Late results after laparoscopic fundoplication denote durable symptomatic relief of gastroesophageal reflux disease

Does Patient Sex Influence the Symptom Pattern for Patients With Gastro-Oesophageal Reflux Disease and the Response of Symptoms to Fundoplication?

BACKGROUND

Several studies show that female patients experience lower satisfaction after anti-reflux surgery. We hypothesised that there is a pattern of symptoms common to female patients presenting with GORD and that it is these symptoms in particular that lead to inferior outcomes. We also hypothesised that these symptoms would respond differently to the different types of fundoplication.

METHODS

Pre-operative and post-operative questionnaires for all patients undergoing laparoscopic fundoplication were analysed. Pre-operative symptoms, improvement of symptoms, patient demographics and type of fundoplication were assessed.

RESULTS

The study evaluated 328 patients, 156 females and 172 males. Eighty-seven females (55.8%) and 135 males (78.5%) underwent a Nissen Fundoplication (p < 0.001) with the rest undergoing a posterior 270° (partial) fundoplication. Females reported most symptoms more frequently than males, and a predominantly female pattern of symptoms was identified. Bloating (p ≤ 0.001), asthma (p = 0.045), constipation (p = 0.010) and diarrhoea (p = 0.023) were significantly more associated with being female. At 18 months post-surgery, outcomes for patients presenting with 'female-pattern' symptoms were not improved by undertaking partial fundoplication when compared to Nissen fundoplication. The only symptom that was affected by the type of fundoplication was dysphagia, with a significant number of patients experiencing worsening of dysphagia after a Nissen fundoplication (p < 0.01).

CONCLUSION

There are certain symptoms that affect female patients who present with GORD more commonly than male patients, and this may contribute to lower satisfaction outcomes. Partial fundoplication does not appear to offer a significant advantage in improving these symptoms.

Pressure dynamics of the esophagogastric junction at rest and during inspiratory maneuvers after Nissen fundoplication

Low sphincter pressure and inability of the crural diaphragm to elevate it at the esophagogastric junction are important pathophysiological mechanisms of gastroesophageal reflux disease (GERD). The object of this study was to depict how Nissen fundoplication changed the resting and inspiratory pressures of the anti-reflux barrier. We selected 14 patients (eight males; mean age 42.7 years; mean body mass index 27.8) for surgery. They answered symptoms questionnaires and underwent high-resolution manometry (HRM) before and 6 months after Nissen fundoplication. We used a standard manometric protocol (resting and liquid swallows) and assessment of esophagogastric junction (EGJ) pressure metrics during standardized forced inspiratory maneuvers against increasing loads (Threshold Maneuvers). We used the Wilcoxon test for comparison of pre and postoperative data. After fundoplication, heartburn and regurgitation scores diminished remarkably (from 4.5 and 2, respectively, to zero; P = 0.002 and P = 0.0005, respective medians). Also, the median expiratory EGJ pressure had a significant increase from 8.1 to 18.1 mmHg (P = 0.002), while mean respiratory pressure and EGJ contractility integral (EGJ-CI) increased without statistical significance (P = 0.064 and P = 0.06, respectively). Axial EGJ displacement was lower after fundoplication. The EGJ relaxation pressure (P = 0.001), the mean distal esophageal intrabolus pressure (P = 0.01) and the distal latency (P = 0.017) increased after fundoplication. There was a reduction in the contraction front velocity (P = 0.043). During evaluation with standardized inspiratory maneuvers, the inspiratory EGJ pressures (under loads of 12, 24, 36 and 48 cmH2O) were lower after surgery for all loads (median for load 12 cmH2O: 145.6 vs. 102.7 mmHg; P = 0.004). Fundoplication and hiatal closure increased the expiratory EGJ pressure and promoted a great GERD symptom relief. The surgery seemed to overcompensate a reduced EGJ mobility and inspiratory pressure.

