Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision

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.

Association of preoperative workup and comorbidities with risk of gastroesophageal surgery failure

Background

While surgical failure rates for fundoplication and hiatal hernia repair are low, there has been no clear evaluation of the preoperative risk factors associated with surgical failure. This study aimed to identify risk factors predisposing patients to surgical failure.

Methods

Patients who underwent antireflux surgery during a 3-year period were evaluated for evidence of surgical complications and placed accordingly into the failure or control group. Demographic data, comorbidities, clinical presentation, preoperative evaluation, and surgical data were collected and compared between the groups.

Results

In total, 86 patients with failure and 42 controls were identified among our cohort. No significant differences were found between groups based on sex (P=0.640). However, patients with failure were younger than controls (57.0 vs. 64.7 years, P=0.0001). Body mass index, tobacco use and alcohol use did not differ significantly between the groups (P=0.189, P=0.0999, P=0.060). Notably, psychiatric illness was more common in the failure group (P=0.0086). Neither hypertension (P=0.134) nor diabetes (P=0.335) had significant differences between groups. For procedures, no significant differences were found for the frequencies of preoperative imaging (P=0.395) or manometry (P=0.374), but pH/BRAVO studies (P=0.0193) and endoscopy (P<0.001) were both performed more frequently in the failure group.

Conclusions

Patients with psychiatric comorbidities are at higher risk of surgical failure. Alcohol use trended toward significance, which warrants further investigation. We also noted an increase in rates of preoperative pH and endoscopy studies, contrary to the prior literature; this is likely due to more complex cases requiring additional workup.

Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study

INTRODUCTION

Robotic-assisted redo fundoplication has some advantages compared to the laparoscopic approach in adults, although to date there are no studies in children.

METHODS

A retrospective case-control study was performed among consecutive children who underwent redo antireflux surgery between 2004 and 2020, divided into two groups: LAF group (laparoscopic redo-fundoplication) and RAF group (robotic-assisted redo-fundoplication). Demographics, clinical, intraoperative, postoperative and economic data were compared.

RESULTS

A total of 24 patients were included (10 LAF group; 14 RAF group) without demographic or clinical differences. The RAF group presented lower intraoperative blood loss (52 ± 19 vs. 145 ± 69 mL; p < 0.021), shorter surgery time (135 ± 39 vs. 179 ± 68 min; p = 0.009) and shorter length of hospital stay (median 3 days [2-4] vs. 5 days [3-7]; p = 0.002). The RAF group presented a higher rate of symptom improvement (85.7% vs. 60%; p = 0.192) and lower overall associated economic costs (25 800$ vs. 45 500$; p = 0.012).

CONCLUSION

Robotic-assisted redo antireflux surgery may offer several benefits over the laparoscopic approach. Prospective studies are still needed.

The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial

Background

Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair.

Patients and methods

All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh.

Results

The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation.

Trial Registration

ClinicalTrials.gov, identification number NCT04179578.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

Efficacy and safety of laparoscopic Roux-en-Y gastric bypass in symptomatic patients following fundoplication failure: a meta-analysis

Revisional surgery may be required in a subset of patients who remain symptomatic despite undergoing laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD). While revisional LF (RLF) is feasible in these patients, laparoscopic Roux-en-Y gastric bypass (LRYGB) may serve as an alternative, although its efficacy and safety remains unknown. This study aimed to determine the outcomes of LRYGB in symptomatic patients following failed LF for GERD. MEDLINE, EMBASE, and PubMed databases were systematically searched for studies reporting LRYGB outcomes in symptomatic adults despite undergoing LF for GERD. Postoperative symptom resolution, recurrence of heartburn and dysphagia, proton pump inhibitor (PPI) use, and body mass index (BMI) reduction were assessed to determine LRYGB efficacy. Postoperative morbidity and mortality were used to evaluate LRYGB safety. Twenty-two studies with 1523 patients were included. Pooled rates of symptom resolution, recurrence of heartburn and dysphagia, PPI use, morbidity, and mortality were 71.6% (95% CI 59.4-86.4), 15.6% (8.9-27.3), 20.7% (12.5-34.3), 29.6% (18.8-46.5), 39.5% (29.9-52.3), and 2.2% (1.2-4.0), respectively, following LRYGB. Similar rates were observed after RLF. However, BMI reduction was significantly greater after LRYGB compared with RLF (mean difference 6.1 kg/m², 4.8-7.4; p < 0.0001). LRYGB resulted in symptom relief in a majority of patients, and proved comparable to RLF regarding symptom recurrence and PPI use. Morbidity and mortality following LRYGB also did not differ from RLF. However, LRYGB was associated with considerably greater weight loss relative to RLF. Therefore, LRYGB is efficacious and an acceptable revisional procedure in symptomatic GERD patients who have previously undergone LF.

Is systematic formal crural repair mandatory at the time of magnetic sphincter augmentation implantation?

