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Bang PK, Andersen NH, Hvid-Jensen F, Bjerregaard NC, Kjaer DW. Long-term efficacy and quality of life after antireflux surgery. Surg Endosc 2025; 39:2354-2363. [PMID: 39966125 PMCID: PMC11933211 DOI: 10.1007/s00464-025-11608-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Accepted: 02/02/2025] [Indexed: 02/20/2025]
Abstract
BACKGROUND Antireflux surgery (ARS) has been found to be an effective treatment of gastro-esophageal reflux disease (GERD); however, the long-term effects are uncertain. This study aimed to evaluate the long-term efficacy of ARS on quality of life, symptom severity, and use of proton pump inhibitors (PPIs). METHODS A validated GERD Health-Related Quality of Life (GERD-HRQL) Questionnaire was sent to 419 patients who underwent ARS at Aarhus University Hospital from January 2012 to April 2020. Patient records were reviewed retrospectively. The Danish National Prescription Registry was used to collect data on the use of PPIs before and after ARS. RESULTS A response rate of 71% resulted in a total of 164 patients included in the study with a median follow-up time of 4.8 years (interquartile range: 2.5-6.7). The total GERD-HRQL median score at follow-up was 11.5 (IQR: 4-22). The proportion of patients experiencing daily symptoms of heartburn and regurgitation was significantly reduced pre- to postoperatively from 90 to 70% to 32% and 29%, respectively. Five years after surgery, 47% of patients had completely ceased PPI usage, while 44% were long-term users. CONCLUSION A lasting long-term effect of ARS on GERD symptoms was found, although almost a third of patients still experience heartburn and/or regurgitation daily. Almost half of patients were not taking PPIs 5 years after ARS, but 44% became long-term users. Patients should be made aware that long-term PPI therapy often is necessary following ARS.
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Affiliation(s)
- Philip K Bang
- Department of Anesthesiology and Intensive Care, Regional Hospital Viborg, Viborg, Denmark.
| | - Naja H Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Daniel W Kjaer
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
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Shukla RN, Woodman R, Myers JC, Watson DI, Bright T, Thompson SK. Application of machine learning models to identify predictors of good outcome after laparoscopic fundoplication. J Gastrointest Surg 2025; 29:102029. [PMID: 40122374 DOI: 10.1016/j.gassur.2025.102029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Revised: 03/14/2025] [Accepted: 03/18/2025] [Indexed: 03/25/2025]
Abstract
BACKGROUND Laparoscopic fundoplication remains the gold standard treatment for gastroesophageal reflux disease. However, 10% to 20% of patients experience new, persistent, or recurrent symptoms warranting further treatment. Potential predictors for the best outcome after laparoscopic fundoplication were tested using a mature prospectively maintained database. METHODS Data from 894 consecutive patients who underwent primary laparoscopic fundoplication from 1998 to 2015 were examined using regression and machine learning (ML) models. Preoperative factors were assessed for influence on postoperative outcomes: heartburn, dysphagia, and satisfaction scores at a median follow-up of 5 years. RESULTS The accuracy in predicting heartburn score (range, 0-10) assessed using the root mean squared error (RMSE) was similar to a negative binomial regression model (RMSE = 2.39) and the least absolute shrinkage support operator ML model (RMSE = 2.34). The multivariate analysis using only patients with complete data (n = 221) generated a lower error than using mean imputation for patients with missing values. The most predictive variables were male sex for heartburn (β = -1.48 [95% CI, -2.37 to -0.6; P =.001) and dysphagia (β = -4.70 [95% CI, -8.02 to -1.39; P =.006) and percentage of esophageal peristalsis for satisfaction (β = 0.63 [95% CI, 0.16-1.10]; P =.009) and dysphagia (β = -1.85 [95% CI, -3.43 to -0.27]; P =.02). CONCLUSION Although male sex and degree of intact peristalsis are significant predictors for outcomes after laparoscopic fundoplication, prediction of individual patient outcome was relatively poor, and ML prediction models provided only marginal improvement in accuracy. Clinical acumen and a discussion with patients to set realistic postoperative expectations cannot be replaced by regression models or standard ML prediction algorithms at the present time.
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Affiliation(s)
- Rippan N Shukla
- Flinders University Discipline of Surgery, College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Richard Woodman
- Flinders University Discipline of Surgery, College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jennifer C Myers
- Flinders University Discipline of Surgery, College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia; Discipline of Surgery, Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Woodville, South Australia, Australia
| | - David I Watson
- Flinders University Discipline of Surgery, College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Tim Bright
- Flinders University Discipline of Surgery, College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Sarah K Thompson
- Flinders University Discipline of Surgery, College of Medicine and Public Health, Flinders Medical Centre, Bedford Park, South Australia, Australia.
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Nasr B, Altamimi A, Altohari B, Obad A, Ali G, Alaidaroos A, Barabaa S, Bahanan S, Othman G. Laparoscopic Hiatal Hernia Repair: Short-Term Results From Yemen in a Resource-Limited Setting. Cureus 2025; 17:e78010. [PMID: 40013195 PMCID: PMC11862865 DOI: 10.7759/cureus.78010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2025] [Indexed: 02/28/2025] Open
Abstract
Background The laparoscopic minimally invasive surgery with anti-reflux procedure is the preferred method for hiatal hernia repair, showcasing a noticeable decrease in surgery-related morbidity and mortality. This study aimed to investigate various elements and variables that could affect and enhance the advantages of minimally invasive surgery for hiatal hernias and minimize the chances of complications occurring both during and after laparoscopic repair with fundoplication for hiatal hernia. Methods Hiatal hernia repair with fundoplication as anti-reflux surgery was conducted to evaluate perioperative and postoperative outcomes at Aden Hospital between 2023 and 2024. The inclusion criteria included patients with hiatal hernia and a positive history of gastroesophageal reflux treated with laparoscopic minimally invasive hernial repair involving anti-reflux procedures such as laparoscopic Nissen fundoplication or Dor fundoplication. Data on baseline population characteristics, including age and gender, as well as hernia types (type 1, 2, 3, and 4), hernia size, and the surgical techniques used were collected. Information regarding operative duration, intraoperative complications, postoperative complications, and length of hospital stay was also gathered. Follow-up assessments were conducted at one, three, six, and 12 months. Results From 2023 to 2024, a total of 21 individuals underwent minimally invasive laparoscopic hiatal hernial repair, which included 12 (57%) females and nine (43%) males, with an average age of 55 years (ages ranging from 35 to 80 years). Symptoms of gastroesophageal reflux such as heartburn manifested in 18 (85%) patients. Three (14%) patients had abdominal surgery history. The types of hiatal hernia observed were as follows: 12 patients had type 1, five had type 2, three had type 3, and one had type 4. Conversion from laparoscopic surgery to open surgery was performed in one case (4.7%). Sixteen (76.1%) patients had laparoscopic hiatal hernia repair combined with Nissen fundoplication, three (14.2%) patients had Heller myotomy with Dor fundoplication, and two (9.5%) patients underwent sleeve gastrectomy along with hiatal hernia repair. The average duration of the operation was 116 ± 60 minutes, while the average length of hospital stay was 3 ± 1.5 days. There was one (4.7%) patient with intraoperative complication (pneumothorax), and 15 (71.4%) patients were free of postoperative complications; however, four (19%) patients complained of postoperative flatulence and abdominal distension, one (4.7%) patient complained of transient recurrent reflux and dysphagia, and one (4.7%) patient had aspiration pneumonia and death. Recurrent hiatal hernia was not detected during follow-up at three to 12 months after laparoscopic surgery. Conclusions Laparoscopic hiatal hernia repair with anti-reflux surgery can be successful in resource-limited settings, providing an effective and safe option for managing hiatal hernias and alleviating gastroesophageal reflux disease.
