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Alzahrani MA, Alqaraawi AM, Alzubide SR, Abufarhaneh E, Alkhowaiter SS, Alsulaimi M, Alkhiari R, AlMalki AS, Alfadda AA, Aljahdli ES, Alsohaibani FI, AlLehibi AH, Almadi MA. The Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of GERD. Saudi J Gastroenterol 2024:00936815-990000000-00086. [PMID: 38813746 DOI: 10.4103/sjg.sjg_82_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
ABSTRACT Gastroesophageal reflux disease (GERD) is one of the most common problems encountered in outpatient general medicine and gastroenterology clinics. GERD may present with classic esophageal symptoms, extraesophageal symptoms, or mixed symptoms. The diagnosis and treatment of GERD are challenging due to the variety of symptoms and multifactorial pathophysiology. Since there is no consensus on the diagnosis and treatment of GERD in Saudi Arabia, the Saudi Gastroenterology Association established an expert group to formulate a consensus on the clinical care pathway for the diagnosis and treatment of GERD to update health-care providers in Saudi Arabia. The expert group reviewed the literature including recently published international guidelines, clinical trials, and expert opinion and conducted virtual and in-person meetings. A total of 22 statements on the definition, diagnosis, and treatment of GERD were formulated, and three algorithms for the clinical care of GERD were developed with a detailed description for each step. The expert group endorsed the new definition of GERD, the practical principles of interpretation of the diagnostic GERD evaluation, and the practical guidance for GERD treatment including medical, surgical, and endoscopic therapy. The expert group recommends further studies to investigate local data on the diagnosis and treatment of GERD.
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Affiliation(s)
- Mohammed A Alzahrani
- Department of Medicine, College of Medicine, King Khalid University, Abha, Riyadh, Saudi Arabia
| | - Abdullah M Alqaraawi
- Department of Medicine, Gastroenterology Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saeed R Alzubide
- Department of Gastroenterology and Hepatology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ehab Abufarhaneh
- Liver and Small Bowel Health Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saad S Alkhowaiter
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Resheed Alkhiari
- Department of Medicine, College of Medicine, Qassim University, Qassim, Saudi Arabia
| | - Ahmed S AlMalki
- Gastroenterology Section, Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Abdulrahman A Alfadda
- Department of Medicine, Gastroenterology Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Emad S Aljahdli
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Gastrointestinal Oncology Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Fahad I Alsohaibani
- Department of Medicine, Gastroenterology Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abid H AlLehibi
- Department of Gastroenterology and Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Majid A Almadi
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Valdovinos Díaz MA, Amieva-Balmori M, Carmona-Sánchez R, Coss-Adame E, Gómez-Escudero O, González-Martínez M, Huerta-Iga F, Morel-Cerda E, Remes-Troche JM, Tamayo-de la Cuesta JL, Torres-Villalobos G, Valdovinos-García LR, Vázquez-Elizondo G, Villar-Chávez AS, Arenas-Martínez JA. Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:121-143. [PMID: 38580493 DOI: 10.1016/j.rgmxen.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/06/2023] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment. AIM The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD. METHODS The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires. RESULTS Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient. CONCLUSIONS An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.