Laparoscopic placement of the LINX Magnetic Sphincter Augmentation (MSA) device has become an accepted alternative to fundoplication in appropriate patients. Initial studies of MSA targeted to patients with 'early' disease allowed for the most minimal dissection of the esophagus to place the device, without hiatal dissection or repair (NoHHR), in patients with no or minimal hernia findings at surgery. Subsequent studies have compared systematic formal hiatal dissection and repair (Formal HHR) with the original minimal dissection technique. Review of published literature on MSA includes discussion on treatment of hiatal hernia at the time of implantation, accompanying the review of the physiology of the crural diaphragm. Formal hiatal hernia repair at the time of MSA implantation results in better control of reflux with less dysphagia and risk of postoperative hernia than NoHHR, regardless of the presence or size of hiatal hernia. Systematic crural repair should accompany any MSA implantation regardless of the presence or size of hiatal hernia.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Regional Anesthesia to the Rescue: Phrenic Nerve Block to Prevent Wound Dehiscence From Intractable Hiccups-A Case Report

Increased intra-abdominal pressure (IAP) following large abdominal surgeries can lead to postoperative complications, including wound dehiscence and surgical reoperation. Numerous factors can contribute to increased postoperative IAP, and intractable hiccups have been implicated as a culprit. Different treatment modalities have been widely used with variable success in addressing intractable hiccups. Here, we present a case in which postoperative hiccups leading to wound dehiscence and reoperation were successfully treated with an indwelling phrenic nerve catheter. Following placement, a significant reduction in hiccup severity and frequency was noted, improving the patient's quality of postoperative course and preventing further surgical intervention.

Factors affecting the treatment outcomes of laparoscopic fundoplication for erosive reflux esophagitis: findings of esophageal pathological function tests

PURPOSE

To identify the factors that affect laparoscopic fundoplication (LF) treatment efficacy in patients with erosive gastroesophageal reflux disease (e-GERD) esophagitis, based on the findings of multichannel intraluminal impedance pH (MII-pH) and high-resolution manometry (HRM).

METHODS

The subjects were 102 patients with e-GERD diagnosed by endoscopy, who underwent LF as the initial surgery. To analyze the findings of MII-pH and HRM, the patients were divided into two groups: a cured group (CR), comprised of patients whose esophagitis was cured postoperatively; and a recurrence group (RE), comprised of patients who suffered recurrent esophagitis.

RESULTS

There were 96 patients in the CR group and 6 in the RE group. MII-pH indicated that the acid reflux time, the longest reflux time, and the number of refluxes longer than 5 min, were significantly higher in the RE group than in the CR group (p = 0.0028, p = 0.0008, p = 0.012, respectively). The HRM indicated that only the distal contractile integral (DCI) was significantly lower in the RE group (p = 0.0109).

CONCLUSION

The results of this study indicate that esophageal clearance may affect the treatment outcome of LF. Based on the findings of MII-pH, the longest reflux time and the number of refluxes longer than 5 min were important factors influencing the therapeutic effect, whereas based on the HRM, the DCI value was most important.

Role of Wrap-Crural Fixation and Minimal Dissection in Prevention of Transmigration After Laparoscopic Nissen Fundoplication in Children

Background: Laparoscopic Nissen fundoplication is the gold standard antireflux procedure in pediatric age group. Intrathoracic migration of the fundic wrap is a common cause failure, leading to recurrence of gastroesophageal reflux disease (GERD) symptoms. Objectives: To investigate the impact of wrap-crural fixation and minimal esophageal dissection in prevention of wrap transmigration after laparoscopic Nissen fundoplication in children. Methods: Prospective randomized study of 46 pediatric patients with refractory GERD who underwent laparoscopic Nissen fundoplication divided into two equal groups. In Group A, wrap crural fixation was done, whereas in group B no fixation was done. Minimal esophageal dissection with preservation of the phrenoesophageal ligament was done in both groups. Approval of the Ethics Committee of our Faculty was obtained. Results: There was no difference between both groups regarding operative time, intraoperative complications, or length of hospital stay. Two patients in group B without wrap fixation suffered recurrence of GERD symptoms. On contrast study, they both showed intrathoracic wrap migration. One of them was reoperated. Whereas in group A, no recurrence of symptoms and no wrap transmigration were noticed in follow-up. Conclusion: In laparoscopic Nissen fundoplication, with minimal esophageal dissection and preservation of the phrenoesophageal ligament, there is no additional benefit from wrap-crural fixation in prevention of wrap transmigration.

ENDOSCOPIC EVALUATION OF POST-FUNDOPLICATION ANATOMY AND CORRELATION WITH SYMPTOMATOLOGY

Background:

Upper digestive endoscopy is important for the evaluation of patients submitted to fundoplication, especially to elucidate postoperative symptoms. However, endoscopic assessment of fundoplication anatomy and its complications is poorly standardized among endoscopists, which leads to inadequate agreement.

Aim:

To assess the frequency of postoperative abnormalities of fundoplication anatomy using a modified endoscopic classification and to correlate endoscopic findings with clinical symptoms.

Method:

This is a prospective observational study, conducted at a single center. Patients were submitted to a questionnaire for data collection. Endoscopic assessment of fundoplication was performed according to the classification in study, which considered four anatomical parameters including the gastroesophageal junction position in frontal view (above or at the level of the pressure zone); valve position at retroflex view (intra-abdominal or migrated); valve conformation (total, partial, disrupted or twisted) and paraesophageal hernia (present or absent).

Results:

One hundred patients submitted to fundoplication were evaluated, 51% male (mean age: 55.6 years). Forty-three percent reported postoperative symptoms. Endoscopic abnormalities of fundoplication anatomy were reported in 46% of patients. Gastroesophageal junction above the pressure zone (slipped fundoplication), and migrated fundoplication, were significantly correlated with the occurrence of postoperative symptoms. There was no correlation between symptoms and conformation of the fundoplication (total, partial or twisted).