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Affiliation(s)
- Burkan Nasr
- Department of Surgery, University of Aden, Aden, YEM
- Department of Surgery, Aden German International Hospital, Aden, YEM
| | | | - Badr Altohari
- Department of Surgery, University of Aden, Aden, YEM
| | - Ali Obad
- Department of Surgery, University of Aden, Aden, YEM
| | - Ghassan Ali
- Department of Surgery, University of Aden, Aden, YEM
| | | | - Salem Barabaa
- Department of Surgery, University of Aden, Aden, YEM
| | | | - Gubran Othman
- Department of Surgery, University of Aden, Aden, YEM
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Erol MF, Demir B, Kayaoglu HA. Comparative analysis of laparoscopic Nissen fundoplication and Rossetti modification in gastroesophageal reflux disease: A focus on life-quality enhancement. Asian J Surg 2024; 47:5096-5100. [PMID: 38945768 DOI: 10.1016/j.asjsur.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/09/2024] [Accepted: 06/13/2024] [Indexed: 07/02/2024] Open
Abstract
OBJECTIVE This study aims to investigate the focus of surgical treatment of gastroesophageal reflux disease (GERD) on enhancing life quality beyond symptom relief. The comparison involves laparoscopic Nissen fundoplication and Rossetti modification techniques. METHODS Patients intolerant to or experiencing relapse after medical therapy underwent either standard Nissen procedure (Group 1, n = 61) or Rossetti modification (Group 2, n = 42). A disease-specific quality of life questionnaire for GERD was utilized for evaluating life quality preoperatively and 2 years postoperatively. Symptom scores and patient satisfaction were also assessed. RESULTS Preoperatively, groups were similar in symptom duration, hiatal hernia presence, and DeMeester scores (p = 0.127, p = 0.427, and 0.584, respectively). Both groups exhibited a statistically significant increase in life quality postoperatively (p < 0.001), with no significant intergroup difference. Symptoms decreased after both surgeries, except for dysphagia and bloating. Bloating significantly increased in both groups after surgery (p = 0.018 and p = 0.017, respectively), and dysphagia increased significantly only in Group 2 (p = 0.007). The surgery refusal rate was significantly higher in Group 2 for similar preoperative symptoms (p = 0.040). CONCLUSION Despite increased life quality scores, the combination of increased dysphagia and bloating in patients undergoing Rossetti modification resulted in a decreased satisfaction rate.
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Affiliation(s)
- Mehmet Fatih Erol
- Yuksek Ihtisas Education and Training Hospital, Department of General Surgery, Bursa, Turkey.
| | - Berkay Demir
- Bilkent City Hospital, Department of Gastrointestinal Surgery, Ankara, Turkey
| | - Huseyin Ayhan Kayaoglu
- Private Hayat Hospital, Department of General Surgery, Obesity and Metabolic Surgery Center, Bursa, Turkey
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Schlottmann F, Bertona S, Herbella FAM, Patti MG. Gastroesophageal reflux disease: indications for antireflux surgery, outcomes, and side effects. Expert Rev Gastroenterol Hepatol 2024; 18:693-703. [PMID: 39632344 DOI: 10.1080/17474124.2024.2438719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 10/21/2024] [Accepted: 12/03/2024] [Indexed: 12/07/2024]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is a frequent digestive disorder that presents with a broad spectrum of symptoms. Global consensus on which patients should be selected for anti-reflux surgery is lacking. AREAS COVERED This evidence-based review will analyze current indications for anti-reflux surgery, outcomes of the operation, and potential side effects. EXPERT COMMENTARY Treatment of GERD has three main purposes: control symptoms, improve quality of life, and prevent potential serious complications such as bleeding, esophageal stenosis, Barrett's esophagus, and esophageal adenocarcinoma. Although medical therapy is effective in the majority of patients, some might require anti-reflux surgery in order to achieve these goals. Adequate patient selection for anti-reflux surgery is critical to obtain optimal outcomes. Most patients undergoing a fundoplication have adequate long-term symptomatic relief. However, potential side effects of anti-reflux surgery should also be discussed with patients to help manage expectations from the operation.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sofia Bertona
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Vázquez-Elizondo G, Remes-Troche JM, Valdovinos-Díaz MÁ, Coss-Adame E, Morán ES, Achem SR. Diagnostic differences in high-resolution esophageal motility in a large Mexican cohort based on geographic distribution. Dis Esophagus 2024; 37:doae049. [PMID: 38857460 DOI: 10.1093/dote/doae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/04/2024] [Accepted: 05/26/2024] [Indexed: 06/12/2024]
Abstract
High-resolution esophageal manometry [HRM] has become the gold standard for the evaluation of esophageal motility disorders. It is unclear whether there are HRM differences in diagnostic outcome based on regional or geographic distribution. The diagnostic outcome of HRM in a diverse geographical population of Mexico was compared and determined if there is variability in diagnostic results among referral centers. Consecutive patients referred for HRM during 2016-2020 were included. Four major referral centers in Mexico participated in the study: northeastern, southeastern, and central (Mexico City, two centers). All studies were interpreted by experienced investigators using Chicago Classification 3 and the same technology. A total of 2293 consecutive patients were included. More abnormal studies were found in the center (61.3%) versus south (45.8%) or north (45.2%) P < 0.001. Higher prevalence of achalasia was noted in the south (21.5%) versus center (12.4%) versus north (9.5%) P < 0.001. Hypercontractile disorders were more common in the north (11.0%) versus the south (5.2%) or the center (3.6%) P.001. A higher frequency of weak peristalsis occurred in the center (76.8%) versus the north (74.2%) or the south (69.2%) P < 0.033. Gastroesophageal junction obstruction was diagnosed in (7.2%) in the center versus the (5.3%) in the north and (4.2%) in the south p.141 (ns). This is the first study to address the diagnostic outcome of HRM in diverse geographical regions of Mexico. We identified several significant diagnostic differences across geographical centers. Our study provides the basis for further analysis of the causes contributing to these differences.
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Affiliation(s)
- Genaro Vázquez-Elizondo
- Gastroenterology Department, Centro de Enfermedades Digestivas ONCARE, Monterrrey, Nuevo León, Mexico
| | - José María Remes-Troche
- Gastroenterology Department, Laboratorio de Motilidad Gastrointestinal y Fisiología Digestiva, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, México
| | | | - Enrique Coss-Adame
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, México
| | | | - Sami R Achem
- Gastroenterology Department, Mayo College of Medicine, Mayo Clinic, Florida, USA
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S2k guideline Gastroesophageal reflux disease and eosinophilic esophagitis of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1786-1852. [PMID: 39389106 DOI: 10.1055/a-2344-6282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
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Fuchs KH, Kafetzis I, Hann A, Meining A. Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications. Life (Basel) 2024; 14:1145. [PMID: 39337928 PMCID: PMC11433396 DOI: 10.3390/life14091145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/15/2024] [Accepted: 08/19/2024] [Indexed: 09/30/2024] Open
Abstract
INTRODUCTION A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment. METHODS Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context. RESULTS In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use. CONCLUSIONS The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.
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Affiliation(s)
- Karl Hermann Fuchs
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Ioannis Kafetzis
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Alexander Hann
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
| | - Alexander Meining
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
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Elshennawy AT, Shatla IM, Agwa RH, Alghamdi HA, Alghamdi MTN, Alnashri AMM, Alqarni SDS, Alghamdi SSB, Alghamdi SIM, Alghamdi MAM. Prevalence of Gastroesophageal Reflux Disease and Its Impact on the Quality of Life Among Obese Individuals in Al-Baha Region, Saudi Arabia. Cureus 2024; 16:e63073. [PMID: 38933342 PMCID: PMC11200320 DOI: 10.7759/cureus.63073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 06/28/2024] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is a global gastrointestinal disorder, and obesity is a particular risk factor. Symptoms of GERD, such as heartburn and acid reflux, are caused by abnormal relaxation in the lower esophagus, causing gastric acid reflux. Persistent symptoms can affect the patient's quality of life (QOL) and can cause complications, such as esophageal adenocarcinoma. Management of GERD includes lifestyle changes, antacids, and anti-reflux surgery. Even though GERD is a common disease, few research has been carried out on it in Saudi Arabia. Aim This study aimed to estimate the prevalence of GERD and its associated risk factors among obese individuals in the Al-Baha region population and the effect of GERD on their QOL. Methods A cross-sectional study included 314 obese participants from the Al-Baha region. A questionnaire was filled out to measure the prevalence of GERD, risk factors, and effects on the QOL of the participants. Data were analyzed by the IBM SPSS Statistics for Windows, version 26.0 (released 2019, IBM Corp., Armonk, NY). Descriptive statistics and the chi-squared test were applied. Logistic regression analysis was used to determine the factors associated with the incidence of GERD. A p-value of <0.05 was considered statistically significant. Results A total of 314 patients who met our inclusion criteria completed the survey; 42% of them were women, the mean age of all patients was 35.3 ± 12.9 years, and 38.2% of the patients were diagnosed with GERD. Epigastric pain and burning sensation were the most common symptoms (44.9%). Five out of six domains in the QOL questionnaire showed more effects among GERD participants than non-GERD participants, and the results were statistically significant (p = 0.001). Logistic regression analysis showed that men are 1.8 times more likely than women to be diagnosed with GERD, and smokers have 2.6 times the risk of being diagnosed with GERD than non-smokers. Conclusion The present study showed a high prevalence of GERD among obese patients in the Al-Baha region, negatively affecting their QOL. Major risk factors included gender, smoking, dyslipidemia, and hypertension. Public health programs to raise awareness of these risk factors and lifestyle habits are necessary to improve QOL and prevent complications.