Crural closure, not fundoplication, results in a significant decrease in lower esophageal sphincter distensibility

INTRODUCTION

The esophagogastric junction (EGJ) is a complex anti-reflux barrier whose integrity relies on both the intrinsic lower esophageal sphincter (LES) and extrinsic crural diaphragm. During hiatal hernia repair, it is unclear whether the crural closure or the fundoplication is more important to restore the anti-reflux barrier. The objective of this study is to analyze changes in LES minimum diameter (D_min) and distensibility index (DI) using the endoluminal functional lumen imaging probe (FLIP) during hiatal hernia repair.

METHODS

Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This data were reviewed retrospectively for all patients undergoing hiatal hernia repair. FLIP measurements were collected prior to hernia dissection, after hernia reduction, after cruroplasty, and after fundoplication. Additionally, subjective assessment of the tightness of crural closure was rated by the primary surgeon on a scale of 1 to 5, 1 being the loosest and 5 being the tightest.

RESULTS

Between August 2018 and February 2020, 97 hiatal hernia repairs were performed by a single surgeon. FLIP measurements collected using a 40-mL volume fill without pneumoperitoneum demonstrated a significant decrease in LES D_min (13.84 ± 2.59 to 10.27 ± 2.09) and DI (6.81 ± 3.03 to 2.85 ± 1.23 mm²/mmHg) after crural closure (both p < 0.0001). Following fundoplication, there was a small, but also statistically significant, increase in both D_min and DI (both p < 0.0001). Additionally, subjective assessment of crural tightness after cruroplasty correlated well with DI (r = - 0.466, p < 0.001) and all patients with a crural tightness rating ≥ 4.5 (N = 13) had a DI < 2.0 mm²/mmHg.

CONCLUSION

Cruroplasty results in a significant decrease in LES distensibility and may be more important than fundoplication in restoring EGJ competency. Additionally, subjective estimation of crural tightness correlates well with objective FLIP evaluation, suggesting surgeon assessment of cruroplasty is reliable.

Post-operative complications and readmissions following outpatient elective Nissen fundoplication

INTRODUCTION

Traditionally, laparoscopic Nissen fundoplication (LNF) has been considered an inpatient procedure. Advances in surgical and anesthetic techniques have led to a shift towards outpatient LNF procedures. However, differences in surgical outcomes between outpatient and inpatient LNF are poorly understood. The objectives of this study were (1) to describe the frequency of outpatient LNF in a national cohort and (2) to identify any differences in complications or readmission rates between outpatient and inpatient LNF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify elective LNF cases from 2012 to 2016. Patients discharged on the day of surgery were compared to those discharged 24-48 h post-operatively. Outcomes included 30-day readmission and death or serious morbidity (DSM). Bivariate analyses were completed with Chi squared testing for categorical variables and two sided t tests for continuous variables. Associations between outpatient surgery and outcomes were assessed using multivariable logistic regression. Differences in readmission were analyzed using Kaplan-Meier failure estimates and log-rank tests.

RESULTS

Of 7734 patients who underwent elective LNF, 568 (7.3%) were discharged on the day of surgery. The overall 30-day readmission rate was 4.1% (n = 316) and the overall rate of DSM was 1.0% (n = 79). The most common 30-day readmission diagnoses overall were infectious complications (16.1%), dysphagia (12.9%), and abdominal pain (11.7%). On multivariable analysis, there was no association between outpatient surgery and 30-day readmission (3.9% vs. 4.1%; aOR 0.97, 95% CI 0.62-1.52, p = 0.908) or DSM (1.1% vs. 1.0%; aOR 0.91, 95%CI 0.36-2.29, p = 0.848). Kaplan-Meier analysis showed no difference in rates of hospital readmission between groups at 30-days from discharge (3.9% vs. 4.1%, p = 0.325).

CONCLUSIONS

Among patients undergoing elective LNF, there were no significant differences in post-operative complications and 30-day readmission when compared to traditional inpatient postoperative care. Further consideration should be given to transitioning LNF to an outpatient procedure.