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Affiliation(s)
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Intestinal, Instituto de Investigaciones Médico-Biológicas de la Universidad Veracruzana, Veracruz, Mexico
| | - R Carmona-Sánchez
- Servicio de Gastroenterología, Práctica privada, San Luis Potosí, Mexico
| | - E Coss-Adame
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia y Motilidad Gastrointestinal, Endoneurogastro, Hospital Ángeles Puebla, Puebla, Mexico
| | - M González-Martínez
- Departamento de Endoscopia, Hospital de Especialidades del CMN Siglo XXI IMSS, Mexico City, Mexico
| | - F Huerta-Iga
- Servicio de Gastroenterología, Hospital Ángeles Torreón, Torreón, Mexico
| | - E Morel-Cerda
- Departamento de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Intestinal, Instituto de Investigaciones Médico-Biológicas de la Universidad Veracruzana, Veracruz, Mexico
| | - J L Tamayo-de la Cuesta
- Servicio de Gastroenterología y Endoscopia Gastrointestinal, Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - G Torres-Villalobos
- Cirugía Experimental, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - G Vázquez-Elizondo
- Servicio de Gastroenterología, Centro de Enfermedades Digestivas ONCARE, Monterrey, Mexico
| | - A S Villar-Chávez
- Servicio de Gastroenterología, Hospital Ángeles Acoxpa, Mexico City, Mexico
| | - J A Arenas-Martínez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Jani K. 'Critical circle of fundoplication' - A key concept towards creating identical, replicable and consistent fundoplication wraps. J Minim Access Surg 2023; 19:355-360. [PMID: 36695240 PMCID: PMC10449043 DOI: 10.4103/jmas.jmas_173_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 07/20/2022] [Indexed: 01/22/2023] Open
Abstract
Background There is a significant learning curve associated with laparoscopic Nissen's fundoplication, during which, complications due to surgical errors are more likely to occur. Moreover, length of the wrap, its situation on the lower esophagus and the points of the fundus brought together to create the wrap are arbitrary and as per the surgeon's judgement and estimation. This leads to a lot of variation in the wraps created, not only from surgeon to surgeon, but also from case to case for each individual surgeon. We propose a new concept of 'Critical Circle of Fundoplication' and the new approach to construct the fundoplication based on this concept, by application of which, a mathematically precise fundoplication can be created which is consistent, accurate and optimum. Patients and Methods A total of 132 patients were operated based on the concept of 'Critical Circle of Fundoplication' between 2015 and 2020, of which 116 patients completed one year of follow-up and are included in the paper. Results The demographic characteristics, intraoperative findings and postoperative are described in detail. An additional average time of 10.5 minutes (range: 8-26 minutes) was required in the precise measurements and markings that were required by this approach. Conclusion By application of the concept of 'Critical Circle of Fundoplication', precise, consistent and optimum wraps can be created. By eliminating the errors of structural construction and placement of the wrap, overall results can be improved.
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Affiliation(s)
- Kalpesh Jani
- Department of GI and Laparoscopic Surgery, VIGOS Hospital, Vadodara, Gujarat, India
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Lee Y, Tahir U, Tessier L, Yang K, Hassan T, Dang J, Kroh M, Hong D. Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials. Surg Endosc 2023:10.1007/s00464-023-10151-5. [PMID: 37308760 DOI: 10.1007/s00464-023-10151-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/20/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND In the surgical management of GERD, the traditional procedure is laparoscopic total (Nissen) fundoplication. However, partial fundoplication has been advocated as providing similar reflux control while potentially minimizing dysphagia. The comparative outcomes of different approaches to fundoplication are a topic of ongoing debate and long-term outcomes remain uncertain. This study aims to compare long-term gastroesophageal reflux disease (GERD) related outcomes following different fundoplication procedures. METHODS MEDLINE, EMBASE, PubMed, and CENTRAL databases were searched up to November 2022 to identify randomized controlled trials (RCTs) comparing different types of fundoplications reporting long-term (> 5 years) outcomes. The primary outcome was incidence of dysphagia. Secondary outcomes included incidence of heartburn/reflux, regurgitation, inability to belch, abdominal bloating, reoperation, and patient satisfaction. DataParty, which uses Python 3.8.10 was used to perform the network meta-analysis. We evaluated the overall certainty of evidence with the GRADE framework. RESULTS 13 RCTs were included, with 2063 patients across Nissen (360°), Dor (anterior 180°-200°), and Toupet (posterior 270°) fundoplications. Network estimates demonstrated that Toupet had lower incidence of dysphagia compared to Nissen (OR 0.285; 95% CrI 0.06-0.958). There were no differences in dysphagia between Toupet and Dor (OR 0.473, 95% CrI 0.072-2.835) or between Dor and Nissen (OR 1.689, 95% CrI 0.403-7.699). The three fundoplication types were comparable in all other outcomes. CONCLUSIONS All three approaches of fundoplication share similar long-term outcomes, with the Toupet fundoplication likely providing the best long-term durability with lowest odds of developing postoperative dysphagia.
