Gastric Emptying as a Prognostic Factor for Long-term Results of Total Laparoscopic Fundoplication for Weakly Acidic or Mixed Reflux

Innovative laparoscopic 'Tunnel' approach in managing hiatal hernia with gastroesophageal reflux disease: a retrospective study

BACKGROUND

Hiatal hernia (HH) is a major cause of gastroesophageal reflux disease (GERD), and laparoscopic repair combined with anti-reflux surgery is a common treatment. However, postoperative complications such as vagus nerve injury remain a concern. This study introduces a novel Laparoscopic "Tunnel" Approach aiming to minimize damage to the vagus nerve and preserve perigastric vessels.

METHODS

Clinical data were consecutively collected from patients who underwent laparoscopic "tunnel" approach for the treatment of hiatal hernia combined with gastroesophageal reflux disease at the First Affiliated Hospital of Ningbo University between June 2023 and June 2024. Data collected included age, gender, BMI, DeMeester score, surgical time, and postoperative symptoms. Follow-ups were conducted at 1, 3, and 6 months postoperatively.

RESULTS

The average age was 54 ± 9 years, BMI was 25.56 ± 4.32 kg/m2, DeMeester score was 118.05 ± 17.71, and GERD-Q score was 13 ± 2. The average surgical time was 115 ± 15 min. Postoperatively, symptoms significantly improved, with an average GERD-Q score of 5 ± 1 at 6 months. At 1 month, dysphagia was observed in 14 patients, belching in 19, abdominal distension in 5, nausea in 16, and diarrhea in 8. By 6 months, only 2 patients exhibited belching, with no other symptoms persisting. No cases of vomiting or gallstones were reported.

CONCLUSIONS

The Laparoscopic "Tunnel" Approach may effectively minimizes vagus nerve injury and preserves perigastric vessels, resulting in improved postoperative outcomes and quality of life. This method shows potential for wider application in treating HH and GERD. However, since this study was retrospective and lacked a control group, further studies are needed to verify our conclusions.

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.

Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication

BACKGROUND

Currently, the reported parameters that predict the resolution of symptoms after surgery are largely subjective and unreliable. Considering that fundoplication rebuilds the structural integrity of the lower esophageal sphincter (LES), the authors focused on searching for objective and quantitative predictors for the resolution of symptoms based on the anatomical issues and whether an antireflux barrier can be well established or not.

MATERIALS AND METHODS

The authors reviewed the prospectively collected data of 266 patients with gastroesophageal reflux disease (GERD) who had undergone laparoscopic Nissen fundoplication (LNF). All patients were diagnosed with GERD using preoperative esophagogastroduodenoscopy, 24-h ambulatory esophageal pH monitoring, and high-resolution esophageal manometry. The patients received GERD symptom surveys using the validated Korean Antireflux Surgery Group questionnaire twice: preoperatively and 3 months after the surgery.

RESULTS

After excluding patients with insufficient follow-up data, 152 patients were included in the analysis. Multivariate logistic regression analyses revealed that a longer length of the LES and lower BMI determined better resolution of typical symptoms after LNF (all P <0.05). Regarding atypical symptoms, higher resting pressure of LES and DeMeester score greater than or equal to 14.7 were associated with better resolution after the surgery (all P <0.05). After LNF, typical symptoms improved in 34 out of 37 patients (91.9%) with a length of LES >greater than .05 cm, BMI less than 23.67 kg/m 2 , and atypical symptoms were resolved in 16 out of 19 patients (84.2%) with resting pressure of LES greater than or equal to 19.65 mm Hg, DeMeester score greater than or equal to 14.7.

CONCLUSION

These results show that the preoperative length and resting pressure of LES is important in the objective prediction of symptom improvement after LNF.

Laparoscopic antireflux surgery for refractory gastroesophageal reflux disease: long-term clinical outcomes

Persistent symptoms despite adequate Proton Pump Inhibitors (PPI) treatment are described in up to 40% of patients with Gastroesophageal Reflux Disease (GERD). The efficacy of Laparoscopic Antireflux Surgery (LARS) in PPI non-responder patients is still unclear. This observational study aims to report the long-term clinical outcomes and predictors of dissatisfaction in a cohort of refractory GERD patients submitted to LARS. Patients with preoperative refractory symptoms and objective GERD evidence submitted to LARS between 2008 and 2016 were included in the study. Primary endpoint was overall satisfaction with the procedure, secondary endpoints were long-term GERD symptom relief and endoscopic findings. Univariate and multivariate analyses were performed to compare satisfied and dissatisfied patients, in order to identify preoperative predictors of dissatisfaction. A total of 73 refractory GERD patients who underwent LARS were included in the study. At a mean follow-up of 91.2 ± 30.5 months, the satisfaction rate was 86.3%, with a statistically significant reduction in typical and atypical GERD symptoms. Causes of dissatisfaction were severe heartburn (6.8%), gas bloat syndrome (2.8%), and persistent dysphagia (4.1%). Multivariate analysis showed that a number of Total Distal Reflux Episodes (TDRE) > 75 was a predictive factor of long-term dissatisfaction after LARS while a partial response to PPI was a protective factor against dissatisfaction. LARS guarantees a high level of long-term satisfaction for selected refractory GERD patients. An abnormal TDRE at 24 h-multichannel intraluminal impedance-pH monitoring and the lack of response to preoperative PPI were predictors of long-term dissatisfaction.