Long-term (15-year) objective evaluation of 150 patients after laparoscopic Nissen fundoplication

INTRODUCTION

Laparoscopic Nissen fundoplication is the preferred operative treatment for patients with gastroesophageal reflux disease. The most recent published results only refer to clinical evaluations and few discuss objective measurements. Our purpose was to determine the late results of laparoscopic Nissen fundoplication, performing clinical, endoscopic, histologic, and functional studies.

MATERIAL AND METHODS

A total of 179 patients were included in a prospective study. All had gastroesophageal reflux disease symptoms of at least 5-year duration, daily dependence on proton pump inhibitors, and a type I hiatal hernia less than 5 cm. Exclusion criteria included Barrett's esophagus, hiatal hernia >5 cm, failed antireflux surgery, and obesity (body mass index >30). We performed a radiologic study, 3 or more endoscopic procedures with biopsy samples of the antrum and esophagogastric junction, esophageal manometry, and 24-hour pH monitoring.

RESULTS

We found that 4 patients (2.2%) died 3-4 years after operation from nonoperatiove reasons. A total of 25 patients (14%) were lost to follow-up, and 150 patients (83.8%) submitted to late objective evaluations (15 years). Visick I-II symptoms were observed in 79.3% and III-IV (failures) in 20.7%. Endoscopy showed a normal positioning of the esophagogastric junction in the Visick I-II patients and a type III cardia or hiatal hernia with erosive esophagitis in Visick III-IV patients. Short-segment Barrett's esophagus developed in 5.3% of patients. Lower esophageal sphincter pressure remained increased over the preoperative value in all groups. The 24-hour pH monitoring also was decreased over the preoperative value in Visick I-II patients but showed no significant change in Visick III-IV patients. Carditis at the esophagogastric junction regressed to fundic mucosa in 50% of Visick I-II patients.

CONCLUSION

Laparoscopic Nissen fundoplication produces control of symptoms in 80% of patients late (up to 15 years) after surgeries corroborated by endoscopic, histologic examinations, and functional studies. It is essential to perform these objective evaluations to demonstrate the "antireflux effect" after laparoscopic Nissen fundoplication.

Endoscopic Evaluation of Post-Fundoplication Anatomy

PURPOSE OF REVIEW

We aim to review the endoscopic evaluation of post-fundoplication anatomy and its role in assessment of fundoplication outcomes and in pre-operative planning for reoperation in failed procedures.

RECENT FINDINGS

There is no universally accepted system for evaluating post-fundoplication anatomy endoscopically. However, multiple reports described the usefulness of post-operative endoscopy as a quality control measure and in the evaluation of complex cases such as repeat procedures and paraesophageal hernias (PEH). Endoscopic evaluation of post-fundoplication anatomy has an important role in assessing the outcomes of operative repair and pre-operative planning for failed fundoplications. Attempts have been made to characterize the appearance of the newly formed gastroesophageal valve after successful repairs and to standardize endoscopic reporting and classification of anatomic descriptions of failed fundoplications. However, there is no consensus. More studies are needed to evaluate the applicability and reproducibility of proposed endoscopic evaluation systems in order for such tools to become widely accepted.

Psychosocial Factors Are Associated with Quality of Life After Laparoscopic Antireflux Surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) is the gold standard treatment for refractory gastroesophageal reflux disease (GERD). Traditional surgical outcomes following LARS are well described, but limited data exist regarding patient-reported outcomes. We aimed to identify preoperative characteristics that were independently associated with a high GERD health-related quality of life (GERD-HRQL) following LARS.

METHODS

Clinical data from our single institution foregut surgery database were used to identify all patients with GERD who underwent primary LARS from June 2010 to November 2015. Electronic health record data were reviewed to extract patient characteristics, diagnostic study characteristics, and operative data. Postoperative GERD-HRQL data were obtained through telephone follow-up. Variables hypothesized a priori to be associated with high GERD-HRQL after LARS, which were significant at P ≤ .2 on bivariate analysis, were entered into a multivariable linear regression model with GERD-HRQL as the outcome.

