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Tsai MH, Wang JW. Antireflux mucosal ablation as rescue therapy for fundoplication failure. Gastrointest Endosc 2024; 99:1059-1060. [PMID: 37995771 DOI: 10.1016/j.gie.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/15/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Min-Hsuan Tsai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Division of Gastroenterology, Department of Internal Medicine, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan
| | - Jiunn-Wei Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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2
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Mazzini GS, Campos GM. Comment on: Effectiveness of sleeve gastrectomy plus fundoplication versus sleeve gastrectomy alone for treatment of patients with severe obesity: a systematic review and meta-analysis. Surg Obes Relat Dis 2024; 20:543-544. [PMID: 38600018 DOI: 10.1016/j.soard.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 04/12/2024]
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3
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Loo JH, Chue KM, Lim CH, Toh BC, Kariyawasam GMD, Ong LWL, Tan JTH, Wong WK, Yeung BPM. Effectiveness of sleeve gastrectomy plus fundoplication versus sleeve gastrectomy alone for treatment of patients with severe obesity: a systematic review and meta-analysis. Surg Obes Relat Dis 2024; 20:532-543. [PMID: 38302307 DOI: 10.1016/j.soard.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) is a widely performed bariatric surgery, but it is associated with an increased risk of gastroesophageal reflux (GERD) in the long term. The addition of fundoplication to laparoscopic SG may improve lower oesophageal sphincter function and reduce postoperative GERD. OBJECTIVES This systematic review and meta-analysis aims to compare the efficacy and safety of SG plus fundoplication (SG + F) versus SG alone for the treatment of patients with severe obesity (≥35 kg/m2). SETTING Meta-analysis. METHODS Three electronic databases were searched from inception until January 2023. Studies were included if they compared outcomes of SG + F versus SG in patients with severe obesity (≥35 kg/m2). The primary outcome was remission of GERD postoperatively. Secondary outcomes were the percentage of excess weight loss, percentage of total weight loss, postoperative complication rate, operative time, and length of stay. RESULTS A total of 5 studies with 539 subjects (212 SG + F and 327 SG alone) were included. The mean preoperative body mass index was 42.6 kg/m2. SG + F achieved higher remission of GERD compared with laparoscopic SG (odds ratio [OR] = 13.13; 95% CI, 3.54-48.73; I2 = 0%). However, the percentage of total weight loss was lower in the SG + F group (mean difference [MD] = -2.75, 95% CI, -4.28 to -1.23; I2 = 0%), whereas there was no difference in the percentage of excess weight loss (MD = -0.64; 95% CI, -20.62-19.34; I2 = 83%). There were higher postoperative complications in SG + F (OR = 2.56; 95% CI, 1.12-5.87; I2 = 0%) as well. There was no difference in operative time or length of stay between the 2 groups. CONCLUSION SG + F achieved better GERD remission but is associated with lesser weight loss and increased postoperative complications compared with SG alone. Further studies are required to ascertain the overall clinical benefit of SG + F for patients with severe obesity.
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Affiliation(s)
- Jing Hong Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Koy Min Chue
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore.
| | - Chin Hong Lim
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore; Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Republic of Singapore
| | - Bin Chet Toh
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore
| | | | - Lester Wei Lin Ong
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore
| | - Jeremy Tian Hui Tan
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore; Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Republic of Singapore
| | - Wai Keong Wong
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore; Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Republic of Singapore
| | - Baldwin Po Man Yeung
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore
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Bomio-Pacciorini L, Gaspar-Figueiredo S, Mantziari S, Godat S, Schäfer M, Teixeira Farinha H. Functional results after hiatal repair and gastropexy without fundoplication in patients with paraoesophageal hernia. Langenbecks Arch Surg 2024; 409:150. [PMID: 38702556 PMCID: PMC11068662 DOI: 10.1007/s00423-024-03340-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Paraoesophageal hernias (PEH) are associated with a high complication rate and often occur in elderly and fragile patients. Surgical gastropexy without fundoplication is an accepted alternative procedure; however, outcomes and functional results are rarely described. Our study aims to evaluate short-term outcomes and the long-term quality of life after gastropexy as treatment for PEH. METHODS Single center cohort analysis of all consecutive patients who underwent gastropexy for PEH without fundoplication. Postoperative outcomes and functional results were retrospectively collected. Reflux symptoms developed postoperatively were reported using the validated quality of life questionnaire: GERD-Health Related Quality of Life Qestionnaire (GERD-HRQL). RESULTS Thirty patients (median age: 72 years (65-80)) were included, 40% classified as ASA III. Main PEH symptoms were reflux (63%), abdominal/thoracic pain (47%), pyrosis (33%), anorexia (30%), and food blockage (26%). Twenty-six laparoscopies were performed (86%). Major complications (III-IVb) occurred in 9 patients (30%). Seven patients (23%) had PEH recurrence, all re-operated, performing a new gastropexy. Median follow-up was 38 (17-50) months. Twenty-two patients (75%) reported symptoms resolution with median GERD-HRQL scale of 4 (1-6). 72% (n = 21) reported operation satisfaction. GERD-HRQL was comparable between patients who were re-operated for recurrence and others: 5 (2-19) versus 3 (0-6), p = 0.100. CONCLUSION Gastropexy without fundoplication was performed by laparoscopy in most cases with acceptable complications rates. Two-thirds of patients reported symptoms resolution, and long-term quality-of-live associated to reflux symptoms is good. Although the rate of PEH recurrence requiring a new re-intervention remained increased (23%), it does not seem to affect long-term functional results.
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Affiliation(s)
- Laura Bomio-Pacciorini
- Department of Visceral Surgery, Faculty of Biology and Medicine UNIL, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sérgio Gaspar-Figueiredo
- Department of Visceral Surgery, Faculty of Biology and Medicine UNIL, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, Faculty of Biology and Medicine UNIL, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sébastien Godat
- Department of Gastroenterology and Hepatology, Faculty of Biology and Medicine UNIL, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, Faculty of Biology and Medicine UNIL, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Hugo Teixeira Farinha
- Department of Visceral Surgery, Faculty of Biology and Medicine UNIL, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Mattioli G, Cipriani MS, Barone G, Palo F, Arrigo S, Gandullia P, Avanzini S, Wong MCY. Pediatric nutritional surgery and its implications: results from a unicentric retrospective analysis. Pediatr Surg Int 2024; 40:116. [PMID: 38695977 PMCID: PMC11065931 DOI: 10.1007/s00383-024-05700-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE Existing guidelines provide weak recommendations on the surgical management of nutritional problems in children. The objective was to design a management pathway to address the best nutritional surgery (NS) procedure in a given patient. METHODS Retrospective analysis of children treated at our department from January 2015 to December 2019. The sample was divided into two groups according to presence or absence of neurological impairment (NI). Patients with NI (Group 1) were classified in three subgroups based on presenting symptoms: A-Dysphagia without gastroesophageal reflux (GER); B-GER with or without dysphagia; C-Symptoms associated with a delayed gastric emptying. RESULTS A total of 154 patients were included, 111 with NI. One-hundred-twenty-eight patients underwent only one procedure. Complications and mortality were superior in Group 1. In subgroup A, isolated gastrostomy was the first NS in all patients. In subgroup B most of patients were subjected to a Nissen fundoplication, while in 5 cases total esophagogastric dissociation (TEGD) was the first intervention. Considering the entire sample, 92.3% patients who underwent a TEGD did not require further procedures. CONCLUSION NS encompasses various procedures depending on presenting symptoms and neurological status. A management flowchart for these patients is proposed.
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Affiliation(s)
- Girolamo Mattioli
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - Maria Stella Cipriani
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy.
- DINOGMI, University of Genoa, Genoa, Italy.
| | - Giulia Barone
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - Federico Palo
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Paolo Gandullia
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Stefano Avanzini
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - Michela Cing Yu Wong
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
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Geerts JH, de Haas JWA, Nieuwenhuijs VB. Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia. Surg Endosc 2024; 38:2398-2404. [PMID: 38565689 PMCID: PMC11078792 DOI: 10.1007/s00464-024-10703-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/16/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement. METHODS A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed. RESULTS 54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%). CONCLUSION In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.
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Liu DS, Wong DJ, Goh SK, Fayed A, Stevens S, Aly A, Bright T, Weinberg L, Watson DI. Quantifying Perioperative Risks for Antireflux and Hiatus Hernia Surgery: A Multicenter Cohort Study of 4301 Patients. Ann Surg 2024; 279:796-807. [PMID: 38318704 DOI: 10.1097/sla.0000000000006223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Using a comprehensive Australian cohort, we quantified the incidence and determined the independent predictors of intraoperative and postoperative complications associated with antireflux and hiatus hernia surgeries. In addition, we performed an in-depth analysis to understand the complication profiles associated with each independent risk factor. BACKGROUND Predicting perioperative risks for fundoplication and hiatus hernia repair will inform treatment decision-making, hospital resource allocation, and benchmarking. However, available risk calculators do not account for hernia anatomy or technical aspects of surgery in estimating perioperative risk. METHODS Retrospective analysis of all elective antireflux and hiatus hernia surgeries in 36 Australian hospitals over 10 years. Hierarchical multivariate logistic regression analyses were performed to determine the independent predictors of intraoperative and postoperative complications accounting for patient, surgical, anatomic, and perioperative factors. RESULTS A total of 4301 surgeries were analyzed. Of these, 1569 (36.5%) were large/giant hernias and 292 (6.8%) were revisional procedures. The incidence rates of intraoperative and postoperative complications were 12.6% and 13.3%, respectively. The Charlson Comorbidity Index, hernia size, revisional surgery, and baseline anticoagulant usage independently predicted both intraoperative and postoperative complications. These risk factors were associated with their own complication profiles. Finally, using risk matrices, we visualized the cumulative impact of these 4 risk factors on the development of intraoperative, overall postoperative, and major postoperative complications. CONCLUSIONS This study has improved our understanding of perioperative morbidity associated with antireflux and hiatus hernia surgery. Our findings group patients along a spectrum of perioperative risks that inform care at an individual and institutional level.
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Affiliation(s)
- David S Liu
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Surgery, The University of Melbourne, Austin Precinct, Austin Health, Victoria, Australia
| | - Darren J Wong
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
- Department of Gastroenterology, Austin Health, Victoria, Australia
| | - Su Kah Goh
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
| | - Aly Fayed
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
| | - Sean Stevens
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, General and Gastrointestinal Surgery Research Group, The University of Melbourne, Victoria, Australia
| | - Ahmad Aly
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Victoria, Australia
- Department of Surgery, The University of Melbourne, Austin Precinct, Austin Health, Victoria, Australia
| | - Tim Bright
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - David I Watson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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Bailey JM. Gastrointestinal Conditions: Gastroesophageal Reflux Disease. FP Essent 2024; 540:7-15. [PMID: 38767884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Gastroesophageal reflux disease (GERD) affects more than 20% of adults. Risk factors include older age, obesity, smoking, and sedentary lifestyle. Lower esophageal sphincter (LES) dysfunction is a primary cause. Classic symptoms include heartburn and regurgitation. With classic symptoms, proton pump inhibitors (PPIs) can be prescribed without further testing; PPIs should be taken on an empty stomach. Patients with atypical symptoms and those not benefiting from management should undergo esophagogastroduodenoscopy (EGD), and potentially pH and impedance testing to confirm GERD or identify other conditions. This is important because GERD increases risk of esophageal erosions/stricture, Barrett esophagus, and esophageal adenocarcinoma. However, a large percentage of adults taking PPIs have no clear indication for treatment, and PPIs and other antisecretory therapy should be tapered off if possible. Of note, vonoprazan, a new drug approved by the Food and Drug Administration (FDA), has shown superiority to PPIs. In addition to pharmacotherapy, lifestyle changes are indicated, including losing weight if overweight, not lying down after meals, and ceasing tobacco use. Procedural interventions, including fundoplication and magnetic sphincter augmentation, can be considered for patients wishing to discontinue drugs or with symptoms unresponsive to PPIs. Procedural interventions are effective for the first 1 to 3 years, but effectiveness decreases over time.