Salvage Options for Fundoplication Failure

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients.

RECENT FINDINGS

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.

Impact of vagus nerve integrity testing on surgical management in patients with previous operations with potential risk of vagal injury

BACKGROUND

Thoracic and foregut operations can cause vagal nerve injury resulting in delayed gastric emptying or gastroparesis. However, the cause of gastroparesis in these patients is not always from a vagal injury. We hypothesize that vagal nerve integrity (VNI) testing may better define who has vagal nerve dysfunction. This information may change subsequent operations. The aim of this study was to evaluate the impact of VNI testing in patients with prior thoracic or gastric surgery.

METHODS

From January 2014 to December 2017, patients who had previous operations with the potential risk of vagal injury and had VNI testing were reviewed. Excluded patients were those with no plan for a second operation or the second operation was only for gastroparesis. The main outcome was the percentage of operations altered due to the results of VNI testing.

RESULTS

Twelve patients (eight females) were included. Ages ranged from 37 to 77 years. VNI results were compatible with vagal injury in eight patients (67%). VNI test results altered subsequent operative plans in 41.7% (5/12). Pyloroplasty was done in addition to fundoplication in two patients. Plans for hiatal hernia repair with or without redo-fundoplication in three patients were changed by an additional pyloroplasty in one patient and partial gastrectomy with Roux-en-Y reconstruction in two patients. All patients who had secondary surgery had resolution of symptoms and improvement in objective testing.

CONCLUSION

The addition of VNI testing in patients with a previous potential risk of vagal nerve injury may help the surgeon select the appropriate secondary operation.

Increased Esophageal Exposure to Weakly Acidic Reflux 5 Years After Laparoscopic Roux-en-Y Gastric Bypass

OBJECTIVE

To evaluate the long-term effects of laparoscopic Roux-en-Y Gastric Bypass (LRYGB) on gastroesophageal function.

BACKGROUND

LRYGB is considered the weight loss procedure of choice for obese patients with gastroesophageal reflux disease (GERD). However, long-term instrumental evaluations of GERD after LRYGB are not available.

METHODS

Morbidly obese patients selected for LRYGB were included in a prospective study. We performed clinical evaluation with GERD-HRQoL questionnaire, upper endoscopy, esophageal manometry, and 24-hour impedance pH (24-hour MII-pH) monitoring preoperatively and at 12 and 60 months after surgery. This trial is registered with ClinicalTrials.gov (no. NCT02618044).

RESULTS

From May 2006 to May 2009, 86 patients entered the study and 72 (84%) completed the 5-year protocol. At preoperative 24-hour MII-pH monitoring, 54 patients (group A) had normal values, whereas 32 (group B) had diagnosis of GERD: 23 had acidic reflux, whereas 9 had combined reflux [acidic + weakly acidic reflux (WAR)]. The groups were similar in preoperative age, body mass index, and comorbidities. At 12 and 60 months, significant improvement in questionnaire scores was observed in group B patients. No manometric changes occurred in both groups; 24-hour MII-pH monitoring showed a significant reduction in acid exposure, but an increase of WAR in both group A (from 0% to 52% to 74%) and group B (from 35% to 42% to 77%). At long-term follow-up, esophagitis was found in 14 group A (30%) and in 18 group B patients (69%) (P < 0.001).

CONCLUSIONS

LRYGB allows to obtain an effective GERD symptom amelioration and a reduction in acid exposure. However, 3 out 4 patients present with distal esophagus exposure to WAR.

Preoperative liquid gastric emptying rate does not predict outcome after fundoplication

AIM OF THE STUDY

Preoperative gastric emptying (GE) rate in patients with gastrointestinal reflux disease (GERD) was evaluated as a predictor of outcome after antireflux surgery.

METHODS AND PATIENTS

GE was assessed using radionuclide scintigraphy and a standardized meal with cow's milk. GE half time (T1/2), patient demographics and GERD symptoms including vomiting (>4days/week), retching (>4days/week), prolonged feeding time (>3h/day), and discomfort after meals were recorded pre- and postoperatively. A standardized follow-up included a 24-h pH-monitoring and an upper gastrointestinal contrast study. Of 74 patients undergoing Nissen fundoplication between 2003 and 2009, 35 underwent a preoperative GE study. The remaining 39 patients were not examined owing to volume intolerance, cow's milk intolerance or allergy, inability to lie still, or parents refusing participation.