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Affiliation(s)
- Yung Lee
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Umair Tahir
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Lea Tessier
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Kevin Yang
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Taaha Hassan
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Jerry Dang
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Kroh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dennis Hong
- Division of General Surgery, McMaster University, Hamilton, ON, Canada.
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Kendrick K, Kothari SN. Updates on Surgical Treatment for Gastroesophageal Reflux Disease. Am Surg 2023:31348231157414. [PMID: 36789472 DOI: 10.1177/00031348231157414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common condition that is on the rise. Obesity is one risk factor that has increased in parallel with the rise of GERD. Typical symptoms include heartburn, regurgitation, dysphagia, cough, and chest pain. Patients with typical symptoms are empirically treated with proton pump inhibitors (PPIs). If the diagnosis is not clear, further evaluation is performed with endoscopy, pH monitoring, and esophageal manometry. Untreated GERD increases the risk of esophagitis, esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma. Treatment begins with lifestyle modification and medical therapy. If these fail, surgical and endoscopic surgical techniques are available, to provide treatment, symptom relief, and reduce long-term PPI use.
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Affiliation(s)
- Katherine Kendrick
- Department of Gastroenterology and Hepatology, 3626Prisma Health Upstate-Greenville Memorial Hospital, Greenville, SC, USA
| | - Shanu N Kothari
- University of South Carolina School of Medicine Greenville, 3626Prisma Health Upstate, Greenville, SC, USA
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Gastroesophageal Reflux Disease in Idiopathic Pulmonary Fibrosis: Viewer or Actor? To Treat or Not to Treat? Pharmaceuticals (Basel) 2022; 15:ph15081033. [PMID: 36015181 PMCID: PMC9412643 DOI: 10.3390/ph15081033] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/14/2022] [Accepted: 08/19/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Idiopathic pulmonary fibrosis (IPF) is a rare and severe disease with a median survival of ∼3 years. Several risk factors have been identified, such as age, genetic predisposition, tobacco exposure, and gastro-oesophageal reflux disease (GERD). Prevalence of GERD in IPF is high and may affect 87% of patients, of whom only half (47%) report symptoms. Objective: The aim of this study is to review current evidence regarding the correlation between GERD and IPF and to evaluate the current studies regarding treatments for GERD-IPF. Methods: A review to identify research papers documenting an association between GERD and IPF was performed. Results: We identified several studies that have confirmed the association between GERD and IPF, with an increased acid exposure, risk of gastric aspiration and bile acids levels in these patients. Few studies focused their attention on GERD treatment, showing how antiacid therapy was not able to change IPF evolution. Conclusions: This review investigating the correlation between GERD and IPF has confirmed the hypothesized association. However, further large prospective studies are needed to corroborate and elucidate these findings with a focus on preventative and treatment strategies.
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Hoffsten J, Forsell Y. Laparoscopic Nissen fundoplication versus 90° and 180° fundoplication for gastroesophageal reflux disease. Eur Surg 2022. [DOI: 10.1007/s10353-021-00745-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Summary
Background
Laparoscopic Nissen fundoplication (LNF) is standard care for surgical treatment of gastroesophageal reflux disease (GERD) in adults. The main disadvantage is the compression of the food passageway, affecting the ability to belch and vomit, and causing swallowing difficulties. Therefore, partial fundoplication methods encircling esophagus as little as 90° and 180° have been developed. Previous studies have been inconclusive. The aim was to assess the effectiveness of LNF compared to laparoscopic anterior 90° and 180° fundoplication.