Conclusion:

This modified endoscopic classification proposal of fundoplication anatomy is reproducible and seems to correlate with symptomatology. The most frequent abnormalities observed were slipped and migrated fundoplication, and both correlated with the presence of symptoms.

High Resolution Manometry Guidance During Laparoscopic Fundoplication in Pediatric Surgically "Fragile" Patients: Preliminary Report

Background: High resolution manometry (HRM), has been recently introduced in clinical practice to detect esophageal intraluminal pressure and esophageal motor function. We evaluated the feasibility and usefulness of intraoperative esophageal HRM during antireflux laparoscopic procedures in pediatric cases with neurological impairment (NI) or esophageal atresia (EA). Methods: From January to November 2019, seven children (5 NI, 2 EA) with gastroesophageal reflux (GER) were enrolled. Data on intraoperative pressure changes of the esophagogastric junction (EGJ) and postoperative follow-up data were collected. Results: Average preoperative LES pressures were not significantly different from postoperative pressures. A sliding hernia was detected in all patients as evidenced by EGJ double peak pressures. Hernia correction after esophageal traction was complete in 71.4% of the patients, and residual hernia (<2 cm) was detected in 28.6%. Postoperative EGJ pressures were higher compared to preoperative sphincteric pressures (p < 0.001); in NI patients, higher postoperative values were noted compared to EA (p = 0.05). No sliding hernia and/or GER relapses were recorded. Two patients reported dysphagia postoperatively. Conclusions: Intraoperative HRM may optimize esophageal pressure changes during laparoscopic fundoplication. Further studies are needed to confirm the usefulness of a tailored surgical approach to reduce postoperative complications.

Less is more: cruroplasty alone is sufficient for revisional hiatal hernia surgery

BACKGROUND

Recurrence of hiatal hernia after anti-reflux surgery is common, with past studies reporting recurrence rates of 10-15%. Most patients experience relief from GERD symptoms following initial repair; however, those suffering from recurrence can have symptoms severe enough to warrant another operation. Although the standard of care is to revise the fundoplication or convert to magnetic sphincter augmentation (MSA) in addition to redo cruroplasty, it stands to reason that with an intact fundoplication, a repeat cruroplasty is all that is necessary to alleviate the patients' symptoms. In other words, only fix that which is broken.

METHODS

A retrospective review of patients with symptomatic hiatal hernia recurrence who underwent reoperation between January 2011 and September 2018 was conducted. Patients who received revisional cruroplasty alone were compared with cruroplasty plus some other revision (fundoplication revision, or takedown and MSA placement). Demographics, operative details, and postoperative outcomes were collected.

RESULTS

There were 73 patients identified. Median time to recurrence after the first procedure was 3.7 (1.9-8.2) years. Thirty-two percent of the patients had GERD symptoms for more than 10 years. Twenty-six patients underwent cruroplasty only. Forty-seven patients underwent cruroplasty plus fundoplication revision. There were no significant differences in operative times (2.4 h cruroplasty alone, 2.8 h full revision, p = 0.75) or postoperative complications between the two groups. Patients had a mean follow-up time of 1.64 years. Of the 73 patients, 8 had subsequent hiatal hernia recurrence. The recurrence rate for patients with cruroplasty alone was 11%, and the recurrence rate for the full revision group was 12% (p = 1.00).

CONCLUSION

Leaving an intact fundoplication alone at the time of revisional surgery did not adversely affect surgical outcomes. This data suggests a role for hernia-only repair for recurrent hiatal hernias.

Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion?

BACKGROUND

Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution.

METHODS

A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed.

RESULTS

180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m² (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m² and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001).

CONCLUSIONS

RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Innovations in Endoscopic Therapy for Gastroesophageal Reflux Disease

Minimally invasive endoscopic antireflux therapies are critical for bridging the gap between medical and surgical treatments for gastroesophageal reflux disease (GERD). Although multiple endoscopic devices have been developed, perhaps some of the most exciting options that are currently evolving are the full-thickness suturing techniques using widely available and low-cost platforms. Full-thickness endoscopic suturing can allow for a highly durable recreation of the anatomic and functional components of a lower esophageal sphincter, which are deficient in patients with GERD. Proper patient selection, endoscopic hiatal hernia evaluation, and standardized suturing methods are necessary to ensure success of endoscopic suturing for antireflux therapy.

Laparoscopic Surgery for Recurrent Hiatal Hernia

Surgical treatment of hiatal hernia (HH) is well standardized. However, recurrence is observed in 15%-60% of cases, and is challenging to manage. The aim of this study was to analyze the causes of surgical failure and provide some guidelines for treatment. The symptoms of recurrent HH vary widely, and include persistent reflux, dysphagia, and permanent discomfort, leading to a marked change in the quality of life. Morphological and functional pretherapeutic evaluation is necessary to determine whether the symptoms are due to recurrent HH, and to understand the cause of failure. Redo surgery is technically difficult and challenging, and should only be used in symptomatic patients whose symptoms are definitively those of recurrent HH.

