Management of failure after surgery for gastro-esophageal reflux disease

Characterization of gastric dysfunction after fundoplication using body surface gastric mapping

BACKGROUND

Adverse gastric symptoms persist in up to 20% of fundoplication operations completed for gastroesophageal reflux disease, causing significant morbidity and driving the need for revisional procedures. Noninvasive techniques to assess the mechanisms of persistent postoperative symptoms are lacking. This study aimed to investigate gastric myoelectrical abnormalities and symptoms in patients after fundoplication using a novel noninvasive body surface gastric mapping (BSGM) device.

METHODS

Patients with a previous fundoplication operation and ongoing significant gastroduodenal symptoms and matched controls were included. BSGM using Gastric Alimetry (Alimetry Ltd) was employed, consisting of a high-resolution 64-channel array, validated symptom-logging application, and wearable reader.

RESULTS

A total of 16 patients with significant chronic symptoms after fundoplication were recruited, with 16 matched controls. Overall, 6 of 16 patients (37.5%) showed significant spectral abnormalities defined by unstable gastric myoelectrical activity (n = 2), abnormally high gastric frequencies (n = 3), or high gastric amplitudes (n = 1). Patients with spectral abnormalities had higher Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index scores than those of patients without spectral abnormalities (3.2 [range, 2.8-3.6] vs 2.3 [range, 2.2-2.8], respectively; P = .024). Moreover, 7 of 16 patients (43.8%) had BSGM test results suggestive of gut-brain axis contributions and without myoelectrical dysfunction. Increasing Principal Gastric Frequency Deviation and decreasing Rhythm Index scores were associated with symptom severity (r > .40; P < .05).

CONCLUSION

A significant number of patients with persistent postfundoplication symptoms displayed abnormal gastric function on BSGM testing, which correlated with symptom severity. Our findings advance the pathophysiologic understanding of postfundoplication disorders, which may inform diagnosis and patient selection for medical therapy and revisional procedures.

Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

Peroral endoscopic myotomy (POEM) and Heller myotomy with fundoplication (HMF) effectively treat achalasia, an esophageal motor disease. Although a significant number of meta-analyses have compared POEM and HMF, these studies showed discrepant postoperative gastroesophageal reflux disease (GERD) conclusions. This review aimed to objectively compare GERD over time, as well as the efficiency, safety, and adverse events in POEM versus HMF for treating achalasia. We performed a systematic review and meta-analysis by searching Medline, Embase, Cochrane Library, Scopus, and Clinicaltrials.gov. The evaluated outcomes included early (within 12 months) and late (beyond 12 months) endoscopic assessment of GERD using the Lyon Consensus, clinical success, operative duration (OD), length of stay (LOS), and major adverse events (MAE). A total of 29 observational studies and two randomized clinical trials (RCTs) with 13,914 patients were included. GERD was 28% higher among RCTs discussing POEM at early assessment (95%CI 0.02, 0.54) and was not different at late evaluation (95% confidence interval (CI) = 0.00, 0.22). No difference in reflux was observed among observational studies in both periods. The clinical success was 9% higher (95% CI = 0.05, 0.12), and the OD was 37.74 minutes shorter (95% CI = -55.44, -20.04) in POEM among observational studies, whereas it was not different among RCTs. The LOS and MAE were similar in the groups. Comparisons among studies yielded divergent results. RCTs revealed that POEM had a higher incidence of GERD in the early assessment, whereas observational studies showed higher clinical success and a shorter OD in POEM. Ultimately, the between-group difference waned over time in GERD in all comparisons, resulting in no difference among RCTs in the late evaluation. Our meta-analysis demonstrated a non-preferential treatment of achalasia between endoscopic or surgical cardiomyotomy, prioritizing an individualized approach in the long term.

Failed fundoplication with delayed gastric emptying: efficacy of subtotal gastrectomy

BACKGROUND

The management of patients with gastroparesis and recurrent reflux after previous fundoplication is challenging. The aim of this study was to evaluate the safety and efficacy of subtotal gastrectomy with Roux-en-Y reconstruction as a remedial procedure in this select patient population.

METHOD

Retrospective analysis of a prospectively populated database identified all patients that underwent subtotal gastrectomy with Roux-en-Y reconstruction (SGRNY) due to reflux symptoms and delayed gastric emptying (DGE). Demographic, intra-operative and post-operative data including pre and post-operative modified reflux aspiration scintigraphy studies were evaluated. Standardized questionnaires were used to assess symptomatic outcomes.

RESULTS

From 2018 SGRNY has been selectively performed in 13 patients. Preoperative workup confirmed DGE and severe symptomatic reflux in all patients. The median number of previous fundoplication and or hiatal hernia operations was two (range 1-3). The mean hospital length of stay was 10 ± 6 days. Post-operative morbidity was experienced in three patients (23%). Seven patients (64%) had significant improvement or complete resolution of reflux on post-operative scintigraphy. Symptom improvement was reported in 92% of patients.

CONCLUSION

In a select patient cohort with post-fundoplication reflux and DGE symptoms, SGRNY is a moderately safe and effective salvage option.

Practice-Changing Milestones in Anti-reflux and Hiatal Hernia Surgery: a Single Surgeon Perspective over 27 years and 1200 Operations

BACKGROUND

There have been steady innovations in hiatal hernia and anti-reflux surgery. The purpose of this article is to provide a historical perspective on practice-changing innovations in the context a single surgeon experience's over a career.

METHODS

Patients undergoing anti-reflux surgery or hiatal hernia repair by a single surgeon from 12/1992 to 3/2020 were reviewed.

DATA COLLECTED

sex, age, hiatal hernia type, operation type, adjuncts used, and additional procedure performed during index operation. Superimposed on this experience are the practice-changing innovations that occurred over this timeframe.

RESULTS

During the time period, 1200 operations were performed. Distributions: Hernia type: I, 707 (58.9%); II-IV, 325 (27.1%); Recurrent/Failed, 168 (14.0%). Type of operation, including laparoscopic and open: Nissen fundoplication: 889 (74.1%); Toupet fundoplication: 162 (13.5%); Collis-Nissen/Toupet fundoplication: 44 (3.7%); hiatal hernia repair without fundoplication (laparoscopic and open): 38 (3.2%); endoluminal fundoplication: 35 (2.9%); hiatal hernia repair with Heller myotomy/ Dor fundoplication: 10 (0.8%); transthoracic Belsey Mark IV: 2 (0.2%); hiatal hernia repair with magnetic sphincter augmentation: 20 (1.7%). Mesh reinforcement: 185 (15.4%). Additional procedures, 210 (17.5%). During this time, these practice-changing innovations occurred: laparoscopic surgery, 48-h pH monitoring, high-resolution manometry, tailoring of fundoplication, energy sources for tissue division and hemostasis, pyloroplasty for symptomatic gastroparesis, the rise and fall of endoluminal therapies, mesh reinforcement, abandonment of short gastric vessel division, and magnetic sphincter augmentation.

CONCLUSIONS

Over the last 27 years, a number of practice-changing advances have been made. These have led to changes in technique and operation selection of anti-reflux and hiatal hernia surgery.