Methods
Randomized controlled trials were searched for in MEDLINE, Embase, CINAHL, the Cochrane Library, and Web of Science, and in eligible studies’ reference lists and relevant reviews. Outcomes of interest were 5-year heartburn, medication use, dysphagia, reoperation, and satisfaction. Dichotomous data were calculated as risk ratios (RR). Subgroup analyses were performed to compare each comparator separately with LNF. The meta-analyses were conducted using a random-effects model with an inverse variance statistical method and a significance level of 0.05.
Results
Four eligible trials were included with 398 participants, of which half compared LNF with 90°. At 5 years there was higher risk of dysphagia for solids after LNF compared to 90° and 180° fundoplication (RR 1.68 [1.14, 2.49]). However, LNF was associated with a significantly lower risk of medication use compared to laparoscopic anterior 90° fundoplication (RR 0.23 [0.09, 0.58], subgroup analysis). No differences between treatments in terms of heartburn, reoperation, and satisfaction were found.
Conclusion
The limited evidence fails to provide an unequivocal method of choice, but rather indicates a trade-off between reflux control and complications.
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ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117:27-56. [PMID: 34807007 PMCID: PMC8754510 DOI: 10.14309/ajg.0000000000001538] [Citation(s) in RCA: 260] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 01/30/2023]
Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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The learning curve for transoral incisionless fundoplication. Endosc Int Open 2021; 9:E1785-E1791. [PMID: 34790546 PMCID: PMC8589558 DOI: 10.1055/a-1547-6599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/22/2021] [Indexed: 11/02/2022] Open
Abstract
Background and study aims Transoral incisionless fundoplication (TIF) is a safe and effective minimally invasive endoscopic technique for treating gastroesophageal reflux disease (GERD). The learning curve for this technique has not been reported. We studied the learning curve for TIF when performed by a gastroenterologist by identifying the threshold number of procedures needed to achieve consistent technical success or proficiency (consistent creation of TIF valve ≥ 270 degrees in circumference, ≥ 2 cm long) and efficiency after didactic, hands-on and case observation experience. Patients and methods We analyzed prospectively collected data from patients who had TIF performed by a single therapeutic endoscopist within 17 months after basic training. We determined thresholds for procedural learning using cumulative sum of means (CUSUM) analysis to detect changes in achievement rates over time. We used breakpoint analysis to calculate procedure metrics related to proficiency and efficiency. Results A total of 69 patients had 72 TIFs. The most common indications were refractory GERD (44.7 %) and proton pump inhbitor intolerance (23.6 %). Proficiency was achieved at the 18 th to 20 th procedure. The maximum efficiency for performing a plication was achieved after the 26 th procedure, when mean time per plication decreased to 2.7 from 5.1 minutes (P < 0.0001). TIF procedures time varied until the 44 th procedure, after which it decreased significantly from 53.7 minutes to 39.4 minutes (P < 0.0001). Conclusions TIF can be safely, successfully, and efficiently performed in the endoscopy suite by a therapeutic endoscopist. The TIF learning curve is steep but proficiency can be achieved after a basic training experience and 18 to 20 independently performed procedures.
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Efficacy and Safety of Dor Fundoplication in Patients with Severe Gastroparesis and Refractory Gastroesophageal Reflux Disease. GASTROINTESTINAL DISORDERS 2020. [DOI: 10.3390/gidisord2020013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Poor quality of life is a major problem in patients with gastroesophageal reflux disease (GERD). Delayed gastric emptying in patients with severe gastroparesis (GP) worsens GERD symptoms and particularly nocturnal heartburn and regurgitation refractory to medical therapy. With limited therapeutic options, a Nissen fundoplication may be considered but concerns for this surgery are inability to wretch and vomit post-op, increasing the risk of wrap rupture. Dor fundoplication, a 180–200 degree anterior wrap, may improve sphincter competency and provide symptom relieve while minimizing these concerns and avoiding vagal nerve damage.