Retrospective Review and Prospective Follow-up of 85 Consecutive Patients Treated With a Novel Hepatic-derived Surgical Mesh for Hiatal Hernia Repair: Outcomes, Surgical Complications, and Revisions

This study examined outcomes, surgical complications, and revisions in patients treated with laparoscopic Nissen fundoplication for hiatal hernia and substantial gastroesophageal reflux disease. In total, 85 consecutive patients who underwent hernia repair with MIROMESH Biologic Matrix, a novel hepatic-derived surgical mesh served as subjects. Subjects were contacted by phone, consented, and participated in an Institutional Review Board-approved structured phone interview. Responses were acquired from 73 of the 85 patients. The gastroesophageal reflux disease health-related quality of life showed significant improvement postoperatively. Subjects reported high satisfaction with the procedure. The use of proton pump inhibitors was significantly reduced. Three minor complications were reported; these were quickly resolved without further sequelae. There were no mesh-related complications. No subjects reported further surgery. Placement of the surgical mesh, during surgery, to reinforce the hiatal repair was easy and safe. Excellent outcomes and no revisions a mean of 1.3 years after surgery suggest that a durable repair had been achieved.

Laparoendoscopic Single-Site (LESS) versus Robotic “Redo” Hiatal Hernia Repair with Fundoplication: Which Approach is Better?

Only a small percentage of patients fail laparoscopic fundoplications undertaken for gastroesophageal reflux disease. But because many laparoscopic fundoplications have been undertaken, surgeons frequently encounter patients in need of “redo” operations. This study was undertaken to evaluate the robotic approach versus laparoendoscopic single-site (LESS) approach for redo fundoplications. With an Institutional Review Board approval, 64 patients undergoing LESS (n = 32) or robotic (n = 32) redo antireflux operations were prospectively followed up. Data are presented as median (mean + SD). For LESS versus robotic redo operations, the operative duration was 145 (143 ± 33.5) versus 196 (208 ± 76.7) minutes ( P < 0.01), estimated blood loss was 50 (80 ± 92.1) versus 20 (43 ± 57.1) mL ( P = 0.07), and length of stay was 1 (3 ± 5.4) versus 1 (2 ± 1.9) day ( P = 0.57); 1 LESS operation was converted to “open.” Operative duration was longer for men ( P = 0.01). Postoperative complications were not more frequent after Nissen (n = 36) or Toupet (n = 28) fundoplication, regardless of the approach. When matched by BMI, operative duration was prolonged by a large Type I to IV hiatal hernia ( P = 0.01). Symptoms improved dramatically and were similar with both approaches, and patient satisfaction was high. Robotic redo antireflux operations take longer than LESS operations. LESS and robotic redo antireflux operations are both safe and offer significant and similar amelioration of symptoms after failed fundoplications.

Comparison of surgical payer costs and implication on the healthcare expenses between laparoscopic magnetic sphincter augmentation (MSA) and laparoscopic Nissen fundoplication (LNF) in a large healthcare system

Introduction

Magnetic sphincter augmentation (MSA) is a promising antireflux surgical treatment. The cost associated with the device may be perceived as a drawback by payers, which may limit the adoption of this technique. There are limited data regarding the cost of MSA in the management of reflux disease. The aims of the study were to report the clinical outcome and quality of life measures in patients after MSA and to compare the pharmaceutical and procedure payer costs and the disease-related and overall expense of MSA compared to laparoscopic Nissen fundoplication (LNF) from a payer perspective.

Methods and procedures

This prospective observational study was performed in conjunction with the region’s largest health insurance company. Data were collected on patients who underwent MSA over a 2-year period beginning in September 2015 at the study network hospitals. The LNF comparison group was procured from members’ claims data of the payer. Inclusion was predicated by patients having continuous coverage during study period. The total procedural reimbursement and the disease-related and overall medical claims submitted up to 12 months prior to surgery and up to 12 months following surgery were obtained. The payer reimbursement data are presented as allowed cost per member per month (PMPM). These values were then compared between groups.

Results

There were 195 patients who underwent MSA and 1131 that had LNF. MSA results in comparable symptom control, PPI elimination rate, and quality of life measures compared to values reported for LNF in the literature. The median (IQR) reimbursement of surgery was $13,522 (13,195–14,439) for those who underwent MSA and $13,388 (9951–16,261) for patients with LNF, p = 0.02. In patients who underwent MSA, the median reimbursement related to the upper gastrointestinal disease was $ 305 PMPM, at 12 months prior to surgery and $ 104 at 12 months after surgery, representing 66% decrease in cost. These values were $ 233 PMPM and $126 PMPM for patients who underwent LNF, representing a 46% decrease (p = 0.0001). At 12 months following surgery, the reimbursement for overall medical expenses had decreased by 10.7% in the MSA group and 1.4% in the LNF group when compared to the preoperative baseline reimbursement. The reimbursement for PPI use after surgery showed a 95% decrease in the MSA group and 90% among LNF group when compared to the preoperative baseline (p = 0.10).

Conclusion

When compared with LNF, MSA results in a reduction of disease-related expenses for the payer in the year following surgery. While MSA is associated with a higher procedural payer cost compared to LNF, payer costs may offset due to reduction in the expenses after surgery.