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Han T, Liu S, Qiu X. A commentary on 'Intraoperative endomanometric laparoscopic Nissen fundoplication improves postoperative outcomes in large sliding hiatus hernias with severe gastroesophageal reflux disease: a retrospective cohort study'. Int J Surg 2024; 110:3101-3102. [PMID: 38329096 DOI: 10.1097/js9.0000000000001177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/09/2024]
Affiliation(s)
| | - Shuai Liu
- Department of Gastrointestinal Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People's Republic of China
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10
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Randle RJ, Liou DZ, Lui NS. Management of Paraesophageal Hernias. Thorac Surg Clin 2024; 34:163-170. [PMID: 38705664 DOI: 10.1016/j.thorsurg.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Paraesophageal hernias are classified according to the altered anatomic relationships between the gastroesophageal junction or stomach and the diaphragmatic hiatus. Herniation of these structures into the mediastinum may produce common complaints such as reflux, chest pain, and dysphagia. The elective repair of these hernias is well tolerated and significantly improves quality of life among patients with symptomatic disease. The hallmarks of a quality repair include the circumferential mobilization of the esophagus to generate 3 cm of tension-free intra-abdominal length and the performance of a fundoplication.
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Affiliation(s)
- Ryan J Randle
- Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L223, Portland, OR, USA; Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/radonrandle
| | - Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/DouglasLiou
| | - Natalie S Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA.
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Fibiger G, Glądys K, Fibiger W, Pasternak A, Szura M. Repair of type II paraesophageal hernia with Nissen fundoplication in a patient with von Willebrand disease and spondylolisthesis - a clinical case report. Folia Med (Plovdiv) 2024; 66:287-290. [PMID: 38690827 DOI: 10.3897/folmed.66.e111803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/11/2023] [Indexed: 05/03/2024] Open
Abstract
Hiatal hernias continue to be fairly common in clinical practice. However, the variety of different symptoms presented by patients may hinder establishing the ultimate diagnosis. Nevertheless, currently, the diagnosis of hiatal hernia can be easily established, based on barium swallow radiography. We would like to present a clinical case report of a patient with complex medical history, including von Willebrand disease, degenerative spinal disease, and chronic sinusitis, who was finally diagnosed with hiatal hernia and treated with a standard laparoscopic Nissen fundoplication. Our case focuses on the significance of comorbidities on patients' symptoms, which sometimes may mislead the therapeutic process.
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Affiliation(s)
| | - Kinga Glądys
- Jagiellonian University Medical College, Kraków, Poland
| | - Wojciech Fibiger
- Podhale State Vocational University in Nowy Targ, Nowy Targ, Poland
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12
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Calzon ME, Koussayer B, Sujka J. How I do it: robotic hiatal hernia repair with stapled conversion from Nissen to Toupet fundoplication. Updates Surg 2024; 76:719-722. [PMID: 38070073 DOI: 10.1007/s13304-023-01712-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/18/2023] [Indexed: 04/05/2024]
Abstract
The purpose of this paper is to describe a robotic surgical technique for converting a slipped Nissen fundoplication to a Toupet fundoplication. Our technique utilizes four 8 mm robotic ports placed in a horizontal pattern above the umbilicus. The robotic tools we used are a vessel sealer, bipolar forceps, and Cadière forceps. In addition, an esophagogastroduodenoscopy (EGD) is placed through the esophagus into the stomach to be used as a bougie. If a hernia is present, we dissect it from the mediastinum until the posterior confluence is identified. Next sutures from the previous Nissen fundoplication are identified and removed to mobilize the crus. All adhesions around the stomach are removed to mobilize the esophagus, ensuing 3 cm of intraabdominal esophagus is available. Using an EGD as a bougie, we used two interrupted, 0 silk suture over Teflon pledgets placed in a horizontal mattress fashion to close the hiatal defect. Using an endoscope, we identified the previous Nissen fundoplication and used a 60 mm blue load stapler to transect the wrap from the stomach. The 360° Nissen fundoplication had now been converted into a 270° Toupet fundoplication, which is confirmed with the EGD. The functionality of the wrap is confirmed if the "Stack of Coins" sign is present, and the wrap lies tight against the scope. A Nissen-to-Toupet fundoplication conversion using a robotic-assisted surgical technique may be useful in reducing reoperations and complications in patients undergoing fundoplication surgery.
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Affiliation(s)
- Maysen E Calzon
- USF Health Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA.
| | - Bilal Koussayer
- USF Health Morsani College of Medicine, 560 Channelside Dr, Tampa, FL, 33602, USA
| | - Joseph Sujka
- USF Department of General Surgery 2 Tampa General Circle, 7th Floor, Tampa, FL, 33606, USA
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Broderick RC, Spurzem GJ, Huang EY, Sandler BJ, Jacobsen GR, Weisman RA, Onaitis MW, Weissbrod PA, Horgan S. A Multidisciplinary Minimally Invasive Approach Is Necessary for the Contemporary Management of Esophageal Diverticula. J Laparoendosc Adv Surg Tech A 2024; 34:291-298. [PMID: 38407920 DOI: 10.1089/lap.2023.0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Background: Esophageal diverticula were traditionally treated with open surgery, which is associated with significant morbidity and mortality rates. Management has shifted to minimally invasive approaches with several advantages. We examine outcomes in patients with esophageal diverticula treated with minimally invasive techniques by a multidisciplinary surgical team at a single center. Materials and Methods: A retrospective review of a prospectively maintained database was performed for patients who underwent minimally invasive surgery for esophageal diverticula at our institution from June 2010 to December 2022. Primary outcomes were 30-day morbidity and mortality rates. Secondary outcomes were symptom resolution, length of stay (LOS), readmission, and need for reintervention. Results: A total of 28 patients were identified. Twelve patients had pharyngeal diverticula, 7 patients had midesophageal diverticula, and 9 patients had epiphrenic diverticula. Thirty-day morbidity and readmission rates were 10.7% (3 patients), 1 pharyngeal (sepsis), 1 midesophageal (refractory nausea), and 1 epiphrenic (poor oral intake). There were no esophageal leaks. Average LOS was 2.3 days, with the pharyngeal group experiencing a significantly shorter LOS (1.3 days versus 3.4 days for midesophageal, P < .01 versus 2.8 days for epiphrenic, P < .05). Symptom resolution after initial operation was 78.6%. Reintervention rate was 17.9%, and symptom resolution after reintervention was 100%. There were no mortalities. Conclusion: This study demonstrates that esophageal diverticula can be repaired safely and efficiently when performed by a multidisciplinary team utilizing advanced minimally invasive endoscopic and robotic surgical techniques. We advocate for the management of this rare condition at a high-volume center with extensive experience in foregut surgery.
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Affiliation(s)
- Ryan C Broderick
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Graham J Spurzem
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Estella Y Huang
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Bryan J Sandler
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Garth R Jacobsen
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Robert A Weisman
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Mark W Onaitis
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Philip A Weissbrod
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
| | - Santiago Horgan
- Department of Surgery, UC San Diego School of Medicine, University of California San Diego, San Diego, California, USA
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Wisniowski P, Putnam LR, Gallagher S, Rawal R, Houghton C, Lipham JC. Short term safety of magnetic sphincter augmentation vs minimally invasive fundoplication: an ACS-NSQIP analysis. Surg Endosc 2024; 38:1944-1949. [PMID: 38334778 PMCID: PMC10978616 DOI: 10.1007/s00464-024-10672-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/30/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE Magnetic Sphincter Augmentation (MSA) is an FDA-approved anti-reflux procedure with comparable outcomes to fundoplication. However, most data regarding its use are limited to single or small multicenter studies which may limit the generalizability of its efficacy. The purpose of this study is to evaluate the outcomes of patients undergoing MSA vs fundoplication in a national database. MATERIALS AND METHODS The 2017-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Registry was utilized to evaluate patients undergoing MSA or fundoplication. Patients requiring Collis gastroplasty, paraesophageal hernia repair, and emergency cases, were excluded. Patient outcomes included overall complication rates, readmissions, reoperations, and mortality. RESULTS A total of 7,882 patients underwent MSA (n = 597) or fundoplication (n = 7285). MSA patients were younger (51 vs 57, p < 0.001), and more often male (49.6 vs 34.3%, p < 0.001). While patients undergoing MSA experienced similar rates of reoperation (1.0 vs 2.0%, p = 0.095), they experienced fewer readmissions (2.2 vs 4.7%, p = 0.005), complications (0.6 vs 4.0%, p < 0.001), shorter mean (SD) hospital length of stay(days) (0.4 ± 4.3 vs 1.8 ± 4.6, p < 0.001) and operative time(min) (80.8 ± 36.1 vs 118.7 ± 63.7, p < 0.001). Mortality was similar between groups (0 vs 0.3%, p = 0.175). On multivariable analysis, MSA was independently associated with reduced postoperative complications (OR 0.23, CI 0.08 to 0.61, p = 0.002), readmissions (OR 0.53, CI 0.30 to 0.94, p = 0.02), operative time (RC - 36.56, CI - 41.62 to - 31.49. p < 0.001) and length of stay (RC - 1.22, CI - 1.61 to - 0.84 p < 0.001). CONCLUSION In this national database study, compared to fundoplication MSA was associated with reduced postoperative complications, fewer readmissions, and shorter operative time and hospital length of stay. While randomized trials are lacking between MSA and fundoplication, both institutional and national database studies continue to support the use of MSA as a safe anti-reflux operation.
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Affiliation(s)
- Paul Wisniowski
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Luke R Putnam
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Shea Gallagher
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Rushil Rawal
- California University of Science and Medicine, Colton, CA, USA
| | - Caitlin Houghton
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - John C Lipham
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA.
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15
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Desir A, Marques C, Farah E, R Hegde S, Holcomb C, Scott DJ, Sankaranarayanan G. Validity and reliability evidence support task-specific metrics for laparoscopic fundoplication. Surg Endosc 2024; 38:2219-2230. [PMID: 38383688 DOI: 10.1007/s00464-024-10675-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/30/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Laparoscopic hiatal hernia repair (LHHR) is a complex operation requiring advanced surgical training. Surgical simulation offers a potential solution for learning complex operations without the need for high surgical volume. Our goal is to develop a virtual reality (VR) simulator for LHHR; however, data supporting task-specific metrics for this procedure are lacking. The purpose of this study was to develop and assess validity and reliability evidence of task-specific metrics for the fundoplication phase of LHHR. METHODS In phase I, structured interviews with expert foregut surgeons were conducted to develop task-specific metrics (TSM). In phase II, participants with varying levels of surgical expertise performed a laparoscopic Nissen fundoplication procedure on a porcine stomach explant. Video recordings were independently assessed by two blinded graders using global and TSM. An intraclass correlation coefficient (ICC) was used to assess interrater reliability (IRR). Performance scores were compared using a Kruskal-Wallis test. Spearman's rank correlation was used to evaluate the association between global and TSM. RESULTS Phase I of the study consisted of 12 interviews with expert foregut surgeons. Phase II engaged 31 surgery residents, a fellow, and 6 attendings in the simulation. Phase II results showed high IRR for both global (ICC = 0.84, p < 0.001) and TSM (ICC = 0.75, p < 0.001). Significant between-group differences were detected for both global (χ2 = 24.01, p < 0.001) and TSM (χ2 = 18.4, p < 0.001). Post hoc analysis showed significant differences in performance between the three groups for both metrics (p < 0.05). There was a strong positive correlation between the global and TSM (rs = 0.86, p < 0.001). CONCLUSION We developed task-specific metrics for LHHR and using a fundoplication model, we documented significant reliability and validity evidence. We anticipate that these LHHR task-specific metrics will be useful in our planned VR simulator.
