Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication

Bolus exposure as a novel predictor of postoperative symptom resolution after laparoscopic Nissen fundoplication: a two-institutional retrospective cohort study

BACKGROUND

Even in the absence of definite evidence of pathological acid reflux, antireflux surgery (ARS) can still effectively improve gastroesophageal reflux symptoms. Nonetheless, predicting postoperative reflux symptom improvement has been primarily dependent on acid-based parameters. No objective index reflecting both acid and nonacid reflux was identified to select ARS candidates.

MATERIALS AND METHODS

Prospectively collected data of 121 patients with gastroesophageal reflux disease (GERD), who underwent laparoscopic Nissen fundoplication from two institutions, were retrospectively reviewed. The patients reported preoperative and postoperative GERD symptoms using the Korean version of the GERD questionnaire, along with the gastroesophageal reflux disease-health-related quality of life (GERD-HRQL). The patients were assessed for reflux symptoms using bolus exposure, acid exposure time (AET), and DeMeester score (DMS) as measurements were selected. For each reflux parameter, its association, correlation, and predictive capacity of the degree of postoperative symptom resolution were analyzed using χ2 tests, point-biserial correlations, logistic regression analyses, and receiver operating characteristic curve analyses.

RESULTS

Seventy-two patients were eligible for this study. Bolus exposure was superior to the other parameters in terms of the degree of association and correlation with a resolution of typical symptoms. Bolus exposure also showed a higher diagnostic accuracy in predicting the resolution of epigastric pain (area under the curve [AUC]=0.723, P =0.013) and regurgitation (AUC=0.981, P <0.001). Secondary analyses were performed in patients without pathological reflux, defined as the DMS-negative (DMS <14.7) or AET-negative (AET <6%) groups. In the secondary analyses, bolus exposure showed considerable diagnostic accuracy with statistical significance for all typical symptoms in both the DMS-negative (heartburn: AUC=0.717, P =0.025; epigastric pain: AUC=0.717, P =0.025; regurgitation: AUC=0.975, P <0.001) and AET-negative (heartburn: AUC=0.681, P =0.045; epigastric pain: AUC=0.749, P =0.009; regurgitation: AUC=0.975, P <0.001) groups.

CONCLUSION

Bolus exposure, a parameter of total reflux, was superior to AET or DMS in defining candidates for ARS. Further studies investigating the surgical indications for ARS in patients with nonacid reflux using bolus exposure are required.

Reappraisal of optimal reconstruction after distal gastrectomy - a study based on the KLASS-07 database

BACKGROUNDS

This study aimed to compare the incidence of bile reflux, quality of life (QoL), and nutritional status among Billroth II (BII), Billroth II with Braun anastomosis (BII-B), and Roux-en-Y (RY) reconstruction after laparoscopic distal gastrectomy (LDG).

MATERIALS AND METHODS

We reviewed the prospective data of 397 patients from a multicentre database who underwent LDG for gastric cancer between 2018 and 2020 at 20 tertiary teaching hospitals in Korea. Postoperative endoscopic findings, QoL surveys using the European Organization for Research and Treatment of Cancer questionnaire (C30 and STO22), and nutritional and surgical outcomes were compared among groups.

RESULTS

In endoscopic findings, bile reflux was the lowest in the RY group ( n =67), followed by the BII-B ( n =183) and BII groups ( n =147) at 1 year (3.0 vs. 67.8 vs. 84.4%, all P <0.05). The anti-reflux capability of BII-B was statistically better than that of BII, but not as perfect as that of RY. From the perspective of QoL, BII-B was not inferior to RY, but better than BII reconstruction in causing fewer STO22 reflux symptoms at 6 and 12 months. However, only RY caused fewer C30 nausea symptoms than BII at 6 and 12 months, but not BII-B. Nutritional status and morbidities were similar among the three groups, and the operative time did not differ between the BII-B and RY groups.

CONCLUSIONS

BII-B cannot substitute for RY in preventing bile reflux, shortening the operative time, or reducing morbidities. Regarding short-term QoL, BII-B was sufficient to reduce STO22 reflux symptoms but failed to reduce C30 nausea symptoms postoperatively.