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature

BACKGROUND

Chronic cough is often associated with gastroesophageal reflux disease (GERD). The role of gastroenterologist in the management of the chronic cough is to identify and manage GERD. Ineffective esophageal motility is often associated with GERD induced cough. Chronic cough is often refractory to medical and surgical management despite adequate acid control. Unresponsiveness warrants a thorough pulmonary evaluation. The pathophysiology of refractory cough in these patients is poorly understood, and hence management is often challenging.

CASE PRESENTATION

A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough.

CONCLUSION

Frequent sips of water can be used in the management of the gastroesophageal reflux and ineffective motility induced cough. It results in increased esophageal clearance of acid, nonacid reflux, and ingested pharyngeal secretions, thus breaking the cycle of cough generated increased intra-abdominal pressure with reflux and more cough.

Does retching matter? Reviewing the evidence-Physiology and forces

Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure. Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking. Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown. Retching needs to be addressed if we are to reduce the incidence of wrap failure. Level of Evidence V.

[Redo laparoscopic surgery for recurrent gastroesophageal reflux disease and hiatal hernia]

AIM

To assess mechanisms of recurrent gastroesophageal reflux disease and the ability to perform adequate surgical correction after previous surgery.

MATERIAL AND METHODS

The authors from various surgical centers have operated 2678 patients with gastroesophageal reflux disease and hiatal hernia for the period 1993-2018. 127 (4.74%) patients underwent redo surgery for recurrent disease, 46 of them were previously operated in other clinics.

RESULTS

Median follow-up after redo surgery was 63 months (12-139). Satisfactory functional result was achieved in 76.4% of patients.

A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication?

BACKGROUND

Nearly 20% of patients who undergo hiatal hernia (HH) repair and anti-reflux surgery (ARS) report recurrent HH at long-term follow-up and may be candidates for redo surgery. Current literature on redo-ARS has limitations due to small sample sizes or single center experiences. This type of redo surgery is challenging due to rare but severe complications. Furthermore, the optimal technique for redo-ARS remains debatable. The purpose of the current multicenter study was to review the outcomes of redo-fundoplication and to identify the best ARS repair technique for recurrent HH and gastroesophageal reflux disease (GERD).

METHODS

Data on 975 consecutive patients undergoing hiatal hernia and GERD repair were retrospectively collected in five European high-volume centers. Patient data included demographics, BMI, techniques of the first and redo surgeries (mesh/type of ARS), perioperative morbidity, perioperative complications, duration of hospitalization, time to recurrence, and follow-up. We analyzed the independent risk factors associated with recurrent symptoms and complications during the last ARS. Statistical analysis was performed using GraphPad Prism^® and R software^®.

RESULTS

Seventy-three (7.49%) patients underwent redo-ARS during the last decade; 71 (98%) of the surgeries were performed using a minimally invasive approach. Forty-two (57.5%) had conversion from Nissen to Toupet. In 17 (23.3%) patients, the initial Nissen fundoplication was conserved. The initial Toupet fundoplication was conserved in 9 (12.3%) patients, and 5 (6.9%) had conversion of Toupet to Nissen. Out of the 73 patients, 10 (13%) underwent more than one redo-ARS. At 8.5 (1-107) months of follow-up, patients who underwent reoperation with Toupet ARS were less symptomatic during the postoperative period compared to those who underwent Nissen fundoplication (p = 0.005, OR 0.038). Patients undergoing mesh repair during the redo-fundoplication (21%) were less symptomatic during the postoperative period (p = 0.020, OR 0.010). The overall rate of complications (Clavien-Dindo classification) after redo surgery was 11%. Multivariate analysis showed that the open approach (p = 0.036, OR 1.721), drain placement (p = 0.0388, OR 9.308), recurrence of dysphagia (p = 0.049, OR 8.411), and patient age (p = 0.0619, OR 1.111) were independent risk factors for complications during the last ARS.

CONCLUSIONS

Failure of ARS rarely occurs in the hands of experienced surgeons. Redo-ARS is feasible using a minimally invasive approach. According to our study, in terms of recurrence of symptoms, Toupet fundoplication is a superior ARS technique compared to Nissen for redo-fundoplication. Therefore, Toupet fundoplication should be considered in redo interventions for patients who initially underwent ARS with Nissen fundoplication. Furthermore, mesh repair in reoperations has a positive impact on reducing the recurrence of symptoms postoperatively.

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.

Late esophageal wall injury after mesh repair for large esophageal hiatal hernia: a case report

Background

Plication of an esophageal hiatus during surgery for esophageal hiatal hernia is a common practice; however, a mesh may be used if the hiatus is markedly enlarged. Recently, various late complications occurring as a result of mesh-induced esophageal and/or gastric wall injuries have been reported.

Case presentation

A 71-year-old woman presented at a neighborhood clinic in November 2010 with chief complaints of respiratory distress on exertion and heartburn. She was diagnosed as having a large esophageal hiatal hernia and was treated at our hospital using a laparoscopic Toupet fundoplication with mesh repair of the esophageal hiatus. Two years and 1 month after the operation, the patient complained of a bowel obstruction. An upper gastrointestinal endoscopy revealed that part of the mesh had extruded into the esophageal lumen, resulting in ulceration and stricture of the esophageal wall. Endoscopic balloon dilatation failed to improve the esophageal stricture. In July 2012, the patient underwent a lower esophagectomy with proximal gastrectomy and was discharged on the 25th hospital day.