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Affiliation(s)
- Alexis Desir
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Carolina Marques
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Emile Farah
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Shruti R Hegde
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Carla Holcomb
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Daniel J Scott
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Ganesh Sankaranarayanan
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
- Artificial Intelligence and Medical Simulation Lab, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
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Patrzyk M, Hummel R, Kersting S. [Surgical strategy for hiatal hernias]. Chirurgie (Heidelb) 2024; 95:336-344. [PMID: 38372742 DOI: 10.1007/s00104-024-02054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 02/20/2024]
Abstract
The indications for surgical treatment of hiatus hernias differentiate between type I and types II, III and IV hernias. The indications for a type I hernia should include a proven reflux disease but the indications for surgical treatment of types II, III and IV hernias are mandatory due to the symptoms with problems in the passage of food and due to the sometimes very severe possible complications. The primary aims of surgery are the repositioning of the herniated contents and a hiatoplasty, which includes a surgical narrowing of the esophageal hiatus by suture implantation. In addition, depending on the clinical situation other procedures, such as hernia sac removal, mesh implantation, gastropexy and fundoplication can be considered. There are various approaches to the repair, all of which have individual advantages and disadvantages. An adaptation to the specific needs situation of the patient and the expertise of the surgeon is therefore essential.
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Affiliation(s)
| | | | - Stephan Kersting
- Klinik für Allgemeine Chirurgie, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Deutschland.
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17
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Wu R, Robayo V, Nguyen DT, Chan EY, Chihara R, Huang HJ, Graviss EA, Kim MP. Enhanced recovery after surgery may mitigate the risks associated with robotic-assisted fundoplication in lung transplant patients. Surg Endosc 2024; 38:2134-2141. [PMID: 38443500 DOI: 10.1007/s00464-024-10719-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. METHODS We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. RESULTS Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). DISCUSSION The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.
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Affiliation(s)
- Rebecca Wu
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Duc T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Edward Y Chan
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Howard J Huang
- Division of Pulmonary Critical Care, and Sleep Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, FACS. 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
| | - Min P Kim
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.
- Division of Thoracic Surgery, Houston Methodist Hospital, Houston, TX, USA.
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Kato D, Uchida H, Amano H, Yokota K, Shirota C, Tainaka T, Sumida W, Makita S, Yasui A, Gohda Y, Maeda T, Hinoki A. A systematic review of Sandifer syndrome in children with severe gastroesophageal reflux. Pediatr Surg Int 2024; 40:91. [PMID: 38526644 DOI: 10.1007/s00383-024-05683-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE Sandifer syndrome (SS), which combines gastroesophageal reflux (GER) and a neurological or psychiatric disorder, is an uncommon condition that often takes a long time to diagnosis. We aimed to systematically review available papers regarding SS. METHODS After presenting our two cases of SS, we systematically reviewed articles published in MEDILINE/PubMed, Cochrane Library, and Web of Science. RESULTS The meta-analysis included 54 reported cases and 2 of our own cases. Our results showed that all cases achieved symptom improvement with appropriate treatment for GER. Notably, 19 of the 56 cases exhibited anatomical anomalies, such as hiatal hernia and malrotation. Significantly more patients with than without anatomical anomalies required surgery (p < 0.001). However, 23 of the 29 patients without anatomical anomalies (79%) achieved symptom improvement without surgery. Patients who did not undergo surgery had a median (interquartile range) duration to symptom resolution of 1 (1-1) month. CONCLUSION The primary care providers should keep SS in the differential diagnosis of patients presenting with abnormal posturing and no apparent neuromuscular disorders. Fundoplication may be effective especially for patients with anatomical anomalies or those whose symptoms do not improve after more than 1 month with nonsurgical treatment.
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Affiliation(s)
- Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Aichi Developmental Disability Center Central Hospital, 713-8 Kagiya-cho, Kasugai, 480-0392, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yousuke Gohda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takuya Maeda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akinari Hinoki
- Department of Rare/Intractable Cancer Analysis Research, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Kamla JI, Bang GA, Tochie JN, Bwelle GM, Oumarou BN, Nonga BN. Perioperative outcomes of the surgical management of achalasia in two tertiary Cameroonian hospitals: a cohort study. BMC Gastroenterol 2024; 24:118. [PMID: 38519934 PMCID: PMC10958949 DOI: 10.1186/s12876-024-03191-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 02/29/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Achalasia is a rare esophageal disease with potentially lethal complications. Knowledge of the outcomes of the different surgical treatment modalities for achalasia by Heller's cardiomyotomy (HCM) helps to choose the safest and most effective option. However, data on the management of achalsia using a Heller myotomy is limited in Africa. Thus, our aim was to determine the perioperative morbidity, mortality and short-term functional outcomes of HCM in Cameroon. METHODOLOGY We conducted a cohort study throughout a 10-year chart review of patients who underwent HCM for achalasia and were followed up postoperatively for at least three months at two tertiary health centers in Cameroon. We analyzed demographic data, preoperative clinical and imaging data, treatment details, and outcomes at three to twelve months after HCM using the Eckardt score. RESULTS We enrolled 29 patients with achalasia having a mean age of 24 ± 16 years and predominantly females (M/F of 1/3.8). The mean symptom duration was 51 ± 20 months. In 80% of cases, the diagnosis was made through a conventional x-ray contrast imaging or "barium swallow test" (93%) and/or an upper gastrointestinal endoscopy (86%). The gold standard diagnostic method via esophageal manometry was unavailable. Preoperatievly, all patients had symptoms suggestive of an active achalasia. HCM was performed via laparotomy in 75% as opposed to 25% laparoscopic HCM procedures. Dor's anterior partial fundoplication was the main anti-reflux procedure performed (59%). Mucosal perforations were the only intraoperative complications in eight patients (2 during laparoscopy vs. 6 during laparotomy; p > 0.5) and were managed successfully by simple sutures. Postoperative complications were non-severe and occurred in 10% of patients all operated via laparotomy. The mean postoperative length of hospital stay was 7 ± 3 days for laparotomy vs. 5 ± 2 days for laparoscopy; p > 0.5. The perioperative mortality rate was nil. Overall, the short-term postoperative functional outcome was rated excellent; average Eckardt score of 1.5 ± 0.5 (vs. preoperative Eckardt Score of 9 ± 1; p < 0.0001). CONCLUSION Achalasia is diagnosed late in this resource-limited setting. HCM yields satisfactory outcomes, especially via laparoscopic management. An improvement in diagnostic esophageal manometry and mini-invasive surgical infrastructure and the required surgical training/skills are needed for optimal achalasia care.
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Affiliation(s)
- Joël Igor Kamla
- Department of Surgery, University Hospital Center, Yaoundé, Cameroon.
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon.
| | - Guy Aristide Bang
- Department of Surgery, University Hospital Center, Yaoundé, Cameroon
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | | | - George Motto Bwelle
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Visceral-Gastrointestinal Surgical unit, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Blondel Nana Oumarou
- Department of Visceral-Gastrointestinal and Laparoscopy surgery, National Insurance Fond Hospital, Yaoundé, Cameroon
| | - Bernadette Ngo Nonga
- Department of Surgery, University Hospital Center, Yaoundé, Cameroon
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
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Shi C, ZhuoMa G, Ying L, Zhang Z, Cui L, Li R, Zhang J. Efficacy and safety of endoscopic cardia peripheral tissue scar formation (ECSF) for the treatment of refractory gastroesophageal reflux disease: A systematic review with meta-analysis. Medicine (Baltimore) 2024; 103:e37062. [PMID: 38457552 PMCID: PMC10919480 DOI: 10.1097/md.0000000000037062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/28/2023] [Accepted: 01/04/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Endoscopic treatment is increasingly used for refractory gastroesophageal reflux disease (rGERD). Unlike the mechanism of conventional surgical fundoplication, gastroesophageal junction ligation, anti-reflux mucosal intervention, and radiofrequency ablation have extremely similar anti-reflux mechanisms; hence, we collectively refer to them as endoscopic cardia peripheral tissue scar formation (ECSF). We conducted a systematic review and meta-analysis to assess the safety and efficacy of ECSF in treating rGERD. METHODS We performed a comprehensive search of several databases, including PubMed, Embase, Medline, China Knowledge Network, and Wanfang, to ensure a systematic approach for data collection between January 2011 and July 2023. Forest plots were used to summarize and combine the GERD-health-related quality of life (HRQL), gastroesophageal reflux questionnaire score, and DeMeester scores, acid exposure time, lower esophageal sphincter pressure, esophagitis, proton pump inhibitors use, and patient satisfaction. RESULTS This study comprised 37 studies, including 1732 patients. After ECSF, significant improvement in gastroesophageal reflux disease health-related quality of life score (mean difference [MD] = 18.27 95% CI: 14.81-21.74), gastroesophageal reflux questionnaire score (MD = 4.85 95% CI: 3.96-5.75), DeMeester score (MD = 42.34, 95% CI: 31.37-53.30), acid exposure time (MD = 7.98, 95% CI: 6.03-9.92), and lower esophageal sphincter pressure was observed (MD = -5.01, 95% CI: -8.39 to 1.62). The incidence of serious adverse effects after ECSF was 1.1% (95% CI: 0.9%-1.2%), and postoperatively, 67.4% (95% CI: 66.4%-68.2%) of patients could discontinue proton pump inhibitor-like drugs, and the treatment outcome was observed to be satisfactory in over 80% of the patients. Subgroup analyses of the various procedures showed that all 3 types improved several objective or subjective patient indicators. CONCLUSIONS Based on the current meta-analysis, we conclude that rGERD can be safely and effectively treated with ECSF as an endoscopic procedure.
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Affiliation(s)
- Chaoyi Shi
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - GeSang ZhuoMa
- Center for General Practice Medicine, Department of Gastroenterology, Zhejiang Provincial People’s Hospital, (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Lina Ying
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhenyu Zhang
- Graduate School of Bengbu Medical University, Bengbu, Anhui, China
| | - Liyang Cui
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ruifang Li
- Center for General Practice Medicine, Department of Gastroenterology, Zhejiang Provincial People’s Hospital, (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Jun Zhang
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, China
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Joseph S, Vandruff VN, Amundson JR, Che S, Zimmermann C, Ishii S, Kuchta K, Denham W, Linn J, Hedberg HM, Ujiki MB. Roux-en-Y gastric bypass versus fundoplication for gastroesophageal reflux disease in patients with obesity results in comparable outcomes. Surgery 2024; 175:587-591. [PMID: 38154997 DOI: 10.1016/j.surg.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/11/2023] [Accepted: 10/24/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass and fundoplication are effective treatments for gastroesophageal reflux disease, though the optimal procedure of choice in obesity is unknown. We hypothesize that Roux-en-Y gastric bypass is non-inferior to fundoplication for symptomatic control of gastroesophageal reflux disease in patients with obesity. METHODS We conducted a retrospective review of a prospectively maintained quality database. Patients with a body mass index ≥of 35 who presented for gastroesophageal reflux disease and subsequently underwent Roux-en-Y gastric bypass or fundoplication were included. Perioperative outcomes and pH testing data were reviewed. Patient-reported outcomes included Reflux Symptom Index, Dysphagia, Gastroesophageal Reflux Disease-Health Related Quality of Life, and Short Form-36 scores. Data were analyzed using the Wilcoxon rank sum test. RESULTS Ninety-five patients underwent fundoplication (n = 72, 75.8%) or Roux-en-Y gastric bypass (n = 23, 24.2%) during the study period. All patients saw an improvement in gastroesophageal reflux disease symptoms and overall quality of life. There were no significant differences in postoperative Reflux Symptom Index, Dysphagia, or Short-Form-36 scores. Significant differences in gastroesophageal reflux disease-Health Related Quality of Life scores were seen at preoperative, 1, 2, and 5 years postoperative (P < .05), with better symptom control in the fundoplication group. No significant difference was noted in postoperative DeMeester scores or percent time pH <4. Weight loss was significantly higher in the Roux-en-Y gastric bypass group at all postoperative time points up to 5 years (P < .05). CONCLUSION Roux-en-Y gastric bypass and fundoplication both decrease gastroesophageal reflux disease symptoms. Subjective data shows that patients undergoing Roux-en-Y gastric bypass may complain of worse symptoms compared to patients undergoing fundoplication. Objective data notes no significant difference in postoperative pH testing. Despite previous data, offering fundoplication or Roux-en-Y gastric bypass to patients with a body mass index of ≥35 kg/m2 is appropriate. The choice of surgical approach should be more directed to patient needs and desired goals at the time of the initial clinic visit.