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Affiliation(s)
- Ahmed T Elshennawy
- Department of Anatomy, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
| | - Ibrahim M Shatla
- Department of Physiology, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
- Department of Physiology, Faculty of Medicine, Al-Azhar University, Damietta, EGY
| | - Ramy H Agwa
- Department of Internal Medicine/Hepatology and Gastroenterology, Mansoura University, Mansoura, EGY
- Department of Internal Medicine/Hepatology and Gastroenterology, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
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Valinoti AC, Angeramo CA, Dreifuss N, Herbella FAM, Schlottmann F. MAGNETIC SPHINCTER AUGMENTATION DEVICE FOR GASTROESOPHAGEAL REFLUX DISEASE: EFFECTIVE, BUT POSTOPERATIVE DYSPHAGIA AND RISK OF EROSION SHOULD NOT BE UNDERESTIMATED. A SYSTEMATIC REVIEW AND META-ANALYSIS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 36:e1781. [PMID: 38451590 PMCID: PMC10911679 DOI: 10.1590/0102-672020230063e1781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 09/10/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Magnetic ring (MSA) implantation in the esophagus is an alternative surgical procedure to fundoplication for the treatment of gastroesophageal reflux disease. AIMS The aim of this study was to analyse the effectiveness and safety of magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD). METHODS A systematic literature review of articles on MSA was performed using the Medical Literature Analysis and Retrieval System Online (Medline) database between 2008 and 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS A total of 22 studies comprising 4,663 patients with MSA were analysed. Mean follow-up was 27.3 (7-108) months. The weighted pooled proportion of symptom improvement and patient satisfaction were 93% (95%CI 83-98%) and 85% (95%CI 78-90%), respectively. The mean DeMeester score (pre-MSA: 34.6 vs. post-MSA: 8.9, p=0.03) and GERD-HRQL score (pre-MSA: 25.8 vs. post-MSA: 4.4, p<0.0001) improved significantly after MSA. The proportion of patients taking proton pump inhibitor (PPIs) decreased from 92.8 to 12.4% (p<0.0001). The weighted pooled proportions of dysphagia, endoscopic dilatation and gas-related symptoms were 18, 13, and 3%, respectively. Esophageal erosion occurred in 1% of patients, but its risk significantly increased for every year of MSA use (odds ratio - OR 1.40, 95%CI 1.11-1.77, p=0.004). Device removal was needed in 4% of patients. CONCLUSIONS Although MSA is a very effective treatment modality for GERD, postoperative dysphagia is common and the risk of esophageal erosion increases over time. Further studies are needed to determine the long-term safety of MSA placement in patients with GERD.
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Affiliation(s)
- Agustin Cesar Valinoti
- Hospital Aleman de Buenos Aires, Esophagus and Stomach Surgical Unit – Buenos Aires, Argentina
| | | | - Nicolas Dreifuss
- Hospital Aleman de Buenos Aires, Esophagus and Stomach Surgical Unit – Buenos Aires, Argentina
| | | | - Francisco Schlottmann
- Hospital Aleman de Buenos Aires, Esophagus and Stomach Surgical Unit – Buenos Aires, Argentina
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Davis TA, Gyawali CP. Refractory Gastroesophageal Reflux Disease: Diagnosis and Management. J Neurogastroenterol Motil 2024; 30:17-28. [PMID: 38173155 PMCID: PMC10774805 DOI: 10.5056/jnm23145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/16/2023] [Indexed: 01/05/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) is common, with increasing worldwide disease prevalence and high economic burden. A significant number of patients will remain symptomatic following an empiric proton pump inhibitor (PPI) trial. Persistent symptoms despite PPI therapy are often mislabeled as refractory GERD. For patients with no prior GERD evidence (unproven GERD), testing is performed off antisecretory therapy to identify objective evidence of pathologic reflux using criteria outlined by the Lyon consensus. In proven GERD, differentiation between refractory symptoms (persisting symptoms despite optimized antisecretory therapy) and refractory GERD (abnormal reflux metrics on ambulatory pH impedance monitoring and/or persistent erosive esophagitis on endoscopy while on optimized PPI therapy) can direct subsequent management. While refractory symptoms may arise from esophageal hypersensitivity or functional heartburn, proven refractory GERD requires personalization of the management approach, tapping from an array of non-pharmacologic, pharmacologic, endoscopic, and surgical interventions. Proper diagnosis and management of refractory GERD is critical to mitigate undesirable long-term complications such as strictures, Barrett's esophagus, and esophageal adenocarcinoma. This review outlines the diagnostic workup of patients presenting with refractory GERD symptoms, describes the distinction between unproven and proven GERD, and provides a comprehensive review of the current treatment strategies available for the management of refractory GERD.
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Affiliation(s)
- Trevor A Davis
- Division of Pediatric Gastroenterology, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Salvador R, Vittori A, Capovilla G, Riccio F, Nezi G, Forattini F, Provenzano L, Nicoletti L, Moletta L, Costantini A, Valmasoni M, Costantini M. Antireflux Surgery's Lifespan: 20 Years After Laparoscopic Fundoplication. J Gastrointest Surg 2023; 27:2325-2335. [PMID: 37580489 PMCID: PMC10661768 DOI: 10.1007/s11605-023-05797-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/29/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy.
| | - Arianna Vittori
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Federica Riccio
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Giulia Nezi
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Francesca Forattini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Loredana Nicoletti
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Lucia Moletta
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Andrea Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, UOC Chirurgia Generale 1, Azienda Ospedale Università, Padova, Italy
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Allaix ME, Rebecchi F, Bellocchia A, Morino M, Patti MG. LAPAROSCOPIC ANTIREFLUX SURGERY: WERE OLD QUESTIONS ANSWERED? PARTIAL OR TOTAL FUNDOPLICATION? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1741. [PMID: 37436210 DOI: 10.1590/0102-672020230023e1741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/28/2021] [Indexed: 07/13/2023]
Abstract
Laparoscopic total fundoplication is currently considered the gold standard for the surgical treatment of gastroesophageal reflux disease. Short-term outcomes after laparoscopic total fundoplication are excellent, with fast recovery and minimal perioperative morbidity. The symptom relief and reflux control are achieved in about 80 to 90% of patients 10 years after surgery. However, a small but clinically relevant incidence of postoperative dysphagia and gas-related symptoms is reported. Debate still exists about the best antireflux operation; during the last three decades, the surgical outcome of laparoscopic partial fundoplication (anterior or posterior) were compared to those achieved after a laparoscopic total fundoplication. The laparoscopic partial fundoplication, either anterior (180°) or posterior, should be performed only in patients with gastroesophageal reflux disease secondary to scleroderma and impaired esophageal motility, since the laparoscopic total fundoplication would impair esophageal emptying and cause dysphagia.
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Affiliation(s)
| | - Fabrizio Rebecchi
- University of Torino, Department of Surgical Sciences - Torino, Italy
| | - Alex Bellocchia
- University of Torino, Department of Surgical Sciences - Torino, Italy
| | - Mario Morino
- University of Torino, Department of Surgical Sciences - Torino, Italy
| | - Marco Giuseppe Patti
- University of North Carolina at Chapel Hill, Department of Medicine and Surgery - Chapel Hill, United States of America
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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Ospanov O, Yeleuov G, Buchwald JN, Zharov N, Yelembayev B, Sultanov K. A Randomized Controlled Trial of Acid and Bile Reflux Esophagitis Prevention by Modified Fundoplication of the Excluded Stomach in One-Anastomosis Gastric Bypass: 1-Year Results of the FundoRing Trial. Obes Surg 2023; 33:1974-1983. [PMID: 37099252 DOI: 10.1007/s11695-023-06618-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND The advantages and disadvantages of one-anastomosis gastric bypass (OAGB) with primary modified fundoplication using the excluded stomach ("FundoRing") is unclear. We aimed to assess the impact of this operation in a randomized controlled trial (RCT) and answer the next questions: (1) What the impact of wrapping the fundus of the excluded part of the stomach in OAGB on protection in the experimental group against developing de novo reflux esophagitis? (2) If preoperative RE could be improved in the experimental group? (3) Can preoperative acid reflux as measured by PH impedance, be treated by the addition of the "FundoRing"? METHODS The study design was a single-center prospective, interventional, open-label (no masking) RCT (FundoRing Trial) with 1-year follow-up. Endpoints were body mass index (BMI, kg/m2) and acid and bile RE assessed endoscopically by Los Angeles (LA) classification and 24-h pH impedance monitoring. Complications were graded by Clavien-Dindo classification (CDC). RESULTS One hundred patients (n = 50 FundoRingOAGB (f-OAGB) vs n = 50 standard OAGB (s-OAGB)) with complete follow-up data were included in the study. During OAGB procedures, patients with hiatal hernia underwent cruroplasty (29/50 f-OAGB; 24/50 s-OAGB). There were no leaks, bleeding, or deaths in either group. At 1 year, BMI in the f-OAGB group was 25.3 ± 2.77 (19-30) vs 26.48 ± 2.8 (21-34) s-OAGB group (p = 0.03). In f-OAGB vs s-OAGB groups, respectively, acid RE was seen in 1 vs 12 patients (p = 0.001) and bile RE in 0 vs 4 patients (p < 0.05). CONCLUSION Routine use of a modified fundoplication of the OAGB-excluded stomach to treat patients with obesity decreased acid and prevented bile reflux esophagitis significantly more effectively than standard OAGB at 1 year in a randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04834635.