Conclusions

We experienced a rare case requiring surgical treatment for a mesh-induced esophageal wall injury after surgery for a giant esophageal hiatal hernia. The selection of a soft, durable mash and its firm securement at a position distant from the gastrointestinal wall may be important to avoid late esophageal wall injury.

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.

Development of a novel ex vivo porcine laparoscopic Heller myotomy and Nissen fundoplication training model (Toronto lap-Nissen simulator)

BACKGROUND

Surgical trainees are required to develop competency in a variety of laparoscopic operations. Developing laparoscopic technical skills can be difficult as there has been a decrease in the number of procedures performed. This study aims to develop an inexpensive and anatomically relevant model for training in laparoscopic foregut procedures.

METHODS

An ex vivo, anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach, diaphragm and spleen. The Toronto lap-Nissen simulator was contained in a laparoscopic box-trainer and included an arch system to simulate the normal radial shape and tension of the diaphragm. We integrated the use of this training model as a part of our laparoscopic skills laboratory-training curriculum. Afterwards, we surveyed trainees to evaluate the observed benefit of the learning session.

RESULTS

Twenty-five trainees and five faculty members completed a survey regarding the use of this model. Among the trainees, only 4 (16%) had experience with laparoscopic Heller myotomy and Nissen fundoplication. They reported that practicing with the model was a valuable use of their limited time, repeating the exercise would be of additional benefit, and that the exercise improved their ability to perform or assist in an actual case in the operating room. Significant improvements were found in the following subjective measures comparing pre- vs. post-training: (I) knowledge level (5.6 vs. 8.0, P<0.001); (II) comfort level in assisting (6.3 vs. 7.6, P<0.001); and (III) comfort level in performing as the primary surgeon (4.9 vs. 7.1, P<0.001). The trainees and faculty members agreed that this model was of adequate fidelity and was a representative simulation of actual human anatomy.

CONCLUSIONS

We developed an easily reproducible training model for laparoscopic procedures. This simulator reproduces human anatomy and increases the trainees' comfort level in performing and assisting with myotomy and fundoplication.

Tension-Free Inlay Repair of Large Hiatal Hernias Using Dual-Sided Composite PTFE/ePTFE Meshes in Laparoscopic Surgery for Gastroesophageal Reflux Disease

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) also frequently suffer from concomitant hiatal hernia. It has been described that a preoperative hiatal hernia of ≥3 cm is associated with a more than threefold relative risk for reflux symptom recurrence after fundoplication without mesh reinforcement. In this report, we describe our experience with the implantation of dual-sided composite PTFE/ePTFE meshes in a tension-free fashion during laparoscopic antireflux surgery (LARS).

METHODS

A prospective database containing data of all patients undergoing LARS and hiatal hernia repair with mesh implantation from January 2009 until December 2014 was interrogated. Ten patients with preoperative esophageal high resolution manometry and 24-hour pH impedance monitoring because of symptoms suggestive of GERD who received hiatal repair using dual-sided meshes in inlay technique were identified and included in this analysis.

RESULTS

There were no conversions to open surgery in the study group. Median operative time was 138 minutes (interquartile range Q1-Q3: 119-151 minutes) and average length of postoperative stay was 3.5 days (interquartile range Q1-Q3: 2.3-4.0 days). During a median follow-up period of 43.3 months (interquartile range Q1-Q3: 18.9-47.1 months), no redo operations had to be performed. Noteworthy, 2 patients complained about dysphagia (20%) during follow-up, but symptoms resolved after endoscopic interventions.

CONCLUSIONS

Tension-free inlay repair of large hiatal hernias using dual-sided composite PTFE/ePTFE meshes during LARS provides promising results. It provides satisfactory symptom relief and prolonged control of GERD. Further studies to validate its efficiency in a larger collective are needed.

Tri-comparison of Laparoscopic Nissen, Hill, and Nissen-Hill Hybrid Repairs for Uncomplicated Gastroesophageal Reflux Disease

BACKGROUND

A randomized controlled trial (RCT) showed that laparoscopic Nissen fundoplication (LNF) and Hill (LHR) repairs are equivalent in treating uncomplicated GERD. We combined both repairs to create a laparoscopic Nissen-Hill Hybrid repair (HYB). The purpose of this study is to compare clinical and objective outcomes of a matched group of HYB to the two cohorts of the RCT.

METHODS

A retrospective analysis of prospectively collected data from the RCT and a prospectively collected data base was performed. Data were collected preoperatively, postoperatively short-term (ST) at 6 weeks and mid-term (MT) at 6-12 months. Evaluation was standardized according to the RCT and included three quality of life metrics (QOLRAD, GERD-HRQL, Dysphagia), endoscopy, manometry, pH testing, and barium swallow.

RESULTS

There were 51 HYB, 46 LNF, and 56 LHR patients. Age, BMI, follow-up, and gender were comparable. QOLRAD, HRQL, PPI use, DeMeester scores, and pH% time <4 significantly improved in all groups and were equivalent. Anatomic recurrence was seen in five LNF, four LHR, and two HYB patients. Reoperations were performed in three LHR, two LNF, and zero HYB patients.

CONCLUSION

Tri-comparison shows that HYB is a promising alternative to LHR and LNF. Side effects were not increased and there were fewer reoperations for failure.

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.