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Affiliation(s)
- Stephanie Joseph
- Department of Surgery, Wayne State University/Detroit Medical Center, Detroit, MI; Department of Surgery, NorthShore University Health System, Evanston, IL.
| | - Vanessa N Vandruff
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, NorthShore University HealthSystem, University of Chicago Medical Center, Chicago, IL
| | - Julia R Amundson
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, NorthShore University HealthSystem, University of Chicago Medical Center, Chicago, IL
| | - Simon Che
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | | | - Shun Ishii
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Woody Denham
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - John Linn
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - H Mason Hedberg
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, IL
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Barron JO, Tasnim S, Toth AJ, Sudarshan M, Sanaka M, Ramji S, Adhikari S, Murthy SC, Blackstone EH, Raja S. The Value of Fundoplication in the Treatment of Type I Achalasia. Ann Thorac Surg 2024; 117:594-601. [PMID: 37479126 DOI: 10.1016/j.athoracsur.2023.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 05/12/2023] [Accepted: 05/30/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Type I achalasia comprises 20% of achalasia and has nearly absent esophageal motor activity. Concerns that fundoplication decreases the effectiveness of Heller myotomy in these patients has increased adoption of peroral endoscopic myotomy (POEM). Hence, we compared outcomes after Heller myotomy with Dor fundoplication vs POEM. METHODS From 2005 to 2020, 150 patients with type I achalasia underwent primary surgical myotomy (117 Heller myotomy, 33 POEM). Patient demographics, prior treatments, timed barium esophagrams, Eckardt scores, and reinterventions were assessed between the 2 groups. Median follow-up was 5 years for Heller myotomy and 2.5 years for POEM. RESULTS The Heller myotomy group was younger, had fewer comorbidities, and lower body mass index vs POEM. Risk-adjusted models demonstrated clinical success (Eckardt ≤3) in 83% of Heller myotomies and 87% of POEMs at 3 years; longitudinal complete timed barium esophagram emptying and reintervention were also similar. An abnormal pH test result was documented in 10% (6 of 60) after Heller myotomy and in 45% (10 of 22) after POEM (P < .001). CONCLUSIONS Despite nearly absent esophageal contractility, Heller myotomy with Dor fundoplication and POEM result in similar long-term symptom relief, esophageal emptying, and occurrence of reintervention in patients with type I achalasia. There is decreased esophageal acid exposure with the addition of a fundoplication, without compromised esophageal drainage, allaying fears of a detrimental effect of a fundoplication. Hence, choice of procedure may be personalized based on patient characteristics and esophageal morphology and not solely on manometric subtype.
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Affiliation(s)
- John O Barron
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sadia Tasnim
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrew J Toth
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Monisha Sudarshan
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Madhusudhan Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sadhvika Ramji
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Saurav Adhikari
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Marcon S, Anania G, Tamburini N. Laparoscopic Approach to Epiphrenic Diverticula Under Endoscopic Assistance: A Technical Report. J Laparoendosc Adv Surg Tech A 2024; 34:162-166. [PMID: 38109227 DOI: 10.1089/lap.2023.0469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Introduction: Epiphrenic diverticulum is a rare disease caused by mucosa and submucosa herniation through the muscular layers of the esophageal wall. This study presents a case of a patient with a symptomatic epiphrenic diverticulum treated with surgery under endoscopic assistance. A review of the literature on this unusual condition was conducted, focusing on the pathogenesis, presentation, and surgical challenges. Methods: A 75-year-old woman who underwent an esophagogastroduodenoscopy (EGD) after experiencing worsening dysphagia for food and liquids. The EGD revealed a large epiphrenic diverticulum 36 cm from the upper incisor teeth. The presence of a diverticulum was verified by barium swallow, which revealed a 6 cm diameter epiphrenic diverticulum on the right side of the esophagus. Results: Patient underwent laparoscopic diverticulectomy associated with Heller's myotomy and anterior partial fundoplication. A gastroscope was placed intraoperatively to calibrate the esophagus to prevent stenosis during diverticulectomy, and it was also used to check the integrity of the esophageal wall. The patient tolerated clear liquids on postoperative day 2. Postoperative course was complicated by right pleural effusion and fever managed with antibiotics and pleural drainage. Conclusion: Epiphrenic diverticulectomy in conjunction with management of the underlying motor dysfunction and avoidance of gastroesophageal reflux disease is an effective procedure. Laparoscopy is considered the approach of choice for the majority of patients. Endoscopic assistance during surgery can help the identification of the diverticulum and verify the integrity of the staple line.
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Affiliation(s)
- Salvatore Marcon
- Department of Surgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Gabriele Anania
- Department of Surgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Nicola Tamburini
- Department of Surgery, Sant'Anna University Hospital, Ferrara, Italy
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24
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Al Asadi H, Najah H, Edelmuth R, Greenberg JA, Marshall T, Salehi N, Lee YJ, Riascos MC, Finnerty BM, Fahey TJ, Zarnegar R. Impedance planimetry (EndoFLIPTM) and surgical outcomes after Hill compared to Toupet fundoplication. Surg Endosc 2024; 38:1020-1028. [PMID: 38097749 DOI: 10.1007/s00464-023-10640-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/29/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Endoluminal functional lumen imaging probe (EndoFLIP) provides a real-time assessment of gastroesophageal junction (GEJ) compliance during fundoplication. Given the limited data on EndoFLIP measurements during the Hill procedure, we investigated the impact of the Hill procedure on GEJ compliance compared to Toupet fundoplication. METHODS Patients who underwent robotic Hill or Toupet fundoplication with intraoperative EndoFLIP between 2017 and 2022 were included. EndoFLIP measurements of the GEJ included cross sectional surface area (CSA), intra-balloon pressure, high pressure zone length (HPZ), distensibility index (DI), and compliance. Subjective reflux symptoms, gastroesophageal reflux disease-health related quality of life (GERD-HRQL) score, and dysphagia score were assessed pre-operatively as well as at short- and longer-term follow-up. RESULTS One-hundred and fifty-four patients (71.9%) had a Toupet fundoplication while sixty (28%) patients underwent the Hill procedure. The CSA [27.7 ± 10.9 mm2 vs 42.2 ± 17.8 mm2, p < 0.0001], pressure [29.5 ± 6.2 mmHg vs 33.9 ± 8.5 mmHg, p = 0.0009], DI [0.9 ± 0.4 mm2/mmHg vs 1.3 ± 0.6 mm2/mmHg, p = 0.001], and compliance [25.9 ± 12.8 mm3/mmHg vs 35.4 ± 13.4 mm3/mmHg, p = 0.01] were lower after the Hill procedure compared to Toupet. However, there was no difference in post-fundoplication HPZ between procedures [Hill: 2.9 ± 0.4 cm, Toupet: 3.1 ± 0.6 cm, p = 0.15]. Follow-up showed no significant differences in GERD-HRQL scores, overall dysphagia scores or atypical symptoms between groups (p > 0.05). CONCLUSION The Hill procedure is as effective to the Toupet fundoplication in surgically treating gastroesophageal reflux disease (GERD) despite the lower CSA, DI, and compliance after the Hill procedure. Both procedures led to DI < 2 mm2/mmHg with no significant differences in dysphagia reporting (12-24) months after the procedure. Further studies to elucidate a cutoff value for DI for postoperative dysphagia development are still warranted.
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Affiliation(s)
- Hala Al Asadi
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Haythem Najah
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | | | - Jacques A Greenberg
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Teagan Marshall
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Niloufar Salehi
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Yeon Joo Lee
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Maria Cristina Riascos
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Brendan M Finnerty
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Thomas J Fahey
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Division of Endocrine & Minimally Invasive Surgery, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68 Street, K-836, New York, NY, 10065, USA.
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25
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Fantasia JJ, Cock C, Watson DI, Bright T, Thompson SK. Assessment of laparoscopic fundoplication with endoscopy: room for improvement. Surg Endosc 2024; 38:713-719. [PMID: 38036765 DOI: 10.1007/s00464-023-10570-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/22/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease affects a significant portion of the Australian and world population. Minimally invasive laparoscopic fundoplication is a highly effective treatment in appropriately selected patients, with a 90% satisfaction rate. However, up to 5% will undergo revisional surgery. Endoscopy is an important investigation in the evaluation of persistent or new symptoms after fundoplication. Our study sought to evaluate the inter-rater reliability and variability in assessing fundoplication with endoscopy. METHODS Upper gastrointestinal (UGI) surgeons and gastroenterologists were invited to join the cohort study through their professional membership with two societies based in Australia. Participants completed a two part 25-item multiple choice questionnaire, involving the analysis of ten static endoscopic images post-fundoplication. RESULTS A total of 101 participants were included in the study (64 UGI surgeons and 37 gastroenterologists). Over 95% of participants were consultant level, working in non-rural tertiary hospitals. Total accuracy for all 10 cases combined was 76% for UGI surgeons and 69.9% for gastroenterologists. In three of the 10 cases, UGI surgeons performed significantly better than gastroenterologists (p < 0.05). When assessing performance across each of the 4 questions for each case, UGI surgeons were more accurate than gastroenterologists in describing the integrity of the wrap (p = 0.014). Inter-rater reliability was low across both groups for most domains (kappa < 1). CONCLUSION Our study confirms low inter-rater reliability between endoscopists and large variations in reporting. UGI surgeons performed better than gastroenterologists in certain cases, usually when describing the integrity of the fundoplication. Our study provides further support for the use of a standardized reporting system in post-fundoplication patients.
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Affiliation(s)
- Joseph J Fantasia
- Flinders Medical Centre, Flinders University Discipline of Surgery, College of Medicine & Public Health, Bedford Park, SA, 5042, Australia
| | - Charles Cock
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - David I Watson
- Flinders Medical Centre, Flinders University Discipline of Surgery, College of Medicine & Public Health, Bedford Park, SA, 5042, Australia
| | - Tim Bright
- Flinders Medical Centre, Flinders University Discipline of Surgery, College of Medicine & Public Health, Bedford Park, SA, 5042, Australia
| | - Sarah K Thompson
- Flinders Medical Centre, Flinders University Discipline of Surgery, College of Medicine & Public Health, Bedford Park, SA, 5042, Australia.
- Flinders Medical Centre, Rm 5E221.3, Bedford Park, SA, 5042, Australia.
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26
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Logarajah S, Karumuri J, Ahle D, Osman H, Jeyarajah DR. Fundoplication at the time of paraesophageal hernia repair may not reduce postoperative reflux. J Gastrointest Surg 2024; 28:70-71. [PMID: 38353077 DOI: 10.1016/j.gassur.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/19/2023] [Accepted: 09/29/2023] [Indexed: 02/16/2024]
Abstract
Hiatal hernias are observed in approximately 15% to 20% of the population in Western society. Most patients are diagnosed with a sliding-type hiatal hernia, of which gastroesophageal reflux is the predominant driving symptom. Surgical repair of these types of hernias often involves a wrap procedure during the index operation as standard of care. For type 2, 3, and 4 hernias, also known as paraesophageal hernias (PEHs), the symptom complexes vary and often involve symptoms other than reflux, including dysphagia, anemia, shortness of breath, and chest pain. We sought to evaluate whether patients who underwent PEH repair without fundoplication reported different rates of postoperative symptoms compared with those who did.