MAIN RESULTS

Median age at fundoplication was 4.9 [range 1.1-15.4] years, and follow-up time was median 4.3 [1.9-8.9] years. GERD recurred in 7 (20%) patients. Preoperative T1/2 in the seven patients with recurrent GERD was median 45 [21-87] min compared to 44 [16-121] min in the 28 patients without recurrent GERD (p=0.92). There was no significant difference between the one third of patients with the slowest GE [T1/2 54-121min] and the remaining patients [T1/2 16-49min] regarding GERD recurrence or postoperative vomiting, retching, prolonged feeding time, or discomfort after meals.

CONCLUSION

Preoperative GE rate did not predict outcome after antireflux surgery, as slow GE was not associated with recurrent GERD or postoperative troublesome symptoms such as vomiting, retching, or meal discomfort.

A case report: Liraglutide as a novel treatment option in late dumping syndrome

RATIONALE

Postprandial hyperinsulinemic hypoglycemia, known as late dumping syndrome, is a rare but often misdiagnosed complication after gastric surgery. The pathophysiological mechanisms are poorly understood and the treatment of this syndrome is challenging.

PATIENT CONCERNS

New-onset postsurgical late dumping syndrome after Toupet fundoplication.

DIAGNOSES

Sigstad Score, OGTT, CGM.

INTERVENTIONS

Daily subcutaneous injection of liraglutide (0.6 mg and 1.2 mg).

OUTCOMES

Reduction in fasting and postprandial peak insulin level with improvement in symptomatic hypoglycemic events.

LESSONS

Liraglutide may be a novel treatment option for postprandial hyperinsulinemic hypoglycemia after gastric surgery.

Laparoscopic antireflux surgery increases health-related quality of life in children with GERD

INTRODUCTION

Improving health-related quality of life (HRQoL) is increasingly recognized as an essential part of patient care outcome. Little is known about the effect of laparoscopic antireflux surgery (LARS) on the HRQoL in the pediatric patients. The aims of this study were to evaluate the effect of LARS on HRQoL in children with gastroesophageal reflux disease (GERD) and to identify predictors that influence HRQoL outcome after LARS.

METHODS

Between 2011 and 2013, 25 patients with therapy-resistant GERD [median age 6 (2-18) years] were included prospectively. Caregivers and children with normal neurodevelopment (>4 years) were asked to fill out the validated PedsQL 4.0 Generic Core Scales before and 3-4 months after LARS.

RESULTS

The PedsQL was completed by all caregivers (n = 25) and 12 children. HRQoL total score improved significantly after LARS, both from a parental (p = 0.009) and child's perspective (p = 0.018). The psychosocial health summary and physical health summary scores also improved significantly after LARS. HRQoL before and after LARS was significantly lower in children with impaired neurodevelopment (p < 0.001). However, neurodevelopment did not influence the effect of LARS on HRQoL. The only significant predictor for improvement in HRQoL after LARS was age at the time of operation (p = 0.001).

CONCLUSIONS

HRQoL significantly improves after LARS. Although children with impaired neurodevelopment had lower overall HRQoL, neurodevelopment by itself does not predict inferior improvement in HRQoL after LARS. Older children have a more favorable HRQoL outcome after LARS compared to younger children. This may suggest caution when considering LARS in younger GERD patients.

Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation

OBJECTIVE

To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) in morbidly obese patients.

BACKGROUND

Symptomatic GERD is considered by many a contraindication to LSG. However, studies evaluating the relationship between LSG and GERD by 24-hour pH monitoring are lacking.

METHODS

Consecutive morbidly obese patients selected for LSG were included in a prospective clinical study. Gastroesophageal function was evaluated using a clinical validated questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring before and 24 months after LSG. This trial is registered with ClinicalTrials.gov (no. NCT02012894).

RESULTS

From June 2009 to September 2011, a total of 71 patients were enrolled into the study; 65 (91.5%) completed the 2-year protocol. On the basis of preoperative 24-hour pH monitoring, patients were divided into group A (pathologic, n=28) and group B (normal, n=37). Symptoms improved in group A, with the Gastroesophageal Reflux Disease Symptom Assessment Scale score decreasing from 53.1±10.5 to 13.1±3.5 (P<0.001). The DeMeester score and total acid exposure (% pH<4) decreased in group A patients (DeMeester score from 39.5±16.5 to 10.6±5.8, P<0.001; % pH<4 from 10.2±3.7 to 4.2±2.6, P<0.001). Real "de novo" GERD occurred in 5.4% group B patients. No significant changes in lower esophageal sphincter pressure and esophageal peristalsis amplitude were found in both groups.

CONCLUSIONS

LSG improves symptoms and controls reflux in most morbidly obese patients with preoperative GERD. In obese patients without preoperative evidence of GERD, the occurrence of "de novo" reflux is uncommon. Therefore, LSG should be considered an effective option for the surgical treatment of obese patients with GERD.