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Affiliation(s)
- Oral Ospanov
- Department of Surgical Disease and Bariatric Surgery, Astana Medical University, Beybitshilik Street 49A, 010000, Astana, Kazakhstan.
- Surgery Center of Professor Oral Ospanov, Astana, Kazakhstan.
| | - Galymzhan Yeleuov
- Department of Surgical Disease and Bariatric Surgery, Astana Medical University, Beybitshilik Street 49A, 010000, Astana, Kazakhstan
| | - J N Buchwald
- Division of Scientific Research Writing, Medwrite Medical Communications, Maiden Rock, WI, USA
| | - Nurlan Zharov
- Department of Surgical Disease and Bariatric Surgery, Astana Medical University, Beybitshilik Street 49A, 010000, Astana, Kazakhstan
| | | | - Kassymkhan Sultanov
- Department of Surgical Disease, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
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16
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Fuchs KH, Musial F, Retzbach L, Hann A, Meining A. Quality of life in benign colorectal disease-a review of the assessment with the Gastrointestinal Quality of Life Index (GIQLI). Int J Colorectal Dis 2023; 38:172. [PMID: 37338676 PMCID: PMC10282040 DOI: 10.1007/s00384-023-04473-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND AND PURPOSE The Gastrointestinal Quality of Life Index (GIQLI) is an instrument for the assessment of quality of life (QOL) in diseases of the upper and lower GI tract, which is validated in several languages around the world. The purpose of this literature review is the assessment of the GIQLI in patients with benign colorectal diseases. Reports on GIQLI data are collected from several institutions, countries, and different cultures which allows for comparisons, which are lacking in literature. METHODS The GIQL Index uses 36 items around 5 dimensions (gastrointestinal symptoms (19 items), emotional dimension (5 items), physical dimension (7 items), social dimension (4 items), and therapeutic influences (1 item). The literature search was performed on the GIQLI and colorectal disease, using reports in PubMed. Data are presented descriptively as GIQL Index points as well as a reduction from 100% maximum possible index points (max 144 index points = highest quality of life). RESULTS The GIQLI was found in 122 reports concerning benign colorectal diseases, of which 27 were finally selected for detailed analysis. From these 27 studies, information on 5664 patients (4046 female versus 1178 male) was recorded and summarized. The median age was 52 years (range 29-74.7). The median GIQLI of all studies concerning benign colorectal disease was 88 index points (range 56.2-113). Benign colorectal disease causes a severe reduction in QOL for patients down to 61% of the maximum. CONCLUSIONS Benign colorectal diseases cause substantial reductions in the patient's QOL, well documented by GIQLI, which allows a comparison QOL with other published cohorts.
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Affiliation(s)
- Karl-Hermann Fuchs
- Laboratory for Interventional and Experimental Endoscopy (InExEn), Gastroenterology, University of Würzburg, Auvera-Haus, Grombühlstr.12, 97080, Würzburg, Germany.
| | - Frauke Musial
- National Research Center in Complementary and Alternative Medicine (NAFKAM), Department of Community Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Laura Retzbach
- Laboratory for Interventional and Experimental Endoscopy (InExEn), Gastroenterology, University of Würzburg, Auvera-Haus, Grombühlstr.12, 97080, Würzburg, Germany
| | - Alexander Hann
- Laboratory for Interventional and Experimental Endoscopy (InExEn), Gastroenterology, University of Würzburg, Auvera-Haus, Grombühlstr.12, 97080, Würzburg, Germany
| | - Alexander Meining
- Laboratory for Interventional and Experimental Endoscopy (InExEn), Gastroenterology, University of Würzburg, Auvera-Haus, Grombühlstr.12, 97080, Würzburg, Germany
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17
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Castillo-Larios R, Gunturu NS, Cornejo J, Trooboff SW, Giri AR, Bowers SP, Elli EF. Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-reflux surgery: which is better? Surg Endosc 2023:10.1007/s00464-023-10074-1. [PMID: 37130984 DOI: 10.1007/s00464-023-10074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/26/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Different techniques have been proposed for reoperation after failed anti-reflux surgery. However, there is no consensus on which should be preferred. We aim to report and compare the outcomes of different revisional techniques for failed anti-reflux surgery. METHODS We performed a retrospective analysis of patients who underwent redo fundoplication (RF) or Roux-en-Y gastric bypass (RYGB) conversion after a failed fundoplication at our institution between 2016 and 2021. The primary outcome was long-term presence of reflux or dysphagia following revisional surgery. Secondary outcomes included 30-day perioperative complications as well as long-term use of anti-reflux medication and radiographic recurrence of hiatal hernia (HH). RESULTS A total of 165 (median age 63 years, 73.9% female) patients were included. RF was performed in 120 (73 Toupet and 47 Nissen), RYGB in 38, and 7 patients had fundoplication takedown alone. The RYGB group had a significantly higher BMI, and more prior revisional surgeries compared to the other groups. Median operative time and length of stay were longer for RYGB. Twenty (12.1%) patients experienced postoperative complications, with the highest incidence in the RYGB group. Reflux and dysphagia improved significantly for the whole cohort, with the greatest improvement noted with reflux in the RYGB group (89.5% with preoperative reflux vs. 10.5% with postoperative reflux, p = < .001). On multivariable regression we found that prior re-operative surgery was associated with persistent reflux and dysphagia, whereas RYGB conversion was protective against reflux. CONCLUSION Conversion to RYGB may offer superior resolution of reflux than RF, especially for obese patients.
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Affiliation(s)
- Rocio Castillo-Larios
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Naga Swati Gunturu
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Jorge Cornejo
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Spencer W Trooboff
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | | | - Steven P Bowers
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Enrique F Elli
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Salman MA, Salman A, Shaaban HED, Alasmar M, Tourky M, Elhaj MGF, Khalid S, Gebril M, Alrahawy M, Elsherbiney M, Assal MM, Osman MHA, Mohammed AA, Elewa A. Nissen Versus Toupet Fundoplication For Gastro-oesophageal Reflux Disease, Short And Long-term Outcomes. A Systematic Review And Meta-analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:171-183. [PMID: 36971517 DOI: 10.1097/sle.0000000000001139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/22/2022] [Indexed: 03/29/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) remains one of the most commonly encountered gastrointestinal disorders. Proton pump inhibitors still show an inadequate effect on about 10% to 40% of the patients. Laparoscopic antireflux surgery is the surgical alternative for managing GERD in patients who are not responding to proton pump inhibitors. AIM OF THE STUDY This study objected at comparing laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication (LTF) concerning the short-term and long-term outcomes. PATIENTS AND METHODS This is a systematic review and meta-analysis that evaluated the studies comparing between Nissen fundoplication and LTF for the treatment of GERD. Studies were obtained by searching on the EMBASE, the Cochrane Central Register of Controlled Trials, and PubMed central database. RESULTS The LTF group showed significantly longer operation time, less postoperative dysphagia and gas bloating, less pressure on the lower esophageal sphincter, and higher Demeester scores. No statistically significant differences were found between the 2 groups in the perioperative complications, the recurrence of GERD, the reoperation rate, the quality of life, or the reoperation rate. CONCLUSION LTF is favored for the surgical treatment of GERD being of lower postoperative dysphagia and gas bloating rates. These benefits were not at the expense of significantly additional perioperative complications or surgery failure.