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Affiliation(s)
- Shankar Logarajah
- Department of Surgery, Methodist Richardson Medical Center, Richardson, Texas, United States
| | - Jash Karumuri
- Department of Surgery, Methodist Richardson Medical Center, Richardson, Texas, United States
| | - David Ahle
- Department of Surgery, Methodist Richardson Medical Center, Richardson, Texas, United States
| | - Houssam Osman
- Department of Surgery, Methodist Richardson Medical Center, Richardson, Texas, United States; Department of Surgery, Texas Christian University, Fort Worth, Texas, United States
| | - D Rohan Jeyarajah
- Department of Surgery, Methodist Richardson Medical Center, Richardson, Texas, United States; Department of Surgery, Texas Christian University, Fort Worth, Texas, United States.
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Salcedo Cabañas G, Martín Ríos MD, Posada González M, Barragán Serrano C, Serrano Yébenes E, García Olmo D, Vorwald P. Fundoplication with extensive dissection of the esophagogastric junction: Lessons learned and outcomes from 178 consecutives patients. Cir Esp 2024; 102:25-31. [PMID: 38141845 DOI: 10.1016/j.cireng.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/10/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Antireflux surgery is commonly associated with significant recurrence and complication rates, and several surgical techniques have been proposed to minimize them. The aim of this study is to evaluate the results of a fundoplication with extensive dissection of the esophagogastric junction 1 and 3 years after the procedure. METHODS Retrospective observational study including 178 patients with gastroesophageal reflux disease or hiatal hernia who underwent fundoplication with extensive dissection of the esophagogastric junction between 2015 and 2020. Hernia recurrence, symptoms and quality of life at 1 and 3 years after surgery were assessed by barium transit, endoscopy and questionnaires for symptoms and quality of life (GERD-HRQL). RESULTS Heartburn rate was 7.5% and 10.7% at 1 and 3 years respectively, regurgitation 3.8% and 6.9% and dysphagia was 3.7% and 7.6%. The presence of hiatal hernia was evident preoperatively in 55.1% and in 7.8% and 9.6% at follow-up and the median GERD-HRQL scale was 27, 2 and 0 respectively. There were no cases of slippage of the fundoplication or symptoms suggestive of vagal injury. No differences were found when comparing the different types of fundoplication in terms of reflux and recurrence or complications. CONCLUSIONS Fundoplication with extensive dissection of the esophagogastric junction contributes to correct positioning and better anchorage of the fundoplication, which is associated with low rates of hiatal hernia and reflux recurrence, as well as absence of slippage and lower possibility of vagal injury.
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Affiliation(s)
| | - María Dolores Martín Ríos
- Departamento de Medicina Preventiva, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain; Universidad Autónoma, Madrid, Spain
| | - María Posada González
- Departamento de Cirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | | | - Damián García Olmo
- Departamento de Cirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain; Universidad Autónoma, Madrid, Spain
| | - Peter Vorwald
- Departamento de Cirugía, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain; Universidad Autónoma, Madrid, Spain
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Tsuboi K, Masuda T, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Sakashita Y, Fukushima N, Takeuchi H, Takahashi K, Yano F, Eto K. Is it meaningful to add mesh reinforcement to laparoscopic fundoplication for esophageal hiatal hernias in the patients with high risk of hiatal hernia recurrence? Esophagus 2024; 21:67-75. [PMID: 37817043 DOI: 10.1007/s10388-023-01026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof. The aim of this study is to investigate whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias. METHODS The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias. RESULTS The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p = 0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p = 0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p < 0.0001) and a higher frequency of intraoperative complications (p = 0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p = 0.049), with the rate of postoperative reflux esophagitis also tending to be low (p = 0.083). CONCLUSIONS Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50, Takashima-Cho, Fuji, Shizuoka, 416-0951, Japan.
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishisaitama-Chuo National Hospital, Saitama, Japan
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hideyuki Takeuchi
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Keita Takahashi
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Wong K, Grams J, Schwarz E, Wood L, Dort J, Reinke C. A synopsis of the SAGES ADOPT course for foregut surgery and its positive impact on surgeons' confidence levels. Surg Endosc 2024; 38:306-311. [PMID: 37749204 DOI: 10.1007/s00464-023-10413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/20/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program was established by SAGES to develop and expand individual surgeon's comfort with specific, complex operations using hands-on teaching and longitudinal mentoring. The 2022-2023 Foregut (Dominating the Hiatus) section of the course focused on hiatal hernia dissection and gastric fundoplication techniques. Our aim was to describe the experience of surgeons who participated in the course. METHODS The hands-on component occurred in March 2022 at the SAGES annual meeting. Each expert mentor was matched to two participants. The mentors guided the surgeons through steps of a laparoscopic paraesophageal (PEH) hernia repair and fundoplication using a cadaveric model. Afterwards, monthly group webinars occurred and participants could receive individual coaching from their assigned mentor for a year. Each participant was given a pre-course survey with 3 and 12-month follow-up questionnaires. RESULTS The majority of the 16 participants were employed in non-academic settings (87.5%). Years in practice ranged from 1 to 26, and 69% completed a fellowship. 100% completed the pre-course survey, and 53.8% responded to the 12-month post-course survey. Participant-reported effectiveness in performing a PEH hernia repair with fundoplication increased from 37.5% pre-course to 85.7% by the conclusion of the course. Confidence levels for the six core steps of the operation also increased: pre-course only 56-75% were confident with each step, this improved to 100% in four out of six steps. 85.7% said the course has changed their practice. DISCUSSION Since inception, the ADOPT program has aimed to provide expert instruction for practicing surgeons to learn new techniques or improve their confidence in performing operations. The data for the 2022 ADOPT Foregut course shows that 1 year of participation made a positive impact on these surgeons' practices. This helps to fill in the learning gap that occurs after formal surgical training ends.
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Affiliation(s)
- Kristen Wong
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama, BDB 560, 1720 2nd Avenue South, Birmingham, AL, 35294-0012, USA.
- Department of Surgery, Birmingham VA Healthcare System, Birmingham, AL, USA.
| | - Jayleen Grams
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama, BDB 560, 1720 2nd Avenue South, Birmingham, AL, 35294-0012, USA
- Department of Surgery, Birmingham VA Healthcare System, Birmingham, AL, USA
| | | | - Lauren Wood
- Department of Surgery, University of Alabama, Birmingham, AL, USA
| | - Jonathan Dort
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
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Nguyen CL, Tovmassian D, Zhou M, Seyfi D, Isaacs A, Gooley S, Falk GL. Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases. J Gastrointest Surg 2023; 27:2733-2742. [PMID: 37962716 PMCID: PMC10837213 DOI: 10.1007/s11605-023-05856-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence. METHOD Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. RESULTS Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively). CONCLUSION Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - David Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Michael Zhou
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Doruk Seyfi
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Anna Isaacs
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Suzanna Gooley
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia.
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia.
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Provenzano L, Pulvirenti R, Duci M, Capovilla G, Costantini A, Forattini F, Gamba P, Costantini M, Fascetti-Leon F, Salvador E. Laparoscopic Heller-Dor Is a Persistently Effective Treatment for Achalasia Even in Pediatric Patients: A 25-Year Experience at a Single Tertiary Center. Eur J Pediatr Surg 2023; 33:493-498. [PMID: 36720247 DOI: 10.1055/s-0043-1760822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller-Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital. MATERIALS AND METHODS We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure. RESULTS During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11-15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5-13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux. CONCLUSION LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.
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Affiliation(s)
- Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Rebecca Pulvirenti
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Miriam Duci
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Andrea Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesca Forattini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Piergiorgio Gamba
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesco Fascetti-Leon
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Enato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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Depypere L, Van Veer H, Nafteux P, Coosemans W. Current practice in antireflux and hiatal hernia surgery: exploration of the Belgian field. Acta Chir Belg 2023; 123:647-653. [PMID: 36227741 DOI: 10.1080/00015458.2022.2136048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/09/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND In Belgium, no publicly available information exists on the spread, quality, results nor follow-up of antireflux and hiatal hernia surgery, in contrast to the recently centralized esophageal cancer surgery. The aim of this study was to create a snap shot of the current practice in Belgium. METHODS An online questionnaire was distributed among all members of the Royal Belgian Society for Surgery in autumn 2021. A total of 33 questions spread over four sections were asked, covering demographics, current practice (case load, case mix, indications, preoperative workup, patient information, average length of stay, follow up, quality of life (QOL)), operative techniques and future thoughts. RESULTS Twenty-four surgeons completed the questionnaire. Surgical indications are discussed multidisciplinary and based on guidelines in 67%. Workup includes endoscopy, pH-monitoring and manometry in 100%. Barium swallow, impedance and gastric emptying tests were added in respectively 83%, 42% and 13%. Symptom or QOL scores were used in 17%. About 81% are performed as primary surgery, 18% redo surgery and 1% resections. Laparoscopic procedures are reported in 99%: Nissen(-Rosetti) 79%, Toupet/Lind 15%, partial gastrectomy 5% and Collis gastroplasty 1%. Discharge is planned on POD1 in 42% and on POD2 in 54%. 50% performs follow-up < 1 year. Interest in further clinical research collaboration was expressed in 92%. CONCLUSION Antireflux and hiatal hernia surgery is not standardized in Belgium. There is an evident variety in clinical practice, but this questionnaire shows similarity amongst respondents regarding workup and surgical approach. There is a willingness for future research collaborations.
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Affiliation(s)
- L Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - W Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
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Di Mento C, Chiodi A, Cerulo M, Del Conte F, Coppola V, Carulli R, Lepore B, Escolino M, Esposito C. Fantastic Needles and Where to Find Them During a Laparoscopic Nissen Fundoplication: Review of Safety Measures to Avoid Needle Loss During Minimally Invasive Surgery. Surg Laparosc Endosc Percutan Tech 2023; 33:688-690. [PMID: 37852232 DOI: 10.1097/sle.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/31/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Losing a needle during laparoscopic surgery may be a dramatic moment for the surgeon and potentially have clinical and medico-legal consequences. This case report aims to describe an unusual case of needle loss that occurred during laparoscopic Nissen fundoplication and how to prevent its further occurrence. METHODS The patient is an 11-year-old boy with a body mass index of 32.4 kg/m 2 . He suffered from severe gastroesophageal reflux disease not responding to medical therapy and hiatal hernia. A laparoscopic Nissen fundoplication was performed. RESULTS At the closure of the Nissen wrap, CO 2 leakage through the umbilical trocar caused the needle lost during the introduction of the thread. We attempted to find the needle by exploring the entire abdominal cavity without success. Therefore, we decided to complete the surgical procedure. Another 2/0 nonresorbable thread was inserted in the same way as before. But this suture also disappeared. Hence, we manually straightened the needle and introduced it under vision. The operation was accomplished successfully. An intraoperative x-ray was obtained, showing the 2 needles at the level of the 12th rib, near the working port used for the liver retractor. A peritoneal window was created using a monopolar hook, allowing to finally extract the 2 hidden needles. CONCLUSION The loss of needles, although a rare event, can occur during laparoscopic surgery. Based on our experience, we suggest that needle insertion during laparoscopic operations should be performed under direct vision, especially in obese patients, to reduce the likelihood of such complications.