Short- and Long-Term, 11-22 Years, Results after Laparoscopic Nissen Fundoplication in Obese versus Nonobese Patients

BACKGROUND

Some studies suggest that obesity is associated with a poor outcome after Laparoscopic Nissen Fundoplication (LNF), whereas others have not replicated these findings. The effect of body mass index (BMI) on the short- and long-term results of LNF is investigated.

METHODS

Inclusion criteria were only patients who undergone a LNF with at least 11-year follow-up data available, patients with preoperative weight and height data available for calculation of BMI (Kg/m²), and patients with a BMI up to a maximum of 34.9.

RESULTS

201 patients met the inclusion criteria: 43 (21.4%) had a normal BMI, 89 (44.2%) were overweight, and 69 (34.4%) were obese. The operation was significantly longer in obese patients; the use of drains and graft was less in the normal BMI group (p < 0.0001). The hospital stay, conversion (6,4%), and intraoperative and early postoperative complications were not influenced by BMI.

CONCLUSIONS

BMI does not influence short-term outcomes following LNF, but long-term control of reflux in obese patients is worse than in normal weight subjects.

Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study

Surgery for refractory gastroesophageal reflux disease (GERD) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients. Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality. This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery, with the objective to detect possible advantages for the robot-assisted approach. A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study. Baseline characteristics, symptoms, medical history, procedural data, hospital stay, complications and outcome were prospectively gathered. The main indications for redo surgery were dysphagia, pyrosis or a combination of both in combination with a proven anatomic abnormality. The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups, respectively. The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy (1/45 vs. 5/30, p = 0.035) despite a higher proportion of patients with previous surgery by laparotomy (9/45 vs. 1/30, p = 0.038). Median hospital stay was reduced by 1 day (3 vs. 4, p = 0.042). There were no differences in mortality, complications or outcome. Robotic support, when available, can be regarded beneficial in redo surgery for GERD and hiatal hernia. Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery, a reduced number of conversions and shorter hospital stay.

Multi-institutional outcomes using magnetic sphincter augmentation versus Nissen fundoplication for chronic gastroesophageal reflux disease

BACKGROUND

Magnetic sphincter augmentation (MSA) has emerged as an alternative surgical treatment of gastroesophageal reflux disease (GERD). The safety and efficacy of MSA has been previously demonstrated, although adequate comparison to Nissen fundoplication (NF) is lacking, and required to validate the role of MSA in GERD management.

METHODS

A multi-institutional retrospective cohort study of patients with GERD undergoing either MSA or NF. Comparisons were made at 1 year for the overall group and for a propensity-matched group.

RESULTS

A total of 415 patients (201 MSA and 214 NF) underwent surgery. The groups were similar in age, gender, and GERD-HRQL scores but significantly different in preoperative obesity (32 vs. 40 %), dysphagia (27 vs. 39 %), DeMeester scores (34 vs. 39), presence of microscopic Barrett's (18 vs. 31 %) and hiatal hernia (55 vs. 69 %). At a minimum of 1-year follow-up, 354 patients (169 MSA and 185 NF) had significant improvement in GERD-HRQL scores (pre to post: 21-3 and 19-4). MSA patients had greater ability to belch (96 vs. 69 %) and vomit (95 vs. 43 %) with less gas bloat (47 vs. 59 %). Propensity-matched cases showed similar GERD-HRQL scores and the differences in ability to belch or vomit, and gas bloat persisted in favor of MSA. Mild dysphagia was higher for MSA (44 vs. 32 %). Resumption of daily PPIs was higher for MSA (24 vs. 12, p = 0.02) with similar patient-reported satisfaction rates.

CONCLUSIONS

MSA for uncomplicated GERD achieves similar improvements in quality of life and symptomatic relief, with fewer side effects, but lower PPI elimination rates when compared to propensity-matched NF cases. In appropriate candidates, MSA is a valid alternative surgical treatment for GERD management.

Results of left thoracoscopic Collis gastroplasty with laparoscopic Nissen fundoplication for the surgical treatment of true short oesophagus in gastro-oesophageal reflux disease and Type III-IV hiatal hernia

OBJECTIVES

Controversy exists regarding surgery for true short oesophagus (TSOE). We compared the results of thoracoscopic Collis gastroplasty-laparoscopic Nissen procedure for the treatment of TSOE with the results of standard laparoscopic Nissen fundoplication.

METHODS

Between 1995 and 2013, the Collis-Nissen procedure was performed in 65 patients who underwent minimally invasive surgery when the length of the abdominal oesophagus, measured intraoperatively after maximal oesophageal mediastinal mobilization, was ≤1.5 cm. The results of the Collis-Nissen procedure were frequency-matched according to age, sex and period of surgical treatment with those of 65 standard Nissen fundoplication procedures in patients with a length of the abdominal oesophagus >1.5 cm. Postoperative mortality and morbidity were evaluated according to the Accordion classification. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. Symptoms, oesophagitis and global results were graded according to semi-quantitative scales. The results were considered to be excellent in the absence of symptoms and oesophagitis, good if symptoms occurred two to four times a month in the absence of oesophagitis, fair if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis and poor if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, hiatal hernia of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up.