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Affiliation(s)
| | - Ahmed Salman
- Internal Medicine, Kasralainy School of Medicine, Cairo University, Giza
| | - Hossam El-Din Shaaban
- National Hepatology and Tropical Medicine Research Institute, Gastroenterology and Hepatology, Cairo, Egypt
| | - Mohamed Alasmar
- General/OesophagoGastric Surgery, Salford Royal Hospital, Manchester
- Division of Cancer Sciences, University of Manchester
| | | | | | | | | | | | | | | | | | | | - Ahmed Elewa
- Laparoscopic and HBP Surgery at National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
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19
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Presence of refractory GERD-like symptoms following laparoscopic fundoplication is rarely indicative of true recurrent GERD. Surg Endosc 2023:10.1007/s00464-023-09930-x. [PMID: 36813925 DOI: 10.1007/s00464-023-09930-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/28/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Laparoscopic fundoplication (LF) is the gold standard for gastroesophageal reflux disease (GERD). Recurrent GERD is a known complication; however, the incidence of recurrent GERD-like symptoms and long-term fundoplication failure is rarely reported. Our objective was to identify the rate of recurrent pathologic GERD in patients with GERD-like symptoms following fundoplication. We hypothesized that patients with recurrent GERD-like symptoms refractory to medical management do not have evidence of fundoplication failure as indicated by a positive ambulatory pH study. METHODS This is a retrospective cohort study of 353 consecutive patients undergoing LF for GERD between 2011 and 2017. Baseline demographics, objective testing, GERD-HRQL scores, and follow-up data were collected in a prospective database. Patients with return visits to clinic following routine post-operative visits were identified (n = 136, 38.5%), and those with a primary complaint of GERD-like symptoms (n = 56, 16%) were included. The primary outcome was the proportion of patients with a positive post-operative ambulatory pH study. Secondary outcomes included proportion of patients with symptoms managed with acid-reducing medications, time to return to clinic, and need for reoperation. P values < 0.05 were considered significant. RESULTS Fifty-six (16%) patients returned during the study period for an evaluation of recurrent GERD-like symptoms with a median interval of 51.2 (26.2-74.7) months. Twenty-four patients (42.9%) were successfully managed expectantly or with acid-reducing medications. Thirty two (57.1%) presented with GERD-like symptoms and failure of management with medical acid suppression and underwent repeat ambulatory pH testing. Of these, only 5 (9%) were found to have a DeMeester score of > 14.7, and three (5%) underwent recurrent fundoplication. CONCLUSION Following LF, the incidence of GERD-like symptoms refractory to PPI therapy is much higher than the incidence of recurrent pathologic acid reflux. Few patients with recurrent GI symptoms require surgical revision. Evaluation, including objective reflux testing, is critical to evaluating these symptoms.
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20
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Slater BJ, Collings A, Dirks R, Gould JC, Qureshi AP, Juza R, Rodríguez-Luna MR, Wunker C, Kohn GP, Kothari S, Carslon E, Worrell S, Abou-Setta AM, Ansari MT, Athanasiadis DI, Daly S, Dimou F, Haskins IN, Hong J, Krishnan K, Lidor A, Litle V, Low D, Petrick A, Soriano IS, Thosani N, Tyberg A, Velanovich V, Vilallonga R, Marks JM. Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD). Surg Endosc 2023; 37:781-806. [PMID: 36529851 DOI: 10.1007/s00464-022-09817-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD. METHODS Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m2) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss. CONCLUSION Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.
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Affiliation(s)
- Bethany J Slater
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA.
| | - Amelia Collings
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rebecca Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jon C Gould
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alia P Qureshi
- Division of General & GI Surgery, Foregut Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Ryan Juza
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - María Rita Rodríguez-Luna
- Research Institute Against Digestive Cancer (IRCAD) and ICube Laboratory, Photonics Instrumentation for Health, Strasbourg, France
| | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Shanu Kothari
- Department of Surgery, Prisma Health, Greenville, SC, USA
| | | | | | - Ahmed M Abou-Setta
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Mohammed T Ansari
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | | | - Shaun Daly
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | | | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, USA
| | - Julie Hong
- Department of Surgery, New York Presbyterian/Queens, Queens, USA
| | | | - Anne Lidor
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Virginia Litle
- Section of Thoracic Surgery, Department of Cardiovascular Surgery, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Donald Low
- Virginia Mason Medical Center, Seattle, WA, USA
| | - Anthony Petrick
- Department of General Surgery, Geisinger School of Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Ian S Soriano
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Nirav Thosani
- McGovern Medical School, Center for Interventional Gastroenterology at UTHealth, Houston, TX, USA
| | - Amy Tyberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Vic Velanovich
- Division of Gastrointestinal Surgery, Tampa General, Tampa, FL, USA
| | - Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall d'Hebron University Hospital, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jeffrey M Marks
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Gastroesophageal reflux disease and dysphagia. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution. Surg Endosc 2023; 37:624-630. [PMID: 35713721 DOI: 10.1007/s00464-022-09359-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/16/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. METHODS A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis. RESULTS One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. CONCLUSION Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.
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Wong HJ, Vierra M, Hedberg M, Attaar M, Su B, Kuchta K, Chiao G, Linn JG, Haggerty SP, Ujiki MB. A Tailored Approach to Laparoscopic Fundoplication: Outcomes in Patients with Esophageal Dysmotility. J Gastrointest Surg 2022; 26:2426-2433. [PMID: 36221019 DOI: 10.1007/s11605-022-05452-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 09/03/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Esophageal dysmotility is a common finding in patients being evaluated for antireflux surgery, although its implication remains unclear. We aimed to evaluate outcomes of patients with esophageal dysmotility after fundoplication. METHODS A retrospective review of a prospective quality-database was performed. All patients who underwent laparoscopic Nissen (NF) or Toupet (TF) fundoplication were included. Esophageal dysmotility was defined using the Chicago Classification v4.0 and conventional metrics, creating three sub-groups: ineffective esophageal motility (IEM), distal/diffuse esophageal spasm (DES), and hypercontractile esophagus (HE). Quality of life (QOL) outcomes were measured by the Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Scores. RESULTS Of 487 patients included, 99 (20.3%) had esophageal dysmotility (49 IEM, 40 DES, 10 HE). While a majority in the dysmotility group (81.8%) underwent TF, most patients in the normal group (76.5%) underwent NF (p < 0.001). On multivariable analysis controlling for sex, age, BMI, hiatal hernia, and surgery type, the normal group had higher Dysphagia Scores at 3 weeks (2.2 ± 0.9 vs. 1.7 ± 0.8, p < 0.001), but not at 6-month, 1-year, 2-year, or 5-year follow-up. There were no differences between normal and dysmotility groups in terms of RSI or GERD-HRQL scores at any time point. Patients with different sub-types of esophageal dysmotility had similar QOL outcomes at all time points. CONCLUSION Patients with esophageal dysmotility had similar outcomes compared to those with normal motility after fundoplication, suggesting the tailored approach favoring partial fundoplication for patients with dysmotility as part of an appropriate treatment algorithm.
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Affiliation(s)
- Harry J Wong
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA. .,Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
| | - Mason Vierra
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Mason Hedberg
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA
| | - Mikhail Attaar
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA.,Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Bailey Su
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA.,Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA
| | - Gene Chiao
- Department of Gastroenterology, NorthShore University HealthSystem, Evanston, IL, USA
| | - John G Linn
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA
| | - Stephen P Haggerty
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave GCSI rmB665 Evanston, Evanston, IL, 60201, USA
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Pascotto B, Henrard A, Maillart JF, Arenas-Sanchez M, Postal A, Legrand M. Quality of life and gastric acid-suppression medication post-laparoscopic fundoplication: a ten years retrospective study. Acta Chir Belg 2022; 122:321-327. [PMID: 33534655 DOI: 10.1080/00015458.2020.1860551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background: Although medical treatment is the best approach for treating gastroesophageal reflux disease (GERD), surgery has a significant role to play not only in cases of failure of medical treatment but also as in a long-term approach, specifically in young patient. On the other hand, alarming reports have been published concerning the outcomes and usefulness of antireflux surgery (ARS). The aim of this study was to evaluate medium and long-term functional outcomes following ARS performed in our institution over a 10 year period.Methods: This was a retrospective review of patients in our department who underwent primary or redo laparoscopic fundoplication between 2005 and 2015. Evaluation of the outcomes was made using a validated questionnaire specifically dedicated to GERD (the Gastroesophageal Reflux Disease - Health-Related Quality of Life (GERD-HRQL) questionnaire) and by investigation about the continued use of proton-pump inhibitors (PPIs). Exclusion criteria were patients treated for GERD with Roux-en-Y gastric bypass, emergency reduction of hiatal hernia, patients missing from follow-up and patients deceased from unrelated causes.Results: 296 patients out of 309 met the inclusion criteria. Primary procedures included 214 Nissen, 35 Toupet, and 23 Collis gastroplasty; there were additionally 62 redo operations. Neither postoperative mortality nor conversion was observed. The mean follow-up was 8 years post-surgery, and contact was made with 96% of the original group. 85% of the patients had stopped PPI use since their operation (86% after Nissen, 73% after Toupet, 94% after Collis and 82% after redos). 90% of the patients had good to excellent functional results as reported by their GERD-HRQL score, and independent of the type of previous procedure. 31 patients were dissatisfied due to dysphagia in 7 and GERD recurrence in 24. Again 75% were extremely satisfied and 15% satisfied. Our own incidence of redo procedures was 11% but the functional result and satisfaction index were comparable between redo and primary procedures. The addition of Collis gastroplasty in cases of real short oesophagus did not alter the final result.Conclusions: Laparoscopic ARS presents a superior alternative to lifetime medication use and can provide long-term control of GERD symptoms in the majority of patients if it is performed skillfully and in carefully evaluated patients. Based on the present study, we believed that significant improvement in GERD health-related quality of life can be attained following both primary and reoperative ARS.