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Affiliation(s)
- Claudia Di Mento
- Department of Translational Medical Sciences (DISMET), Pediatric Surgery Unit, Federico II University Hospital, Naples, Italy
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Parsak CK, Halvacı İ, Topal U. "Comparison of Nissen Rossetti and Floppy Nissen techniques in laparoscopic reflux surgery". Ann Med 2023; 55:1000-1008. [PMID: 36896817 PMCID: PMC10795582 DOI: 10.1080/07853890.2023.2187075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE The present study makes a comparative assessment of the Floppy-Nissen (FN) and Nissen-Rossetti fundoplication (NRF) procedures. METHODS Included in the study were 80 patients who presented to the General Surgery Department outpatient clinic of Balcalı Hospital of the Cukurova University Faculty of Medicine with gastroesophageal reflux between March 2010 and March 2013 All patients were operated on by the same surgeon using the laparoscopic FN or NRF techniques in a randomized controlled manner. The preoperative and postoperative reflux-specific and nonspecific gastrointestinal symptoms of the patients were compared. RESULTS The duration of symptoms had no effect on the level of satisfaction; regurgitation, bloating and heartburn were more common in those with a longer duration of symptoms Of the patients, 92.5% were satisfied with their resulting condition, and 92.5% were inclined toward the surgery. It was further found that there was no difference between the symptoms or satisfaction levels of the patient groups who underwent the FN procedure and those who underwent the NRF procedure, other than those related to the duration of surgery. laparoscopic NF and the NRF fundoplication treatments, aside from the duration of surgery. CONCLUSION Our study revealed no significant difference between the laparoscopic NF and the NRF fundoplication treatments, aside from the duration of surgery.KEY MESSAGESThe Nissen-Rossetti technique can be used safely based on the similarity of its outcomes with those of the classical Nissen technique.Despite the documented success of laparoscopic anti-reflux surgery, the absence of studies comparing surgery and medical treatments prevents these discussions from being concluded.Comparison of Nissen Rossetti and Floppy Nissen Techniques in Laparoscopic Reflux Surgery.
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Affiliation(s)
- Cem Kaan Parsak
- Department of General Surgery, Cukurova University, Adana, Turkey
| | - İlker Halvacı
- Department of General Surgery, Cukurova University, Adana, Turkey
| | - Uğur Topal
- Department of General Surgery, Cukurova University, Adana, Turkey
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Markar SR, Menon N, Guidozzi N, Kontouli KM, Mavridis D, Andreou A, Berlth F, Bonavina L, Cushieri A, Fourie L, Gossage J, Gronnier C, Hazebroek EJ, Krishnadath S, Low DE, McCord M, Pouw RE, Watson DI, Carrano FM, Ortenzi M, Antoniou SA. EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias. Surg Endosc 2023; 37:9013-9029. [PMID: 37910246 DOI: 10.1007/s00464-023-10511-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/01/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations. OBJECTIVE To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn . CONCLUSION An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process. GUIDELINE REGISTRATION NUMBER PREPARE-2023CN018.
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Affiliation(s)
- Sheraz R Markar
- Department of General Surgery, Oxford University Hospitals, Oxford, UK
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Nainika Menon
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Nadia Guidozzi
- Department of General Surgery, University of Witwatersrand, Johannesburg, South Africa
| | - Katerina-Maria Kontouli
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Dimitrios Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Alexandros Andreou
- Department of Surgery, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Alfred Cushieri
- Institute for Medical Science and Technology, University of Dundee, Dundee, Scotland, UK
| | - Lana Fourie
- Department of Visceral Surgery, Clarunis, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - James Gossage
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London, SE1 7EH, UK
- School of Cancer and Pharmaceutical Sciences, Kings College London, London, UK
| | - Caroline Gronnier
- Esophagogastric Surgery Unit, Haut Lévêque Hospital, Centre Hospitalier Universitaire Bordeaux, University of Bordeaux, Bordeaux, France
| | - Eric J Hazebroek
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Sheila Krishnadath
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center Seattle, Seattle, USA
| | | | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - David I Watson
- Flinders Medical Centre, Oesophagogastric Surgery Unit, Bedford Park, SA, Australia
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Francesco Maria Carrano
- Department of General Surgery, Busto Arsizio Circolo Hospital ASST-Valle Olona, Busto Arsizio, Italy
| | - Monica Ortenzi
- Department of General Surgery, Università Politecnica Delle Marche, Ancona, Italy
| | - Stavros A Antoniou
- Department of Surgery, Papageorgiou General Hospital, Thessaloníki, Greece.
- EAES Guidelines Subcommittee, Eindhoven, The Netherlands.
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Li G, Jiang N, Chendaer N, Hao Y, Zhang W, Peng C. Laparoscopic Nissen Versus Toupet Fundoplication for Short- and Long-Term Treatment of Gastroesophageal Reflux Disease: A Meta-Analysis and Systematic Review. Surg Innov 2023; 30:745-757. [PMID: 36998190 PMCID: PMC10656788 DOI: 10.1177/15533506231165829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND Laparoscopic Nissen fundoplication (LNF) is the most common standard technique worldwidely for Gastroesophageal reflux disease (GERD). Another type of fundoplication, laparoscopic Toupet fundoplication (LTF), intends to reduce incidence of postoperative complications. A systematic review and meta-analysis are required on short- and long-term outcomes based on randomized controlled trials (RCTs) between LNF and LTF. METHODS We searched databases including PubMed, Cochrane, Embase, and Web of Knowledge for RCTs comparing LNF and LTF. Outcomes included postoperative reflux recurrence, postoperative heartburn, dysphagia and postoperative chest pain, inability to belch, gas bloating, satisfaction with intervention, postoperative esophagitis, postoperative DeMeester scores, operating time (min), in-hospital complications, postoperative use of proton pump inhibitors, reoperation rate, postoperative lower oesophageal sphincter (LOS) pressure (mmHg). We assessed data using risk ratios and weighted mean differences in meta-analyses. RESULTS Eight eligible RCTs comparing LNF (n = 605) and LTF (n = 607) were identified. There were no significant differences between the LNF and LTF in terms of postoperative reflux recurrence, postoperative heartburn, postoperative chest pain, satisfaction with intervention, reoperation rate in short and long term, in-hospital complications, esophagitis in short term, and gas bloating, postoperative DeMeester scores, postoperative use of proton pump inhibitors, reoperation rate in long term. LTF had lower LOS pressure (mmHg), fewer postoperative dysphagia and inability to belch in short and long term and gas bloating in short term compared to LNF. CONCLUSION LTF were equally effective at controlling reflux symptoms and improving the quality of life, but with lower rate of complications compared to LNF. We concluded that LTF surgical treatment was superior for over 16 years old patients with typical symptoms of GERD and without upper abdominal surgical history upon high-level evidence of evidence-based medicine.
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Affiliation(s)
- Gen Li
- Department of Thoracic Surgery, The Second Hospital of Shandong University
| | - Ning Jiang
- Department of Thoracic Surgery, The Second Hospital of Shandong University
| | - Nuerboli Chendaer
- Department of Thoracic Surgery, The Second Hospital of Shandong University
| | - Yingtao Hao
- Department of Thoracic Surgery, The Second Hospital of Shandong University
| | - Weiquan Zhang
- Department of Thoracic Surgery, The Second Hospital of Shandong University
| | - Chuanliang Peng
- Department of Thoracic Surgery, The Second Hospital of Shandong University
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Ovaere S, Depypere L, Van Veer H, Moons J, Nafteux P, Coosemans W. The Belsey Mark IV procedure in the era of minimally invasive antireflux surgery. Dis Esophagus 2023; 36:doad042. [PMID: 37408470 DOI: 10.1093/dote/doad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Different surgical techniques exist in the treatment of giant and complex hiatal hernia. The aim of this study was to identify the role of the Belsey Mark IV (BMIV) antireflux procedure in the era of minimally invasive techniques. METHODS A single-center, retrospective cohort study was conducted. All patients who underwent an elective BMIV procedure aged 18 years or older, during a 15-year period (January 1, 2002 until December 31, 2016), were included. Demographics, pre-, per- and postoperative data were analyzed. Three groups were compared. Group A: BMIV as first procedure-group B: BMIV as a second procedure (first redo intervention)-group C: patients who had two or more previous antireflux interventions. RESULTS A total of 216 patients were included for analysis (group A n = 127; group B n = 51; group C n = 38). Median follow-up in groups A, B and C was 28, 48 and 56 months, respectively. Patients in group A were older and had a higher American Society of Anesthesiologists score compared to groups B and C. There was zero mortality in all groups. The severe complication rate of 7.9% in group A was higher compared with the 2.9% in group B and 3.9% in group C. Long-term outcome showed true recurrence, defined as both radiographic recurrence as well as associated symptoms, in 9.5% of cases in group A, 24.5% in group B and 44.7% in group C. CONCLUSIONS The BMIV procedure is a safe procedure with good results, moreover in the aging and comorbid patient with primary repair of a giant hiatal hernia.
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Affiliation(s)
- Sander Ovaere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
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Cao C, Xu B, Yao QY. [Application of gastric plication in the treatment of obesity]. Zhonghua Wei Chang Wai Ke Za Zhi 2023; 26:1082-1087. [PMID: 37974355 DOI: 10.3760/cma.j.cn441530-20230411-00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Bariatric surgery, as the most effective approach to treating obesity at present, encompasses a wide array of procedures. However, due to the significant anatomical changes to the gastrointestinal tract caused by most of these procedures, they are associated with certain risks of complications. In the pursuit of minimizing trauma, bariatric surgeons have begun exploring new surgeries in addition to traditional procedures. Gastric plication surgeries encompass various procedures such as gastric fundoplication, gastric greater curvature plication, endoscopic sleeve gastroplasty, combined gastric fundoplication with gastric greater curvature plication, and combined gastric fundoplication with sleeve gastrectomy, among others. The efficacy and risks of complications associated with these procedures fall between those of medical therapy and sleeve gastrectomy. Gastric fundoplication, functioning as an anti-reflux procedure, can also be integrated into weight loss surgical interventions to effectively address obesity-related gastroesophageal reflux disease in obese patients. Both gastric greater curvature plication and endoscopic sleeve gastroplasty yield favorable weight loss outcomes. Beyond the impact of folding procedures on body mass, gastric plication surgeries can also be combined with other techniques. The combination of gastric fundoplication with sleeve gastrectomy or greater curvature plication can reduce body mass and mitigate reflux, while the combination of greater curvature plication with gastric bypass and similar procedures can further enhance weight loss and metabolic improvements.
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Affiliation(s)
- C Cao
- Center for Bariatric and Hernia Surgery, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - B Xu
- Center for Bariatric and Hernia Surgery, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Q Y Yao
- Center for Bariatric and Hernia Surgery, Department of General Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
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Takahiro H, Uchiyama M, Tanami Y, Sato Y, Wakabayashi Y, Oguma E. A single-center experience of using milk scintigraphy in 251 pediatric patients: A retrospective study. Medicine (Baltimore) 2023; 102:e35746. [PMID: 37960826 PMCID: PMC10637527 DOI: 10.1097/md.0000000000035746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023] Open
Abstract
To report our experience with milk gastroesophageal scintigraphy and the management of gastroesophageal reflux (GER) in children. In 251 pediatric patients we recorded age, underlying disease, central nervous system (CNS) disorders, and GER management. GER management was classified based on treatment plans: grade 0, non-pharmacological treatment; grade 1, non-pharmacological but using a nasogastric tube; grade 2, pharmacological treatment; grade 3, transpyloric feeding; and grade 4, Nissen fundoplication surgery. Patients were included in classified groups with (grades 2, 3, and 4) and without (grades 0 and 1) GER treatment. We evaluated the GER height (classified based on the height of GER, grade 0; no GER, 1; GER in the lower esophagus, 2; GER in the upper esophagus), GER duration in the lower and upper esophagus, presence or absence of massive GER amounts in the lower and upper esophagus, and gastric emptying time. We compared milk scintigraphy results and patient characteristics between groups with (grades 2, 3, and 4) and without (grades 0 and 1) GER treatment. We treated 121 patients for GER. CNS disorders (presence/absence: 46/74 with vs 21/110 without treatment, P < .001). The GER height grade (1.7 ± 0.5 [range, 0-2] with vs 1.5 ± 0.7 [range, 0-2] without treatment, P = .002), massive GER amount (present/absent: 21/99 with vs 9/122 without treatment, P = .011), and duration of GER (seconds) (324.5 ± 508.3 [range, 0-1800] vs 125.0 ± 291.9 [range, 0-1750], P < .001) in the upper esophageal half differed significantly. Similarly massive GER amount (present/absent: 54/66 with vs 34/97 without treatment, P = .002) and GER duration (621.3 ± 601.0 [range, 0-1800] vs 349.8 ± 452.4 [range, 0-1800], P < .001) in the lower esophageal half differed significantly. Additionally, CNS disorders, age, and massive GER in the upper esophageal half differed significantly among grades 2 and 4 in treated patients (P < .05, P < .001, P < .05, respectively). Milk scintigraphy is useful for deciding whether GER treatment is indicated. However, the treatment plan needs to be decided based on each patient's condition.