RESULTS

The postoperative mortality rate was 1.5% for the Collis-Nissen and 0 for the Nissen procedure. The postoperative complication rate was 24% for the Collis-Nissen and 7% for Nissen (P = 0.001) procedure. The complication rate for the Collis-Nissen procedure was 43% in the first 32 cases and 6% in the last 33 cases (P < 0.0001). The median follow-up period was 96 months. The results were: excellent in 27% of Collis-Nissen and 29% of Nissen; good in 64% of Collis-Nissen and 55% of Nissen; fair in 3% of Collis-Nissen and 11% of Nissen and poor in 6% of Collis-Nissen and 5% of Nissen (P = 0.87).

CONCLUSIONS

In patients affected by a TSOE, the Collis-Nissen procedure may achieve equally satisfactory results as the standard Nissen procedure in uncomplicated patients.

CLINICAL REGISTRATION NUMBER

NCT02288988.

Gastropericardial fistula as a delayed complication of a Nissen fundoplication

A 41-year-old man presented to the emergency department with substernal chest pain and was found to have ST elevations in the inferior leads on his electrocardiogram. An emergent cardiac catheterization did not identify significant coronary narrowing. Computed tomography of the thorax demonstrated a pneumopericardium and a hiatal hernia. The patient had a complicated past surgical history, including a Nissen fundoplication and three additional surgeries for postoperative complications. An esophagram later revealed an ulcer and possible fistula, and the patient underwent gastropericardial fistula resection after the fistula failed to close with fibrin sealant application. Enteropericardial fistulas occur infrequently but have high morbidity and mortality rates. This possibility is much more likely in patients with prior gastroesophageal surgery, including laparoscopic Nissen fundoplication.

The importance of the mesh shape in preventing recurrence after Nissen fundoplication

Gastro esophageal reflux disease (GERD) is the most common gastrointestinal disorder and often is associated with hiatal hernia (HH). Nissen fundoplication is the most common surgical treatment method. Despite surgical treatment, recurrence rate is still high. In this study, we aimed to identify the importance of the mesh shape in preventing recurrence after Nissen fundoplication. A hundred twenty two patients who operated Nissen fundoplication owing to GERD and/or HH were evaluated. Nissen fundoplication was made all patients. Patients were divided into three groups according to hiatoplasty procedure; group 1 (V-shaped mesh), group 2 (V-shaped mesh + Fibrin glue), and group 3 (special designed mesh, Kar's mesh). Groups were compared regarding intraoperative, postoperative early- and long-term complications. Mean age was 42.75 years, and male to female ratio was 1:2.98. The mean follow-up period was 27 mounts. There was no mortality during follow-up. The most common presenting symptom was heartburn (93.4%). There wasn't difference between groups in terms of the intraoperative complications and postoperative early-term complications. The overall recurrences rate was 4.9% and dysphagia > 3 months rate was 1.6%. No recurrence was not observed in group 3, while recurrence was observed in 4 patients in group 1 (P = 0.030). Patients should be carefully selected for surgery because complication rate is high despite successful anti-reflux surgical treatment. In this study, we have used a special designed mesh. We believe that this special designed mesh can be used safely and effectively in anti-reflux surgery because recurrence and complications were not observed.

Surgical treatment of gastroesophageal reflux disease

Operative treatment of GERD has become more common since the introduction of LARS. Careful patient selection based on symptoms, response to medical therapy, and preoperative testing will optimize the chances for effective and durable postoperative control of symptoms. Complications of the LARS are rare and generally can be managed without reoperation. When reoperation is necessary for failed antireflux surgery, it should be performed by high-volume gastroesophageal surgeons.

New surgical approach for giant paraesophageal hernia repair: closure of the esophageal hiatus anteriorly using the left triangular ligament

BACKGROUND

Obtaining a tension-free repair for giant paraesophageal hernias (PEH) is often challenging. Many different techniques have been proposed, including laparoscopic posterior hiatoplasty with the use of prosthetic or biologic mesh as well as the use of autologous teres or falciform ligament flaps. In this report, we describe the use of the left triangular ligament as an onlay autologous vascularized flap to bridge the anterior residual defect after posterior cruroplasty.

METHODS

A novel technique of paraesophageal hiatal hernia repair is described. Posterior hiatoplasty is performed, including the approximation of the diaphragmatic crural fibers to the extent possible. The left triangular ligament is then mobilized and sutured to the right and left crural fibers lining the esophageal hiatus to seal the anterior residual diaphragmatic defect.

RESULTS

This technique has been performed in 4 patients with a mean age of 71 years and a 3:1 female to male ratio. The average hiatal defect size was 5.5 cm and the average length of operation was 122 min. There was no evidence of radiologic or clinical recurrence on follow-up.

CONCLUSION

The use of the left triangular ligament flap is feasible and may be a valuable tool for closure of an anterior diaphragmatic defect in giant PEHs. Additional studies to validate its long-term function are needed.

Management of gastroesophageal reflux disease in pediatric patients: a literature review

Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a physiologic process that occurs throughout the day in healthy infants and children. Gastroesophageal reflux disease (GERD) occurs when gastric contents flow back into the esophagus and produce symptoms. The most common esophageal symptoms are vomiting and regurgitation. Lifestyle changes are the first-line therapy in both GER and GERD; medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. The laparoscopic Nissen antireflux procedure is the gold standard for the treatment of this pathology. A literature search on PubMed and Cochrane Database was conducted with regard to the management of GERD in children to provide a view of state-of-the-art treatment of GERD in pediatrics.