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Affiliation(s)
- Beniamino Pascotto
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
| | - Alexandre Henrard
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
| | | | | | - Alain Postal
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
| | - Marc Legrand
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
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Fuchs KH, Musial F, Eypasch E, Meining A. Gastrointestinal Quality of Life in Gastroesophageal Reflux Disease: A Systematic Review. Digestion 2022; 103:253-260. [PMID: 35605592 DOI: 10.1159/000524766] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Gastrointestinal Quality of Life Index (GIQLI) is a well-established instrument for the assessment of quality of life (QOL) in gastrointestinal (GI) diseases. The purpose of this literature review was to investigate QOL by means of GIQLI in patients with gastroesophageal reflux disease (GERD) prior to any interventional therapy. There are several reports on GIQLI data; however, comparisons from different countries and/or different GERD cohorts assessing the same disease have to date not been conducted. METHODS The GIQLI uses 36 items around 5 dimensions (GI symptoms [19 items], emotional dimension [5 items], physical dimension [7 items], social dimension [4 items], and therapeutic influences [1 item]). A literature search was conducted on the application of GIQLI in GERD patients prior to interventional therapy using reports in PubMed. Data on the mean GIQLI as well as index data for the 5 dimensions as originally validated were extracted from the published patient cohorts. A comparison with the normal healthy control group from the original publication of the GIQLI validation conducted by Eypasch was performed. Data are presented descriptively as GIQLI points as well as a reduction from 100% maximum possible index points (max 144 index points = highest QOL). RESULTS In total, 77 abstracts from studies using the GIQLI on patients with GERD were identified. After screening for content, 21 publications were considered for further analysis. Ten studies in GERD patients comprised complete calculations of all dimensions and were included in the analysis. Data from 1,682 study patients were evaluated with sample sizes ranging from 33 to 568 patients (median age of 789 females and 858 males: 51.8 years). The median overall GIQLI for the patient group was 91.7 (range 86-102.4), corresponding to 63.68% of the maximum GIQLI. The dimensions with the largest deviation from the respective maximum score were the physical dimension (55% of maximum) followed by the emotional dimension (60% of maximum). In summary, the GIQLI level in GERD cohorts was reduced to 55-75% of the maximum possible index. CONCLUSIONS Severe GERD causes substantial reductions in the patient's QOL. The level of GIQLI can carry between different studied GERD cohorts from different departments and countries. GIQLI can be used as an established tool to assess the patient's condition in various dimensions.
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Affiliation(s)
- Karl-Hermann Fuchs
- Laboratory for Interventional and Experimental Endoscopy InExEn, Gastroenterology, University of Würzburg, Würzburg, Germany
| | - Frauke Musial
- Department of Community Medicine, National Research Center in Complementary and Alternative Medicine, NAFKAM, UiT, The Arctic University of Norway, Tromsø, Norway
| | | | - Alexander Meining
- Laboratory for Interventional and Experimental Endoscopy InExEn, Gastroenterology, University of Würzburg, Würzburg, Germany
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Crural closure, not fundoplication, results in a significant decrease in lower esophageal sphincter distensibility. Surg Endosc 2022; 36:3893-3901. [PMID: 34463870 DOI: 10.1007/s00464-021-08706-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/23/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The esophagogastric junction (EGJ) is a complex anti-reflux barrier whose integrity relies on both the intrinsic lower esophageal sphincter (LES) and extrinsic crural diaphragm. During hiatal hernia repair, it is unclear whether the crural closure or the fundoplication is more important to restore the anti-reflux barrier. The objective of this study is to analyze changes in LES minimum diameter (Dmin) and distensibility index (DI) using the endoluminal functional lumen imaging probe (FLIP) during hiatal hernia repair. METHODS Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This data were reviewed retrospectively for all patients undergoing hiatal hernia repair. FLIP measurements were collected prior to hernia dissection, after hernia reduction, after cruroplasty, and after fundoplication. Additionally, subjective assessment of the tightness of crural closure was rated by the primary surgeon on a scale of 1 to 5, 1 being the loosest and 5 being the tightest. RESULTS Between August 2018 and February 2020, 97 hiatal hernia repairs were performed by a single surgeon. FLIP measurements collected using a 40-mL volume fill without pneumoperitoneum demonstrated a significant decrease in LES Dmin (13.84 ± 2.59 to 10.27 ± 2.09) and DI (6.81 ± 3.03 to 2.85 ± 1.23 mm2/mmHg) after crural closure (both p < 0.0001). Following fundoplication, there was a small, but also statistically significant, increase in both Dmin and DI (both p < 0.0001). Additionally, subjective assessment of crural tightness after cruroplasty correlated well with DI (r = - 0.466, p < 0.001) and all patients with a crural tightness rating ≥ 4.5 (N = 13) had a DI < 2.0 mm2/mmHg. CONCLUSION Cruroplasty results in a significant decrease in LES distensibility and may be more important than fundoplication in restoring EGJ competency. Additionally, subjective estimation of crural tightness correlates well with objective FLIP evaluation, suggesting surgeon assessment of cruroplasty is reliable.
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Yadlapati R, Gyawali CP, Pandolfino JE. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Clin Gastroenterol Hepatol 2022; 20:984-994.e1. [PMID: 35123084 PMCID: PMC9838103 DOI: 10.1016/j.cgh.2022.01.025] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/12/2022] [Accepted: 01/20/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS As many as one-half of all patients with suspected gastroesophageal reflux disease (GERD) do not derive benefit from acid suppression. This review outlines a personalized diagnostic and therapeutic approach to GERD symptoms. METHODS The Best Practice Advice statements presented here were developed from expert review of existing literature combined with extensive discussion and expert opinion to provide practical advice. Formal rating of the quality of evidence or strength of recommendations was not the intent of this clinical practice update. BEST PRACTICE ADVICE 1: Clinicians should develop a care plan for investigation of symptoms suggestive of GERD, selection of therapy (with explanation of potential risks and benefits), and long-term management, including possible de-escalation, in a shared-decision making model with the patient. BEST PRACTICE ADVICE 2: Clinicians should provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors, relaxation strategies, and awareness about the brain-gut axis relationship to patients with reflux symptoms. BEST PRACTICE ADVICE 3: Clinicians should emphasize safety of proton pump inhibitors (PPIs) for the treatment of GERD. BEST PRACTICE ADVICE 4: Clinicians should provide patients presenting with troublesome heartburn, regurgitation, and/or non-cardiac chest pain without alarm symptoms a 4- to 8-week trial of single-dose PPI therapy. With inadequate response, dosing can be increased to twice a day or switched to a more effective acid suppressive agent once a day. When there is adequate response, PPI should be tapered to the lowest effective dose. BEST PRACTICE ADVICE 5: If PPI therapy is continued in a patient with unproven GERD, clinicians should evaluate the appropriateness and dosing within 12 months after initiation, and offer endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish appropriateness of long-term PPI therapy. BEST PRACTICE ADVICE 6: If troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy and, in the absence of erosive reflux disease (Los Angeles B or greater) or long-segment (≥3 cm) Barrett's esophagus, perform prolonged wireless pH monitoring off medication (96-hour preferred if available) to confirm and phenotype GERD or to rule out GERD. BEST PRACTICE ADVICE 7: Complete endoscopic evaluation of GERD symptoms includes inspection for erosive esophagitis (graded according to the Los Angeles classification when present), diaphragmatic hiatus (Hill grade of flap valve), axial hiatus hernia length, and inspection for Barrett's esophagus (graded according to the Prague classification and biopsied when present). BEST PRACTICE ADVICE 8: Clinicians should perform upfront objective reflux testing off medication (rather than an empiric PPI trial) in patients with isolated extra-esophageal symptoms and suspicion for reflux etiology. BEST PRACTICE ADVICE 9: In symptomatic patients with proven GERD, clinicians should consider ambulatory 24-hour pH-impedance monitoring on PPI as an option to determine the mechanism of persisting esophageal symptoms despite therapy (if adequate expertise exists for interpretation). BEST PRACTICE ADVICE 10: Clinicians should personalize adjunctive pharmacotherapy to the GERD phenotype, in contrast to empiric use of these agents. Adjunctive agents include alginate antacids for breakthrough symptoms, nighttime H2 receptor antagonists for nocturnal symptoms, baclofen for regurgitation or belch predominant symptoms, and prokinetics for coexistent gastroparesis. BEST PRACTICE ADVICE 11: Clinicians should provide pharmacologic neuromodulation, and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies in patients with functional heartburn or reflux disease associated with esophageal hypervigilance reflux hypersensitivity and/or behavioral disorders. BEST PRACTICE ADVICE 12: In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients. BEST PRACTICE ADVICE 13: In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients, whereas sleeve gastrectomy has potential to worsen GERD. BEST PRACTICE ADVICE 14: Candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, California
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri.