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Affiliation(s)
- Hosokawa Takahiro
- Department of Radiology, Saitama Children’s Medical Center, Saitama, Japan
| | - Mayuki Uchiyama
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children’s Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children’s Medical Center, Saitama, Japan
| | - Yasuharu Wakabayashi
- Division of Radiological Technology, Saitama Children’s Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children’s Medical Center, Saitama, Japan
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Amundson JR, Kuchta K, Zimmermann CJ, VanDruff VN, Joseph S, Che S, Ishii S, Hedberg HM, Ujiki MB. Target distensibility index on impedance planimetry during fundoplication by choice of wrap and choice of bougie. Surg Endosc 2023; 37:8670-8681. [PMID: 37500920 DOI: 10.1007/s00464-023-10301-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Impedance planimetry (FLIP) provides objective feedback to optimize fundoplication outcomes. Ideal FLIP ranges for differing wraps and bougies have not yet been established. We report FLIP measurements during fundoplication grouped by choice of wrap and bougie with associated outcomes. METHODS A retrospective review of a prospective gastroesophageal database was performed for all Nissen or Toupet fundoplication with intraoperative FLIP using an 8-cm catheter, 30-mL and/or 40-mL fill and/or 16-cm catheter, 60-mL fill. Surgeons used no bougie, the FLIP balloon as bougie, or a hard bougie. Outcomes included perioperative data, Reflux Symptom Index, GERD-HRQL, Dysphagia scores, need for dilation, postoperative EGD findings, and hernia recurrence. Group comparisons were made using two-tailed Kruskal-Wallis and Fisher's exact tests. RESULTS Between 2016 and 2022, 333 patients underwent fundoplication and intraoperative FLIP. Procedures included Toupet with hard bougie (TFHB, N = 147), Toupet with FLIP bougie (TFFB, N = 69), Toupet without bougie (TFNB, N = 78), Nissen with hard bougie (NFHB, n = 20), or Nissen with FLIP bougie (NFFB, N = 19). FLIP measurements at 30-mL/40-mL fills varied significantly between groups, notably distensibility index at crural closure (CCDI) and post-fundoplication (FDI). No significant differences in FLIP measurements were seen between those who developed poor postoperative outcomes and those who did not, including when grouping by choice of wrap and bougie. At a 40-mL fill, abnormal motility patients with CCDI > 3.5 mm2/mmHg developed zero postoperative dysphagia. TFFB abnormal motility patients with CCDI > 3.5 mm2/mmHg or FDI > 3.6 mm2/mmHg developed zero postoperative dysphagia. CONCLUSION Intraoperative FLIP measurements vary by fundoplication and bougie choice. A CCDI > 3.5 mm2/mmHg (40 mL fill) should be sought in abnormal motility patients, regardless of wrap or bougie, to avoid postoperative dysphagia. TFFB abnormal motility patients with FDI > 3.6 mm2/mmHg (40 mL fill) also developed zero postoperative dysphagia. FDI > 6.2 mm2/mmHg (40 mL fill) was seen in all postoperative hernia recurrences.
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Affiliation(s)
- Julia R Amundson
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA.
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Christopher J Zimmermann
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Vanessa N VanDruff
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Stephanie Joseph
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Simon Che
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Shun Ishii
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - H Mason Hedberg
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
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Gale KJ, Sanchez S, Sorenson TJ, Elftmann TD. Severe Referred Shoulder Pain Following Revision Fundoplication From a Stich on the Diaphragm. Am Surg 2023; 89:4866-4868. [PMID: 33847159 DOI: 10.1177/00031348211011110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complications following fundoplication surgery for hiatal hernias are rare. Herein, we present the case of a 61-year-old woman who underwent a Nissen fundoplication, complicated by dysphagia, and a revision modified Toupet fundoplication for a hiatal hernia, after which she began to experience severe prandial referred left shoulder pain that was refractory to medical management. We hypothesized that a diaphragmatic suture placed during the revision fundoplication could be the source of the pain, and we elected to remove the suture, resulting in resolution of the pain. This pain remained resolved at the most recent follow-up on postoperative week six, and the patient had no further concerns.
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Affiliation(s)
- Kevin J Gale
- Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Santana Sanchez
- Medical School, University of Minnesota, Minneapolis, MN, USA
| | | | - Todd D Elftmann
- Department of Surgery, Ridgeview Medical Center, Waconia, MN, USA
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Giulini L, Razia D, Latorre-Rodríguez AR, Shacker M, Csucska M, Mittal SK. Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center. J Gastrointest Surg 2023; 27:2308-2315. [PMID: 37715012 DOI: 10.1007/s11605-023-05829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/31/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues. METHODS After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed. RESULTS A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality. CONCLUSIONS HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.
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Affiliation(s)
- Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
- Department of General, Gastrointestinal and Thoracic Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Mark Shacker
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Mate Csucska
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA.
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Sarici IS, Eriksson S, Abu-Nuwar MR, Kuzy J, Gardner M, Zheng P, Jobe B, Ayazi S. Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy with Dor Fundoplication for Esophagogastric Junction Outflow Obstruction (EGJOO): a Comparison of Outcomes and Impact on Physiology. J Gastrointest Surg 2023; 27:2684-2693. [PMID: 37848686 PMCID: PMC10660958 DOI: 10.1007/s11605-023-05844-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO. METHODS This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD-HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis. RESULTS The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22-45) to 4 (0-19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34-59) to 13 (8-17); p < 0.001) and IRP (22 (17-28) to 8 (3-11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10-90) to 10% (0-40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30-68) to 31 (5-34); p = 0.042) and IRP (23 (18-33) to 12 (10-32); p = 0.048), DCI (1920 (1600-5500) to 0 (0-814); p = 0.035), with increased failed swallows (0% (0-30) to 100% (10-100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7-15)-vs-5 (5-6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0-814)-vs-1695 (929-3101); p = 0.004), and intact swallows (90 (70-100)-vs-0 (0-40); p = 0.006), but more failed swallows (100 (10-100); p = 0.018) and incomplete bolus clearance (90 (90-100)-vs-10 (0-40); p = 0.004). CONCLUSION Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function.
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Affiliation(s)
- Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Sven Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Mohamad Rassoul Abu-Nuwar
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Jacob Kuzy
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Margaret Gardner
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Blair Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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Menke V, Kottmann T, Willeke F, Hansen O. Learning curves and procedural times in Senhance®-robotic assisted fundoplication: results from 237 consecutive patients undergoing robotic fundoplication in a single center as part of the European TRUST Robotic Surgery Registry Study. Surg Endosc 2023; 37:8254-8262. [PMID: 37670190 DOI: 10.1007/s00464-023-10226-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/17/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease requiring an operative solution is common. Minimally invasive surgery to generate an anti-reflux barrier at the distal esophagus following the principle of the "floppy Nissen" technique has become the gold standard. Advanced robotic-assisted systems may deliver more consisted outcomes. METHODS This registry study analyzed safety and efficacy of the Senhance® surgical system in the surgical treatment of reflux disease and procedural proficiency. Data from 237 consecutive patients operated in a single center were evaluated. Historic standard laparoscopies from the same center were analyzed to compare robotic surgery learning curve effects. RESULTS Using the Senhance® Surgical System, during the first 50 patients there was a significant decrease in surgery time which was maintained over the duration of study, pointing to the surgical staff's system-specific learning. After this phase, procedural times were comparable between the robotic-assisted and traditional laparoscopic surgery. The effect of learning was greater than for standard laparoscopy. For 237 patients, there were four conversions to laparoscopic surgery. Two serious adverse events were recorded, both cardiac in nature and not related to the use of the robot. CONCLUSIONS Robotic fundoplication was swiftly implemented in a non-university hospital with 65 surgical beds. The operating time was no longer than in standard laparoscopy, the procedure was more standardized than open or laparoscopic surgery and hospitalization times may have been sustainably shortened. The autonomy at the system's digital platform (cockpit) to conduct robotic fundoplications is a big step forward in surgery.
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Affiliation(s)
- Vivianda Menke
- Allgemeinchirurgie, Evangelisches Krankenhaus Wesel GmbH, Schermbecker Landstraße 88, 46485, Wesel, Germany.
- The TRUST European Registry Working Group, Siegen, Germany.
| | | | - Frank Willeke
- The TRUST European Registry Working Group, Siegen, Germany
- St Marien-Krankenhaus Siegen gGmbH, Siegen, Germany
| | - Olaf Hansen
- Allgemeinchirurgie, Evangelisches Krankenhaus Wesel GmbH, Schermbecker Landstraße 88, 46485, Wesel, Germany
- The TRUST European Registry Working Group, Siegen, Germany
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Yergin CG, Herremans KM, Patel S, Pelaez A, Machuca TN, Ayzengart AL, Amaris MA. Laparoscopic Toupet fundoplication: a safe and effective anti-reflux option in lung transplant recipients. Surg Endosc 2023; 37:8429-8437. [PMID: 37438480 DOI: 10.1007/s00464-023-10245-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/23/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Fundoplication is known to improve allograft outcomes in lung transplant recipients by reducing retrograde aspiration secondary to gastroesophageal reflux disease, a modifiable risk factor for chronic allograft dysfunction. Laparoscopic Nissen fundoplication has historically been the anti-reflux procedure of choice, but the procedure is associated with discernable rates of postoperative dysphagia and gas-bloat syndrome. Laparoscopic Toupet fundoplication, an alternate anti-reflux surgery with lower rates of foregut complications in the general population, is the procedure of choice on our institution's lung transplant protocol. In this work, we evaluated the efficacy and safety of laparoscopic Toupet fundoplication in our lung transplant recipients. METHODS A prospective case series of 44 lung transplant recipients who underwent laparoscopic Toupet fundoplication by a single surgeon between September 2018 and November 2020 was performed. Preoperative and postoperative results from 24-h pH, esophageal manometry, gastric emptying, and pulmonary function studies were collected alongside severity of gastroesophageal reflux disease and other gastrointestinal symptoms. RESULTS Median DeMeester score decreased from 25.9 to 5.4 after fundoplication (p < 0.0001), while percentage of time pH < 4 decreased from 7 to 1.1% (p < 0.0001). The severity of heartburn and regurgitation were also reduced (p < 0.0001 and p = 0.0029 respectively). Overall, pulmonary function, esophageal motility, gastric emptying, severity of bloating, and dysphagia were not significantly different post-fundoplication than pre-fundoplication. Patients with decreasing rates of FEV1 pre-fundoplication saw improvement in their rate of change of FEV1 post-fundoplication (p = 0.011). Median follow-up was 32.2 months post-fundoplication. CONCLUSIONS Laparoscopic Toupet fundoplication provides objective pathologic acid reflux control and symptomatic gastroesophageal reflux improvement in lung transplant recipients while preserving lung function and foregut motility. Thus, laparoscopic Toupet fundoplication is a safe and effective antireflux surgery alternative in lung transplant recipients.
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Affiliation(s)
| | - Kelly M Herremans
- University of Florida College of Medicine, Gainesville, FL, USA
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sheetal Patel
- University of Florida College of Medicine, Gainesville, FL, USA
- Department of Medicine, University of Florida College of Medicine, PO Box 100214, Gainesville, FL, 3261, USA
| | - Andres Pelaez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tiago N Machuca
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Manuel A Amaris
- University of Florida College of Medicine, Gainesville, FL, USA.
- Department of Medicine, University of Florida College of Medicine, PO Box 100214, Gainesville, FL, 3261, USA.