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Long-Term Outcomes Following Laparoscopic Repair of Large Hiatus Hernias Performed by Trainees Versus Consultant Surgeons. J Gastrointest Surg 2020; 24:749-755. [PMID: 31012041 DOI: 10.1007/s11605-019-04218-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 03/25/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The laparoscopic approach is the preferred method for repair of large hiatus hernias but can be technically challenging. Training surgeons need experience as the primary operator to gain competency in this operation. However, learning the procedure should not compromise the functional long-term outcome for patients. The aim of this study was to determine whether any difference in long-term outcomes exists for patients having a laparoscopic large hiatus hernia repair performed by a trainee versus a consultant surgeon. METHODS A total of 648 suitable patients who had undergone laparoscopic repair of a large hiatus hernia were identified from a prospective database. Cases were divided into two groups based on whether the primary operator was a trainee or a consultant surgeon. Demographics, perioperative data, revisions and patient-reported clinical outcomes via standardised questionnaires were compared. RESULTS There were no statistically significant differences in the clinical outcomes for patients undergoing laparoscopic repair of a large hiatus hernia performed by a trainee versus a consultant surgeon, with comparable patient-reported outcomes for heartburn, dysphagia, and overall satisfaction with the outcome following surgery. Median operative time was approximately 20 min longer for trainees (p = <0.0001). Revisional surgery rates were similar for the two groups. CONCLUSIONS Patients operated on by trainees have equivalent long-term clinical outcomes to patients operated on by consultant surgeons. For these patients, surgery can be safely performed by supervised trainees.
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Danilova DA, Bazaev AV, Gorbunova LI. [Current aspects of surgical treatment of gastro-esophageal reflux disease]. Khirurgiia (Mosk) 2020:89-94. [PMID: 32105262 DOI: 10.17116/hirurgia202002189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of gastric content into the esophagus, pharynx, respiratory tract and oral cavity. In recent years, there has been a significant increase of the incidence of this disease, that significantly aggravates quality of life of the population. The 'gold standard' for treating GERD is anti-secretory therapy with proton pump inhibitors (PPIs). However, up to 40% of patients are unresponsive to PPIs even after dose adjustment. Advantages and disadvantages of modern surgical approaches for this pathology are reviewed. Laparoscopic fundoplication including Nissen (360°), Toupet (270°) and Dor procedures (180°) is the most common anti-reflux operation. In addition, new alternative surgical options are also discussed. For example, these are minimally invasive methods such as LINX reflux control system, electrical stimulation of the lower esophageal sphincter and transoral incisionless fundoplication (TIF). These methods are less aggressive and have less side effects. A comparative assessment of modern methods of surgical treatment of GERD is made.
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Affiliation(s)
- D A Danilova
- Privolzhsky Research Medical University of the Ministry of Health of the Russia, Nizhniy Novgorod, Russia
| | - A V Bazaev
- Privolzhsky Research Medical University of the Ministry of Health of the Russia, Nizhniy Novgorod, Russia
| | - L I Gorbunova
- Privolzhsky Research Medical University of the Ministry of Health of the Russia, Nizhniy Novgorod, Russia
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Spann MD, Harrison NJ, English WJ, Bolduc AR, Aher CV, Williams DB, Hawkins AT. Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass. Am Surg 2020. [DOI: 10.1177/000313482008600336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.
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Affiliation(s)
- Matthew D. Spann
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noah J. Harrison
- Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - Wayne J. English
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron R. Bolduc
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chetan V. Aher
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D. Brandon Williams
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T. Hawkins
- Department of Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Higgins RM, Gould JC. The Pros and Cons of Partial Versus Total Fundoplication for Gastroesophageal Reflux Disease. J Laparoendosc Adv Surg Tech A 2020; 30:117-120. [DOI: 10.1089/lap.2019.0297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Rana M. Higgins
- Division of General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jon C. Gould
- Division of General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Bramhall SR, Mourad MM. Wrap choice during fundoplication. World J Gastroenterol 2019; 25:6876-6879. [PMID: 31908391 PMCID: PMC6938727 DOI: 10.3748/wjg.v25.i48.6876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/03/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Gastro-oesphageal reflux disease is an increasing health burden. The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication. The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications. These complications include “gas bloat” and dysphagia and can occur relatively frequently. Various modifications have been described to the original operation and some of these have been described. In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use. This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique. The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms. The advantages and disadvantages of an anterior wrap are discussed. The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.