| | - John E Pandolfino
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Analatos A, Håkanson BS, Ansorge C, Lindblad M, Lundell L, Thorell A. Clinical Outcomes of a Laparoscopic Total vs a 270° Posterior Partial Fundoplication in Chronic Gastroesophageal Reflux Disease: A Randomized Clinical Trial. JAMA Surg 2022; 157:473-480. [PMID: 35442430 PMCID: PMC9021984 DOI: 10.1001/jamasurg.2022.0805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The efficacy of fundoplication operations in the management of gastroesophageal reflux disease (GERD) has been documented. However, few prospective, controlled series report long-term (>10 years) efficacy and postfundoplication concerns, particularly when comparing various types of fundoplication. Objective To compare long-term (>15 years) results regarding mechanical complications, reflux control, and quality of life between patients undergoing posterior partial fundoplication (PF) or total fundoplication (TF) (270° vs 360°) in surgical treatment for GERD. Design, Setting, and Participants A double-blind randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from November 19, 2001, to January 24, 2006. A total of 456 patients were recruited and randomized. Data for this analysis were collected from August 1, 2019, to January 31, 2021. Interventions Laparoscopic 270° posterior PF vs 360° TF. Main Outcomes and Measures The main outcome was dysphagia scores for solid and liquid food items after more than 15 years. Generic (36-Item Short-Form Health Survey) and disease-specific (Gastrointestinal Symptom Rating Scale) quality of life and proton pump inhibitor consumption were also assessed. Results Among 407 available patients, relevant data were obtained from 310 (response rate, 76%; mean [SD] age, 66 [11.2] years; 184 [59%] men). A total of 159 were allocated to a PF and 151 to a TF. The mean (SD) follow-up time was 16 (1.3) years. At 15 years after surgery, mean (SD) dysphagia scores were low for both liquids (PF, 1.2 [0.5]; TF, 1.2 [0.5]; P = .58) and solids (PF, 1.3 [0.6]; TF, 1.3 [0.5]; P = .97), without statistically significant differences between the groups. Reflux symptoms were equally well controlled by the 2 types of fundoplications as were the improvements of quality-of-life scores. Conclusions and Relevance The long-term findings of this randomized clinical trial indicate that PF and TF are equally effective for controlling GERD and quality of life in the long term. Although PF was superior in the first years after surgery in terms of less dysphagia recorded, this difference did not prevail when assessed a decade later. Trial Registration ClinicalTrials.gov Identifier: NCT04182178.
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Affiliation(s)
- Apostolos Analatos
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Nyköping Hospital, Nyköping, Sweden.,Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Bengt S Håkanson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery and Anaesthesiology, Ersta Hospital, Stockholm, Sweden
| | - Christoph Ansorge
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Nyköping Hospital, Nyköping, Sweden
| | - Mats Lindblad
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Anders Thorell
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
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Fuchs KH, Breithaupt W, Varga G, Babic B, Eckhoff J, Meining A. How effective is laparoscopic redo-antireflux surgery? Dis Esophagus 2022; 35:6490086. [PMID: 34969079 DOI: 10.1093/dote/doab091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The failure-rate after primary antireflux surgery ranges from 3 to 30%. Reasons for failures are multifactorial. The aim of this study is to gain insight into the complex reasons for, and management of, failure after antireflux surgery. METHODS Patients were selected for redo-surgery after a diagnostic workup consisting of history and physical examination, upper gastrointestinal endoscopy, quality-of-life assessment, screening for somatoform disorders, esophageal manometry, 24-hour-pH-impedance monitoring, and selective radiographic studies such as Barium-sandwich for esophageal passage and delayed gastric emptying. Perioperative and follow-up data were compiled between 2004 and 2017. RESULTS In total, 578 datasets were analyzed. The patient cohort undergoing a first redo-procedure (n = 401) consisted of 36 patients after in-house primary LF and 365 external referrals (mean age: 62.1 years [25-87]; mean BMI 26 [20-34]). The majority of patients underwent a repeated total or partial laparoscopic fundoplication. Major reasons for failure were migration and insufficient mobilization during the primary operation. With each increasing number of required redo-operations, the complexity of the redo-procedure itself increased, follow-up quality-of-life decreased (GIQLI: 106; 101; and 100), and complication rate increased (intraoperative: 6,4-10%; postoperative: 4,5-19%/first to third redo). After three redo-operations, resections were frequently necessary (morbidity: 42%). CONCLUSIONS Providing a careful patient selection, primary redo-antireflux procedures have proven to be highly successful. It is often the final chance for a satisfying result may be achieved upon performing a second redo-procedure. A third revision may solve critical problems, such as severe pain and/or inadequate nutritional intake. When resection is required, quality of life cannot be entirely normalized.
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Affiliation(s)
- K H Fuchs
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany
| | - W Breithaupt
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - G Varga
- AGAPLESION Markus Krankenhaus, Department of General and Visceral Surgery, Frankfurt, Germany
| | - B Babic
- University of Cologne, Department of General-, Visceral-and Cancer Surgery, Cologne, Germany
| | - J Eckhoff
- University of Cologne, Department of General-, Visceral-and Cancer Surgery, Cologne, Germany
| | - A Meining
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany.,University of Würzburg, Zentrum Innere Medizin, Head of Gastroenterology, Würzburg, Germany
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Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up. Surg Endosc 2022; 36:5627-5634. [PMID: 35076737 PMCID: PMC9283162 DOI: 10.1007/s00464-021-08969-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 12/17/2021] [Indexed: 11/27/2022]
Abstract
Aims Numerous reports have addressed the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). Long-term follow-up after direct comparison of these two minimally invasive approaches is scarce. The aim of the present study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomized ROLAF trial. Methods In the ROLAF trial 40 patients with GERD were randomized to RALF (n = 20) or CLF (n = 20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score. Results The GSRS score was similar for RALF (n = 15) and CLF (n = 15) at 12 years´ follow-up (2.1 ± 0.7 vs. 2.2 ± 1.3, p = 0.740). There was no difference in QOLRAD score (RALF 6.4 ± 1.2; CLF 6.4 ± 1.5, p = 0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF [46% (6/13) vs. 33% (4/12), p = 0.806]. Conclusion In accordance with previous short-term outcome studies, the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term. Registration number: DRKS00014690 (https://www.drks.de).