RESULTS

The study included 248 patients; 69.0% were female, 56.9% were married, and 58.1% had concurrent atypical symptoms. The most commonly performed fundoplications were Nissen (44.8%), Toupet (41.3%), and Dor (14.1%), respectively. The median follow-up interval was 3.4 years. The telephone response rate was 60.1%. GERD-HRQL scores improved from 24.8 (SD ±11.4) preoperatively to 3.0 (SD ±5.9) postoperatively. 79.9% of patients were satisfied with their condition at follow-up. On multivariable analysis, being married (P = .04) and absence of depression (P = .02) were independently associated with a higher postoperative QoL.

CONCLUSIONS

Strong social support and psychiatric well-being appear to be important predictors of a higher QoL following LARS. Optimizing social support and treating depression preoperatively and postoperatively may improve QoL outcomes for LARS patients.

Over 250 Laparoendoscopic Single Site (LESS) Fundoplications: Lessons Learned

Laparoendoscopic single site (LESS) surgery is a more recent advance in the progression of minimally invasive surgery. This study was undertaken to assess lessons learned after our first 250 LESS fundoplications for gastroesophageal reflux disease (GERD). All patients undergoing LESS fundoplications were prospectively followed from 2008 to 2014. Patients scored the frequency/severity of their symptoms before/after LESS fundoplication using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients also scored satisfaction with their incision using a Likert scale (1 = revolting to 10 = beautiful). A total of 300 patients undergoing LESS fundoplication for GERD were not different by age or gender. Surgeons undertook 190 Nissen fundoplications and 110 Toupet fundoplications; 28 of which were “redo” fundoplications. Preoperative symptoms were notable, especially heartburn (frequency = 8, severity = 7). Symptoms were ameliorated postoperatively (e.g., heartburn: frequency = 0, severity = 0, P < 0.01). Postoperatively, patients scored satisfaction of their incisions with a median score of 10. Eighty-three per cent of patients were at least satisfied with their overall experience; 92 per cent would undergo the operation again knowing what they know now. Patients report significant symptom relief, high satisfaction, and excellent cosmesis after LESS fundoplication. LESS fundoplication safely ameliorates symptoms of GERD with pronounced satisfaction, in part, because of the cosmetic outcome (i.e., lack of scaring), and its application is encouraged.

Laparoscopic fundoplication for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.

Transoral Incisionless Fundoplication: Is it as Safe and Efficacious as a Nissen or Toupet Fundoplication?

Transoral incisionless fundoplication (TIF) was U.S. Food and Drug Administration-approved in 2007 to treat gastroesophageal reflux disease (GERD), but comparative data are lacking. This study was undertaken to compare outcomes for patients with GERD undergoing TIF versus laparoscopic Nissen or Toupet fundoplications. We undertook a case-controlled study of three cohorts of 20 patients undergoing TIF or laparoscopic Nissen or Toupet fundoplications from 2010 to 2013 controlling for age, body mass index, and preoperative DeMeester scores. All patients were pro-spectively followed. Median data are reported. Patients undergoing TIF had significantly shorter operative times (in minutes: 71 vs 119 and 85, respectively, P < 0.001) and length of stay (in days: 1, 2, and 1, respectively, P < 0.001). No matter the approach, patients reported dramatic and similar reduction in symptom frequency and severity (e.g., heartburn 8 to 0, P < 0.05). At follow-up, 83 per cent of patients after TIF, 80 per cent after Nissen, or 92 per cent after Toupet fundoplications had symptoms less than once per month ( P = 0.12). TIF leads to dramatic symptom resolution, similar when compared with Nissen or Toupet fundoplications. TIF promotes shorter operative times and lengths of stay. Patient satisfaction and effective palliation of symptoms show that TIF is safe and efficacious in comparison to Nissen and Toupet fundoplications and support its continued application and evaluation.