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Affiliation(s)
- Simon R Bramhall
- Department of Surgery, The County Hospital, Hereford HR1 2ER, United Kingdom
| | - Moustafa M Mourad
- Department of Surgery, Worcester Royal Infirmary, Worcester WR5 1DD, United Kingdom
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Patil G, Iyer A, Dalal A, Maydeo A. Antireflux mucosectomy for managing reflux symptoms in an obese patient post laparoscopic sleeve gastrectomy. Scand J Gastroenterol 2019; 54:1494-1497. [PMID: 31791169 DOI: 10.1080/00365521.2019.1697895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is an effective treatment modality for obesity. Commonest delayed complication post LSG is gastroesophageal reflux disease (GER). The prevalence of GER among obese patients is higher than normal individuals. Such patients need long term Proton pump inhibitors (PPI) or antireflux procedures to manage reflux. Antireflux mucosectomy (ARMS) uses techniques of endoscopic mucosal resection to treat reflux for PPI refractory GER. However, it can be technically challenging to perform ARMS with a restricted stomach in patients who have undergone LSG. A 40-year-old female, hypertensive who had previously undergone LSG was treated for GER by a multidimensional approach with ARMS utilizing hypotensive anesthesia. The patient underwent the procedure successfully without any complication. She was discharged and at follow up visit, her reflux symptoms had improved and endoscopy was unremarkable. We describe this unusual case which was treated effectively with ARMS.
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Affiliation(s)
- Gaurav Patil
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Arun Iyer
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Ankit Dalal
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
| | - Amit Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
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Yun JS, Na KJ, Song SY, Kim S, Kim E, Jeong IS, Oh SG. Laparoscopic repair of hiatal hernia. J Thorac Dis 2019; 11:3903-3908. [PMID: 31656664 DOI: 10.21037/jtd.2019.08.94] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Laparoscopic hiatal hernia repair is a complex surgery typically performed by general abdominal surgeons because it typically involves an abdominal approach. Here, we report our experiences on laparoscopic repair of hiatal hernia as thoracic surgeons. Methods Based on our experience of minimally invasive esophageal surgery (MIES) for esophageal cancer, we began performing laparoscopic repair of hiatal hernia in 2009. We analyzed the surgery-related data and postoperative outcomes of 18 consecutive patients we operated on from 2009 to 2017. Results There were 1 male and 17 female patients with a median age of 73 years (range, 37-81 years). Ten of 14 symptomatic patients experienced reflux symptoms, such as heartburn. Four patients had a history of prior abdominal surgery. Hiatal hernia types I, II, III, and IV were observed in 3, 9, 5, and 1 patients, respectively. Two (11.1%) laparoscopic procedures required conversion. Modified Collis gastroplasty was used as an esophageal lengthening procedure in 5 patients (27.8%). Mean operation time was 213.8±70.1 minutes and mean hospital stay was 6.2±1.5 days. There were no postoperative complications. At the last follow-up, 15 patients (83.3%) were asymptomatic; however, 3 (16.7%) complained of reflux or dysphagia. Recurrent hiatal hernia was detected on an esophagogram in only 1 patient at 3.5 years after laparoscopic surgery. Conclusions Laparoscopic repair of hiatal hernia is a feasible technique with a satisfactory surgical outcome. Importantly, it can be performed by thoracic surgeons who are experienced in the laparoscopic approach.