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McKay SC, DeMeester SR, Sharata A, DeSouza ML, Bradley DD, Reavis KM, Dunst CM. Diaphragmatic relaxing incisions for complex hiatal reconstruction: longer-term follow-up confirms safety, efficacy and rare complications. Surg Endosc 2023; 37:8636-8643. [PMID: 37495846 DOI: 10.1007/s00464-023-10293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Tension is an important factor in hernia repairs. Relaxing incisions to reduce tension are common with ventral hernia repairs, and techniques for relaxing incisions also exist for the hiatus. The aim of this study was to update our original experience with a diaphragm relaxing incision (DRI) in a larger group of patients with longer follow-up. METHODS A retrospective chart review was performed to identify all patients who had a DRI between August 2016 and September 2021 during hiatal hernia repair. All DRI defects were repaired with permanent mesh remote from the esophagus. Objective follow-up was with chest x-ray, upper GI series (UGI) or both. RESULTS Seventy-three patients had a total of 79 DRI (right in 63, left in 4, and bilateral in 6 patients), during a primary (n = 52) or redo (n = 21) hiatal hernia repair. Concomitant Collis gastroplasty was used in 38 patients (52%). A single intra-operative complication occurred where the right crus tore during a right DRI. At a median of 15 months, 78% of patients had objective follow-up. There was one hernia through a repaired right DRI (1.2%). No patient had evidence of diaphragm paralysis and there were no mesh infections. The 1-year hernia recurrence rate in these patients was 3.9%. CONCLUSIONS A DRI can be done safely with minimal risk of intra- or post-operative complications. There was a low rate of herniation through the defect when repaired with permanent mesh. No patient developed a mesh infection despite concomitant Collis gastroplasty in 52% of patients, and there was no evidence of diaphragm paralysis on imaging studies. Further, the low rate of hiatal hernia recurrence suggests efficacy of a DRI to reduce crural closure tension. These excellent outcomes should encourage use of a DRI in patients with a difficult hiatus during hernia repair.
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Affiliation(s)
| | - Steven R DeMeester
- The Oregon Clinic: Center for Advanced Surgery, 4805 NE Glisan Ave, Portland, OR, 97213, USA.
- Providence Portland Medical Center, Portland, OR, USA.
| | - Ahmed Sharata
- Department of General Surgery, University of South Florida, Tampa, FL, USA
| | - Melissa L DeSouza
- The Oregon Clinic: Center for Advanced Surgery, 4805 NE Glisan Ave, Portland, OR, 97213, USA
- Providence Portland Medical Center, Portland, OR, USA
| | - Daniel Davila Bradley
- The Oregon Clinic: Center for Advanced Surgery, 4805 NE Glisan Ave, Portland, OR, 97213, USA
- Providence Portland Medical Center, Portland, OR, USA
| | - Kevin M Reavis
- The Oregon Clinic: Center for Advanced Surgery, 4805 NE Glisan Ave, Portland, OR, 97213, USA
- Providence Portland Medical Center, Portland, OR, USA
| | - Christy M Dunst
- The Oregon Clinic: Center for Advanced Surgery, 4805 NE Glisan Ave, Portland, OR, 97213, USA
- Providence Portland Medical Center, Portland, OR, USA
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Wennström B, Lindberg S, Svensson J, Larsson E, Stensby H, Larsson PA. Being Caught in a Vicious Circle: An Interview Study of Individuals Suffering From Grade II-IV Hiatal Hernia. Gastroenterol Nurs 2023; 46:489-496. [PMID: 37498778 PMCID: PMC10720819 DOI: 10.1097/sga.0000000000000771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 06/15/2023] [Indexed: 07/29/2023] Open
Abstract
Large paraesophageal hernias are related to life-threatening complications that warrant immediate surgery. Whether the long-standing chronic symptoms related to the disease in individuals without hernia incarceration motivate surgical treatment is still a subject for discussion. The aim of this study was to explore how individuals suffering from Grade II-IV hiatal hernia describe their symptoms and health, as well as how the disease affects their life. Semistructured interviews were performed with 22 individuals planning to undergo surgery for a large paraesophageal hernia. The data were analyzed using qualitative content analysis and resulted in one main theme "Being caught in a vicious circle" and six subthemes "Distressing and uncertain times," "The symptoms have seized control over my health," "Loss of energy and strength," "Strategies for managing daily life," "Loss of social life," and "Moments of hope despite failing health." Central to the participants' descriptions is their commitment to strategies for managing the ever-present and unpredictable symptoms that have seized control over their health. They were trapped in a hopeless and isolated existence, that is, a vicious circle, from which they were unable to escape. Despite the low incidence of volvulus and incarceration, the symptom burden and effect on general health motivate treatment in these individuals.
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Affiliation(s)
- Berith Wennström
- Berith Wennström, PhD, RNA, is at Departments of Anaesthesia, Surgery, and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Susan Lindberg, PhD, RNA, is at Departments of Anaesthesia and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Johanna Svensson, MD, is at Department of Surgery, Skaraborg Hospital, Skövde, Sweden
- Elin Larsson, RN, is at Department of Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
- Helen Stensby, CNOR, is at Departments of Anaesthesia and Surgery, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Per-Anders Larsson, PhD, MD, is at Departments of Surgery and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
| | - Susan Lindberg
- Berith Wennström, PhD, RNA, is at Departments of Anaesthesia, Surgery, and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Susan Lindberg, PhD, RNA, is at Departments of Anaesthesia and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Johanna Svensson, MD, is at Department of Surgery, Skaraborg Hospital, Skövde, Sweden
- Elin Larsson, RN, is at Department of Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
- Helen Stensby, CNOR, is at Departments of Anaesthesia and Surgery, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Per-Anders Larsson, PhD, MD, is at Departments of Surgery and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
| | - Johanna Svensson
- Berith Wennström, PhD, RNA, is at Departments of Anaesthesia, Surgery, and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Susan Lindberg, PhD, RNA, is at Departments of Anaesthesia and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Johanna Svensson, MD, is at Department of Surgery, Skaraborg Hospital, Skövde, Sweden
- Elin Larsson, RN, is at Department of Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
- Helen Stensby, CNOR, is at Departments of Anaesthesia and Surgery, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Per-Anders Larsson, PhD, MD, is at Departments of Surgery and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
| | - Elin Larsson
- Berith Wennström, PhD, RNA, is at Departments of Anaesthesia, Surgery, and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Susan Lindberg, PhD, RNA, is at Departments of Anaesthesia and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Johanna Svensson, MD, is at Department of Surgery, Skaraborg Hospital, Skövde, Sweden
- Elin Larsson, RN, is at Department of Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
- Helen Stensby, CNOR, is at Departments of Anaesthesia and Surgery, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Per-Anders Larsson, PhD, MD, is at Departments of Surgery and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
| | - Helen Stensby
- Berith Wennström, PhD, RNA, is at Departments of Anaesthesia, Surgery, and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Susan Lindberg, PhD, RNA, is at Departments of Anaesthesia and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Johanna Svensson, MD, is at Department of Surgery, Skaraborg Hospital, Skövde, Sweden
- Elin Larsson, RN, is at Department of Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
- Helen Stensby, CNOR, is at Departments of Anaesthesia and Surgery, Skaraborg Hospital, Skövde, Sweden; and School of Health Sciences, University of Skövde, Skövde, Sweden
- Per-Anders Larsson, PhD, MD, is at Departments of Surgery and Research, Education, Development and Innovation, Skaraborg Hospital, Skövde, Sweden
| | - Per-Anders Larsson
- Correspondence to: Per-Anders Larsson, PhD, MD, Departments of Surgery and Research, Education, Development and Innovation, Skaraborg Hospital, 541 85 Skövde, Sweden ()
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Michael S, Marom G, Brodie R, Salem SA, Fishman Y, Shein GS, Helou B, Pikarsky AJ, Mintz Y. The Angle of His as a Measurable Element of the Anti-reflux Mechanism. J Gastrointest Surg 2023; 27:2279-2286. [PMID: 37620664 DOI: 10.1007/s11605-023-05808-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/21/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux. OBJECTIVES Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model. METHODS The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented. RESULTS Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively). CONCLUSIONS In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.
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Affiliation(s)
- Samer Michael
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Gad Marom
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Samer Abu Salem
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gabriel Szydlo Shein
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Brigitte Helou
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Latorre-Rodríguez AR, Aschenbrenner E, Mittal SK. Magnetic sphincter augmentation may limit access to magnetic resonance imaging. Dis Esophagus 2023; 36:doad032. [PMID: 37224461 DOI: 10.1093/dote/doad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/29/2023] [Indexed: 05/26/2023]
Abstract
Magnetic sphincter augmentation (MSA) is an alternative surgical treatment for gastroesophageal reflux disease; however, >1.5 T magnetic resonance imaging (MRI) is contraindicated for patients who have undergone MSA with the LINX Reflux Management System (Torax Medical, Inc. Shoreview, Minnesota, USA). This drawback can impose a barrier to access of MRI, and cases of surgical removal of the device to enable patients to undergo MRI have been reported. To evaluate access to MRI for patients with an MSA device, we conducted a structured telephone interview with all diagnostic imaging providers in Arizona in 2022. In 2022, only 54 of 110 (49.1%) locations that provide MRI services had at least one 1.5 T or lower MRI scanner. The rapid replacement of 1.5 T MRI scanners by more advanced technology may limit healthcare options and create an access barrier for patients with an MSA device.
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Affiliation(s)
| | - Emma Aschenbrenner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- Creighton University School of Medicine, Phoenix, AZ, USA
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50
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Klimczak T, Strzelczyk J. Endoscopic anti-reflux mucosectomy (ARMS) and endoscopic anti-reflux ablation (ARMA) as a potential treatment for gastroesophageal reflux - preliminary report. Pol Przegl Chir 2023; 96:1-5. [PMID: 38348994 DOI: 10.5604/01.3001.0053.9251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
<b><br>Introduction:</b> Gastroesophageal reflux (GERD) is one of the most common disorders of the alimentary tract. Apart from troublesome symptoms, untreated GERD can lead to Barrett's esophagus and, as a consequence, esophageal adenocarcinoma. As for now, the most common treatment of GERD is PPI pharmacotherapy. However, in a number of cases, this treatment is not sufficient or the patient does not tolerate PPI-group drugs. In such cases, interventional therapy is recommended. So far, laparoscopic fundoplication has been the only suggested option. Other, minimally invasive procedures such as Stretta, MUSE, TIFF, or EsophyX were not recommended due to the lack of clinical data. In 2014, Professor H.Inoue from the Digestive Diseases Center, Showa University in Japan reported on the first series of novel, endoscopic, anti-reflux procedures: anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA).</br> <b><br>Methods:</b> We conducted our prospective, single-center study in 30 patients (14 female, 16 male) with PPI-refractory GERD. All patients underwent FSSG and GERD-HRQL evaluation and GE junction pressure study prior, 6 weeks and 6 months after the procedures. After the procedure, all patients received PPI treatment for 4 weeks.</br> <b><br>Results:</b> We successfully completed the procedures in all 30 patients. The mean procedure time was 42 minutes. No complications occurred. In 86.67% (26) of our patients, we achieved total remission of GERD symptoms, FSSG scores < 6 and GERD-HRQL scores < 8.</br> <b><br>Conclusions:</b> The results of our study show that ARMS and ARMA are simple, safe, improve GERD-related symptoms, and restore the GE junction's anti-reflux capacity.</br>.
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Affiliation(s)
- Tomasz Klimczak
- Department of General, Transplant, Gastroenterological and Oncological Surgery, 1st Teaching Hospital, Medical University of Lodz, Clinic of General and Transplant Surgery, Medical University of Lodz, Poland
| | - Janusz Strzelczyk
- Department of General, Transplant, Gastroenterological and Oncological Surgery, 1st Teaching Hospital, Medical University of Lodz, Clinic of General and Transplant Surgery, Medical University of Lodz, Poland
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