaction level and preference for surgery were 82.8% and 91.6%, respectively. There was no significant difference in GERD-HRQL score according to body mass index.

CONCLUSIONS

This is the first study in which postoperative reflux-related and nonspecific gastrointestinal complaints are analyzed together for a long follow-up period. We found a significant decrease in many reflux-related and nonspecific symptoms. Although some disturbing complaints like inability to belch, early satiety, and flatulence emerged, the preference for surgery did not change.

Development of pseudoachalasia following magnetic sphincter augmentation (MSA) with restoration of peristalsis after endoscopic dilation

Pseudoachalasia is mimicking clinical and physiologic manifestations of idiopathic achalasia but results from alternative etiologies that infiltrate or obstruct the esophagogastric junction (EGJ). Anti-reflux surgery is one of the potential etiologies of pseudoachalasia. The majority of cases with persistent dysphagia after a tightly constructed Nissen fundoplication results from EGJ outlet obstruction (EGJOO) and in rare cases progresses to pseudoachalasia. In these extreme cases, endoscopic dilation is not a sufficient treatment and take down of fundoplication would be necessary. In this case report, we present a patient with long-standing GERD symptoms that underwent magnetic sphincter augmentation (MSA) with complete resolution of his reflux symptoms. He did not have dysphagia prior to surgery and his preoperative manometry showed normal peristaltic progression of esophageal contractions. He developed pseudoachalasia 14 months after surgery. Repeated endoscopic dilation in this case resulted in resolution of dysphagia and complete restoration of peristaltic contractions.

The role of preoperative workup in predicting dysphagia, dilation, or explantation after magnetic sphincter augmentation

BACKGROUND

Magnetic sphincter augmentation (MSA) is a surgical treatment for gastroesophageal reflux disease using a ring of titanium beads to improve the function of the lower esophageal sphincter. Prior to implantation, a comprehensive preoperative esophageal workup is required to determine patient candidacy in an effort to reduce the dysphagia, dilation, and explantation rate of the device. This study was designed to assess the best predictors for these endpoints.

METHODS

A prospectively maintained IRB-approved database was retrospectively reviewed for patients undergoing MSA implantation. Patients were divided into 3 groups, those that needed no intervention, those that needed medical intervention with oral steroids for reported dysphagia, and surgical intervention, which included endoscopic dilation and/or surgical explantation. Primary endpoints included preoperative objective and subjective testing from a comprehensive esophageal workup including intraoperative notation of number of beads on the device.

RESULTS

There were 99 patients eligible for the study with a mean age of 52 and mean follow-up of 10.2 months. Mean BMI was 27 and 59% were female. The no-intervention group had 59 patients, medical intervention group had 25 patients, and surgical intervention group had 15 patients. Preoperative esophageal manometry findings, pH testing off medications, endoscopic and radiologic evaluation showed no difference between the 3 groups. No differences were seen in preoperative subjective evaluations based on GERD-HRQL or RSI scores. There was no difference in average number of beads on the device between the 3 groups.

CONCLUSION

A comprehensive esophageal workup is important to confirm the presence of gastroesophageal reflux disease and rule out other esophageal pathology. However, this study shows that a preoperative comprehensive esophageal workup does not predict which patients will develop dysphagia or require either medical or surgical interventions following MSA implantation.

Tailored modern GERD therapy - steps towards the development of an aid to guide personalized anti-reflux surgery

As the incidence of gastroesophageal reflux disease (GERD) is rising, surgical treatment is continuously advancing in an effort to minimize side effects, whilst maintaining efficacy. From a database of patients that underwent anti-reflux surgery at our institution between 2015 and 2018, the last 25 consecutive patients that underwent electrical stimulation (ES), magnetic sphincter augmentation (MSA) and Nissen fundoplication (NF), following a personalized treatment decision aid, were included in a comparative analysis. After preoperative evaluation each patient was referred for an ES, MSA or NF based on esophageal motility, hiatal hernia (HH) size and the patients’ preferences. Postoperative gastrointestinal symptoms and GERD-Health-related-Quality-of-Life were assessed. Preoperatively the median DCI (299 ES vs. 1523.5 MSA vs. 1132 NF, p = 0.001), HH size (0.5 cm ES vs. 1 cm MSA vs. 2 cm NF, p = 0.001) and presence of GERD-related symptoms differed significantly between the groups. The highest rate of postoperative dysphagia was seen after MSA (24%, p = 0.04), while the median GERD HRQL total score was equally distributed between the groups. The positive short-term postoperative outcome and patient satisfaction indicate that such an aid in treatment indication, based on esophageal motility, HH size and patient preference, represents a feasible tool for an ideal choice of operation and an individualized therapy approach.

[Redo surgery after laparoscopic fundoplication]

OBJECTIVE

To analyze the results of redo surgeries after previous laparoscopic fundoplication.