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Affiliation(s)
- Ju Sik Yun
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Jeollanam-do, South Korea
| | - Kook Joo Na
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Jeollanam-do, South Korea
| | - Sang Yun Song
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Jeollanam-do, South Korea
| | - Seok Kim
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Jeollanam-do, South Korea
| | - Eunchong Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwang-ju, South Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwang-ju, South Korea
| | - Sang Gi Oh
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwang-ju, South Korea
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19
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Is that ‘floppy’ fundoplication tight enough? Surg Endosc 2019; 34:1823-1828. [DOI: 10.1007/s00464-019-06947-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/26/2019] [Indexed: 01/11/2023]
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Abstract
A hiatus hernia is defined as a transdiaphragmatic protrusion/migration of the intrabdominal contents through the esophageal hiatus of the diaphragm. The classification of hiatus hernias is based on anatomical morphological differentiation (types I-IV). The leading symptoms and psychological stress vary with respect to the symptoms, e. g. reflux and compression symptoms. Gastroscopy and multichannel intraluminal impedance pH measurement are obligatory preoperative functional diagnostics. A distinction is made between frequent type I hernia (antireflux surgery), symptomatic paraesophageal, thoracic and mixed hernia types (II-IV). Surgical indications exist in symptomatic type II-IV hernias. Hiatal mesh augmentation reduces recurrences. The complication potential of synthetic meshes must be taken into account. Biological implants show no advantages.
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21
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Perivoliotis K, Sarakatsianou C, Tepetes K, Baloyiannis I. Single incision laparoscopic fundoplication: A systematic review of the literature. World J Gastrointest Surg 2019; 11:179-190. [PMID: 31057702 PMCID: PMC6478600 DOI: 10.4240/wjgs.v11.i3.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision (SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.
AIM To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.
METHODS The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases (Medline, Scopus and Web of Science) was performed.
RESULTS Literature search resulted in the identification of 19 studies. Overall, 266, 137 and 110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.
CONCLUSION Due to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.
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Affiliation(s)
| | | | | | - Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
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Chwiesko A, Kowal-Bielecka O, Sierakowski S. Perspectives on the interlinked nature of systemic sclerosis and reflux disease. Expert Rev Gastroenterol Hepatol 2019; 13:213-227. [PMID: 30791766 DOI: 10.1080/17474124.2019.1561274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systemic sclerosis (SSc) is a multisystem connective tissue disease, characterized by chronic inflammation and vascular changes that result in esophageal smooth muscle atrophy and fibrosis. Subsequent progressive loss of peristalsis in the distal esophagus and loss of lower esophageal sphincter function lead to problems with the protective barrier and exposure of sensitive tissues to the gastroduodenal contents, a disorder called reflux disease. Areas covered: Depending on the range, nature and symptoms of the disease, the term 'reflux disease' may refer to gastroesophageal reflux, laryngopharyngeal reflux, microaspiration into the airways and silent reflux. Despite the links between these visceral complications, this connection remains controversial. This is due to a lack of complete understanding, the asymptomatic nature of the disease and the limited diagnostic accuracy of tests, which can delay diagnosis. Such delays are problematic, given that the early detection of GERD in SSc patients, the timing of assessment, the treatment of the organs involved are critical aspects of patient prognosis and disease outcome. Expert commentary: This review summarizes the most recent knowledge about the pathophysiology, diagnosis and prospective treatment of GERD in SSc patients and highlights how innovative technologies applied through an integrative, interdisciplinary approach may soon lead to effective treatment strategies.
