Magnetic sphincter augmentation: Optimal patient selection and referral care pathways

New Developments in Anti-Reflux Surgery: Where Are We Now?

Background

Gastroesophageal reflux disease is one of the most common chronic diseases, affecting up to 28% of the western population. Therapeutic management ranges from conservative measures to endoscopic or surgical interventions. Laparoscopic Nissen fundoplication (LNF) still is considered as gold standard, but alternative procedures have been developed and evaluated within the past years.

Summary

Magnetic sphincter augmentation (MSA), which aims to be a less disruptive and possibly more standardized laparoscopic procedure than LNF, shows satisfying results regarding short- and long-term follow-up as well as comorbidities. Alternatives, such as the RefluxStop™ procedure or Transoral incisionless fundoplication (TIF), combined with laparoscopic hiatal hernia repair (cTIF) show promising results for short-term follow-up, nevertheless further studies regarding long-term follow-up are necessary.

Key Message

Although there definitely are upcoming and promising trends in upper GI surgery, LNF still represents today's gold standard and MSA is an equivalent alternative. RefluxStop™ and cTIF show promising results, nevertheless, further studies are necessary.

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.

Hybrid-APC treatment for gastric vascular ectasia of an atypical location after failed radiofrequency ablation

A 76-year-old woman was being followed up for chronic anemia secondary to bleeding from vascular ectasias at the gastric antrum and the cardial and subcardial region. On several occasions the patient required fulguration of these lesions with conventional APC, which resulted in no clear improvement. Radiofrequency ablation of these lesions was then attempted using a 90-degree probe, which was successful on antral angiodysplasias but failed to remove lesions in the cardial and subcardial region since anatomy there prevented proper apposition of the probe onto the target mucosa. Given the absence of any improvement, it was decided to use fulguration for angiectasias at the cardial and subcardial level by means of Hybrid-APC, which consists of lifting the mucosa with an injection through the APC probe and then fulgurating in the pulsedAPC® mode, thus achieving a broader ablation area in a shorter time. During the subsequent review a clear reduction of vascular ectasias was observed.

Heartburn Center Set-Up in a Community Setting: Engineering and Execution

Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a "center of excellence" (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD. Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery. Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, <10% had GERD for <1 year, ~60% had GERD for 1-11 years, and ~30% had GERD for ≥12 years. More than one-quarter had atypical GERD symptoms (27.6%). Only 6.4% had been on PPIs for <1 year and >20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution. Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.