MATERIAL AND METHODS

A retrospective analysis included 37 repeated anti-reflux surgeries. Control group consisted of 38 patients after the first anti-reflux surgery performed on the same clinical base. The causes of unsatisfactory results of the first operations were studied. Intraoperative data, immediate and long-term results of surgical treatment were compared in both groups. Quality of life in both groups was studied before surgery and in long-term period using GIQLI questionnaire.

RESULTS

The most common cause of recurrent reflux was a hernia recurrence combined with slipping or destruction of the fundoplication cuff. Dysphagia was usually a result of compression of the esophagus by tightly sutured diaphragmatic crura and recurrent paraesophageal hernia. The main group was characterized by significantly greater surgery time, hospital-stay, incidence of intraoperative and postoperative complications. However, a more significant improvement of quality of life (∆GIQLI) was observed in the main group due to the low QOL index before redo surgery.

CONCLUSION

Redo surgeries are effective and safe procedures. These operations significantly improve QOL in long-term period despite certain technical difficulties. Repeated surgeries for dysphagia accounted for 2%, for recurrent reflux - 6%. Persistent postoperative dysphagia is usually associated with diaphragm repair rather fundoplication cuff. Reflux recurrence is often caused by cuff slippage and recurrent hernia.

Results of Magnetic Sphincter Augmentation for Gastroesophageal Reflux Disease

BACKGROUND

Magnetic sphincter augmentation (MSA) is a modern treatment option for gastroesophageal reflux disease (GERD); however, laparoscopic fundoplication remains the gold standard. The aim of the study was to evaluate outcomes of MSA patients at a reflux center.

METHODS

A retrospective review was performed of all patients that underwent MSA between March 2012 and November 2017. Out of 110 patients, 68 with a follow-up >3 months were included. Postoperative gastrointestinal symptoms, proton pump inhibitor (PPI) intake, GERD-Health-related Quality of Life (GERD-HRQL) and alimentary satisfaction (AS) were assessed. Postoperative esophageal functioning tests were performed in 50% of patients.

RESULTS

Sixty-eight patients underwent MSA; hiatal repair was performed in 31 cases. The median OR time was 27 min, and no intraoperative complications occurred. The median follow-up was 13 months (IQR 4.2-45). Endoscopic dilatation was performed in 2 patients (3%) and device removal in another 2 cases. The postoperative GERD-HRQL score was significantly reduced (3 vs. 24; p < 0.001) and the median AS was 8/10. Preoperative experienced heartburn, regurgitations and dysphagia were eliminated in 92, 96 and 100%. Postoperative new-onset difficulties swallowing with solids only were reported to occur occasionally by 16% and rarely by 21% of patients. Satisfaction with heartburn relief was 95%, and the overall outcome was rated excellent/good in 89%. PPI dependency was eliminated in 87%. The median total percentage pH < 4 and number of reflux episodes were significantly reduced. Postoperative pH results were negative or slightly above the norm in 79% and 12%, respectively.

CONCLUSION

Sphincter augmentation results in significantly reduced reflux symptoms, increased GERD-specific Quality of Life and excellent alimentary satisfaction with low perioperative morbidity. This procedure should be considered an excellent alternative to fundoplication in the treatment of GERD.

Surgical results of laparoscopic Toupet fundoplication for gastroesophageal reflux disease with special reference to recurrence

BACKGROUND

Surgical results of GERD have mainly been reported from the Western countries, with a few reports found in Japan. We examined the surgical results of laparoscopic Toupet fundoplication and clarify the characteristics of recurrent cases.

METHODS

The subjects included 375 patients who underwent laparoscopic Toupet fundoplication from June 1997 to December 2016 as the initial surgery. Patient characteristics, pathophysiology, and surgical results were examined. In addition, we compared the patient characteristics and pathophysiology of recurrent cases in comparison with non-recurrent cases.

RESULTS

Age 59 (43-70) and male 211 (56.3%). The operation time was 141 min (113-180) and intraoperative complications were found to have onset in 13 subjects (3.5%). Dysphagia after surgery was found in 18 cases (4.8%). The A factor (the degree of hiatal hernia), P factor (the degree of esophagitis), and pH < 4 holding time significantly improved after surgery compared with prior to surgery (p < 0.001 for all), while the LES lengths and abdominal LES lengths were extended (p < 0.001 for each). Recurrence was found in 48 patients (15.1%) among the 318 patients for whom we could confirm the presence or absence of recurrence. The A factor, P factor, and pH < 4 holding time prior to surgery were, respectively, higher in the recurrence group (p = 0.031, p < 0.001, p < 0.001).

CONCLUSIONS

Laparoscopic Toupet fundoplication for GERD could be performed safely, with a response rate as good as 85%. Compared with non-recurrent cases, preoperative clinical conditions such as esophageal hiatal hernia, reflux esophagitis, and acid reflux time were all advanced in recurrent cases.

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.

Management of failure after surgery for gastro-esophageal reflux disease

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.