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Affiliation(s)
- Adam Chwiesko
- a Department of Gastroenterology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Otylia Kowal-Bielecka
- b Department of Rheumatology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Stanislaw Sierakowski
- b Department of Rheumatology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
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Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high-volume center. Surg Endosc 2018; 33:2152-2161. [PMID: 30350095 DOI: 10.1007/s00464-018-6494-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 10/11/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Published data regarding robot-assisted hiatal hernia repair are mainly limited to small cohorts. This study aimed to provide information on the morbidity and mortality of robot-assisted complex hiatal hernia repair and redo anti-reflux surgery in a high-volume center. MATERIALS AND METHODS All patients that underwent robot-assisted hiatal hernia repair, redo hiatal hernia repair, and anti-reflux surgery between 2011 and 2017 at the Meander Medical Centre, Amersfoort, the Netherlands were evaluated. Primary endpoints were 30-day morbidity and mortality. Major complications were defined as Clavien-Dindo ≥ IIIb. RESULTS Primary surgery 211 primary surgeries were performed by two surgeons. The median age was 67 (IQR 58-73) years. 84.4% of patients had a type III or IV hernia (10.9% Type I; 1.4% Type II; 45.5% Type III; 38.9% Type IV, 1.4% no herniation). In 3.3% of procedures, conversion was required. 17.1% of patients experienced complications. The incidence of major complications was 5.2%. Ten patients (4.7%) were readmitted within 30 days. Symptomatic early recurrence occurred in two patients (0.9%). The 30-day mortality was 0.9%. Redo surgery 151 redo procedures were performed by two surgeons. The median age was 60 (IQR 51-68) years. In 2.0%, the procedure was converted. The overall incidence of complications was 10.6%, while the incidence of major complications was 2.6%. Three patients (2.0%) were readmitted within 30 days. One patient (0.7%) experienced symptomatic early recurrence. No patients died in the 30-day postoperative period. CONCLUSIONS This study provides valuable information on robot-assisted laparoscopic repair of primary or recurrent hiatal hernia and anti-reflux surgery for both patient and surgeon. Serious morbidity of 5.2% in primary surgery and 2.6% in redo surgery, in this large series with a high surgeon caseload, has to be outweighed by the gain in quality of life or relief of serious medical implications of hiatal hernia when counseling for surgical intervention.
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Dowgiałło-Wnukiewicz N, Frask A, Lech P, Michalik M. Study of the prevalence of gastroesophageal reflux symptoms and the role of each in relation to the GERD Impact Scale, based on a population of patients admitted for laparoscopic surgery compared to a control group. Wideochir Inne Tech Maloinwazyjne 2018; 13:199-211. [PMID: 30002752 PMCID: PMC6041586 DOI: 10.5114/wiitm.2018.75909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/26/2018] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD), demonstrated to impair quality of life (QoL), appears to show significant variation in its prevalence. Estimation of the prevalence is difficult. When defined as at least weekly heartburn and/or acid regurgitation, the prevalence reported in Asia is 2.5-27.6%, in Europe 23.7% and in the US 28.8%. AIM The study evaluates the prevalence of GERD symptoms in the assessment of the GERD Impact Scale (GERD-IS) in two age groups of patients. MATERIAL AND METHODS Evaluation of the prevalence of GERD symptoms with the GERD Impact Scale survey in two groups of patients: younger and older. A total of 2,649 surveys were rated. Statistical analysis was performed using the data analysis software system Statistica version 10.0 and Microsoft Excel. RESULTS According to this study the symptoms of GERD included in GERD-IS in northern Poland vary from 0.9-2.4% as daily sensations to 18.9-40.5% occurring sometimes. Individuals with hiatal hernia (HH) were significantly older than those without HH. HH was significantly more frequent in males than females. CONCLUSIONS Estimation of the prevalence of GERD is difficult, because the medications are widely available and people use them without any consultation. They do not recognize the symptoms as a disease whose treatment can also be surgical. Our analysis shows that the prevalence of symptoms of GERD in northern Poland is as high as 5%. Hence further investigation should be performed and people's awareness should be raised.
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Affiliation(s)
- Natalia Dowgiałło-Wnukiewicz
- Department of General and Minimally Invasive Surgery, University of Warmia and Mazury, Olsztyn, Poland
- Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland
| | - Agata Frask
- General and Vascular Surgery Department, Ceynowa Hospital, Wejherowo, Poland
| | - Paweł Lech
- Department of General and Minimally Invasive Surgery, University of Warmia and Mazury, Olsztyn, Poland
| | - Maciej Michalik
- Department of General and Minimally Invasive Surgery, University of Warmia and Mazury, Olsztyn, Poland
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