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Fuchs KH, Breithaupt W, Varga G, Babic B, Schulz T, Meining A. Primary laparoscopic fundoplication in selected patients with gastroesophageal reflux disease. Dis Esophagus 2022; 35:6277415. [PMID: 34002235 DOI: 10.1093/dote/doab032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite proton pump inhibitors being a powerful therapeutic tool, laparoscopic fundoplication (LF) has proven successful in the treatment of gastroesophageal reflux disease (GERD), through mechanical augmentation of a weak antireflux barrier and the advantages of minimally invasive access. A critical patient selection for LF, based on thorough preoperative assessment, is important for the management of GERD-patients. The purpose of this study is to provide an overview on the management of GERD-patients treated by primary LF in a specialized center and to illustrate the possible outcome after several years. METHODS Patients were selected after going through diagnostic workup consisting of patient's history and physical examination, upper gastrointestinal endoscopy, assessment of gastrointestinal Quality of Life Index, screening for somatoform disorders, functional assessment by esophageal manometry, (impedance)-24-hour-pH-monitoring, and selective radiographic studies. The indication for LF was based on EAES-guidelines. Either a floppy and short Nissen fundoplication was performed or a posterior Toupet-hemifundoplication was chosen. A long-term follow-up assessment was attempted after surgery. RESULTS In total, n = 1131 patients were evaluated (603 males; 528 females; mean age; 48.3 years; and mean body mass index: 27). The mean duration between onset of symptoms and surgery was 8 years. Nissen: n = 873, Toupet: n = 258; conversion rateerativ: 0.5%; morbidity 4%, mortality: 1 (1131). Mean follow-up (n = 898; 79%): 5.6 years; pre/post-op results: esophagitis: 66%/12.1%; Gastrointestinal Quality of Life Index: median: 92/119; daily proton pump inhibitors-intake after surgery: 8%; and operative revisions 4.3%. CONCLUSIONS In conclusion, our data show that careful patient selection for laparoscopic fundoplication and well-established technical concepts of mechanical sphincter augmentation can provide satisfying results in the majority of patients with severe GERD.
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Affiliation(s)
- K H Fuchs
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany
| | - W Breithaupt
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - G Varga
- AGAPLESION Markus Krankenhaus, Department of General and Visceral Surgery, Frankfurt, Germany
| | - B Babic
- University of Cologne, Department of General-, Visceral-and Cancer Surgery, Cologne, Germany
| | - T Schulz
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - A Meining
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany.,University of Würzburg, Zentrum Innere Medizin, Head of Gastroenterology, Würzburg, Germany
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Restoration for the foregut surgery: bridging gaps between foregut surgery practice and academia. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:175-179. [PMID: 35602858 PMCID: PMC8965975 DOI: 10.7602/jmis.2021.24.4.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/05/2021] [Accepted: 10/19/2021] [Indexed: 02/06/2023]
Abstract
Foregut surgery largely involves benign diseases, and not only malignant diseases. However, for foregut surgeons in Asia, this fact has not been extensively utilized in their clinical practice due to the high burden of gastric cancer surgery. Although the prevalence of gastroesophageal reflux disease (GERD) in Eastern Asia, including Korea, is increasing, antireflux surgery (ARS) is still a fairly rare procedure in Korea. ARS is effective as proton pump inhibitors and is cost-effective compared to continuous double-dose proton pump inhibitors in patients with severe GERD. Therefore, we should focus on ARS as a treatment option for GERD also in Asian population. Similarly, although bariatric/metabolic surgery is effective in weight reduction and diabetes mellitus (DM) remission in patients with morbid obesity or DM, bariatric/metabolic surgery is only performed in a limited number of patients. Given that the prevalence of obesity and DM is continuously increasing in Korea, bariatric/metabolic surgery should become an interest among Korean foregut surgeons and should be considered a treatment for obesity and DM. Furthermore, there are new surgical fields that can control both benign and malignant diseases. Oncometabolic surgery is a field under foregut surgery that treats both malignant and benign components of a condition, an example being the control of metabolic syndrome while performing gastric cancer surgery. Therefore, in future gastric cancer treatment, oncometabolic surgery can be applied to patients with gastric cancer accompanied by obesity or metabolic syndrome.
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Fuchs KH, Lee AM, Breithaupt W, Varga G, Babic B, Horgan S. Pathophysiology of gastroesophageal reflux disease-which factors are important? Transl Gastroenterol Hepatol 2021; 6:53. [PMID: 34805575 DOI: 10.21037/tgh.2020.02.12] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/10/2020] [Indexed: 12/16/2022] Open
Abstract
Background Pathophysiology of gastroesophageal reflux disease (GERD) shows a multifactorial background. Different anatomical and functional alterations can be determined such as weakness of the lower esophageal sphincter (LES), changes in anatomy by a hiatal hernia (HH), an impaired esophageal motility (IEM), and/or an associated gastric motility problem with either duodeno-gastro-esophageal reflux (DGER) or delayed gastric emptying (DGE). The purpose of this study is to assess a large GERD-patient population to quantitatively determine different pathophysiologic factors contributing to the disease. Methods For this analysis only patients with documented GERD (pathologic esophageal acid exposure) were selected from a prospectively maintained databank. Investigations: history and physical, body mass index, endoscopy, esophageal manometry, 24 h-pH-monitoring, 24 h-bilirbine-monitoring, radiographic-gastric-emptying or scintigraphy, gastrointestinal quality of life index (GIQLI). Results In total, 728 patients (420 males; 308 females) were selected for this analysis. Mean age: 49.9 years; mean BMI: 27.2 kg/m2 (range, 20-45 kg/m2); mean GIQLI of 91 (range: 43-138; normal level: 121); no esophagitis: 30.6%; minor esophagitis (Savary-Miller type 1 or Los Angeles Grade A): 22.4%; esophagitis [2-4]/B-D: 36.2%; Barrett's esophagus 10%. Presence of pathophysiologic factors: HH 95.4%; LES-incompetence 88%, DGER 55%, obesity 25.6%, IEM 8.8%, DGE 6.8%. Conclusions In our evaluation of GERD patients, the most important pathophysiologic components are anatomical alterations (HH), LES-incompetence and DGER.
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Affiliation(s)
- Karl-Hermann Fuchs
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Arielle M Lee
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Wolfram Breithaupt
- AGAPLESION Markus Krankenhaus, Klinik für Allgemeine und Viszeralchirurgie, Frankfurt am Main, Germany
| | - Gabor Varga
- AGAPLESION Markus Krankenhaus, Klinik für Allgemeine und Viszeralchirurgie, Frankfurt am Main, Germany
| | - Benjamin Babic
- Klinik und Poliklinik für Allgemeine-, Viszeral- und Tumorchirurgie, Universitätskliniken Köln, Cologne, Germany
| | - Santiago Horgan
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
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Rettura F, Bronzini F, Campigotto M, Lambiase C, Pancetti A, Berti G, Marchi S, de Bortoli N, Zerbib F, Savarino E, Bellini M. Refractory Gastroesophageal Reflux Disease: A Management Update. Front Med (Lausanne) 2021; 8:765061. [PMID: 34790683 PMCID: PMC8591082 DOI: 10.3389/fmed.2021.765061] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.
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Affiliation(s)
- Francesco Rettura
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Bronzini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michele Campigotto
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Christian Lambiase
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Andrea Pancetti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Ginevra Berti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Santino Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Singh A, Ford AM, McMichael J, Gabbard S. Role of Neuromodulators for the Management of Post-Gastric-Fundoplication Dyspepsia: A Retrospective Series. Cureus 2021; 13:e18343. [PMID: 34725600 PMCID: PMC8555753 DOI: 10.7759/cureus.18343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2021] [Indexed: 11/05/2022] Open
Abstract
Post-fundoplication dyspepsia is a common complication of gastric fundoplication surgeries. This can be attributable to the loss of fundal relaxation, decreased gastric accommodation, and/or alterations in gastric motility and sensitivity following fundoplication. The role of neuromodulators in the management of such symptoms is unknown. We retrospectively assessed the efficacy of neuromodulators such as tricyclic antidepressants, buspirone, and mirtazapine for the management of post-fundoplication dyspepsia.
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Affiliation(s)
- Achintya Singh
- Internal Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - Andrew M Ford
- Internal Medicine, Cleveland Clinic Foundation, Cleveland, USA
| | - John McMichael
- General Surgery, Cleveland Clinic Foundation, Cleveland, USA
| | - Scott Gabbard
- Gastroenterology, Cleveland Clinic Foundation, Cleveland, USA
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Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis. Ann Surg 2021; 274:78-85. [PMID: 33214483 DOI: 10.1097/sla.0000000000004639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF). SUMMARY OF BACKGROUND DATA Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair. METHODS A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%). CONCLUSIONS LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.
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Van Den Dop LM, De Smet GHJ, Mamound A, Lange J, Wijnhoven BPL, Hueting W. Use of Polypropylene Strips for Reinforcement of the Cruroplasty in Laparoscopic Paraesophageal Hernia Repair: A Retrospective Cohort Study. Dig Surg 2021; 38:290-299. [PMID: 34350869 DOI: 10.1159/000518182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/24/2021] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Laparoscopic paraesophageal hernia repair is an effective treatment for symptomatic paraesophageal hernias. To reduce recurrence rates, the use of prosthetics for the crural repair has been suggested. Mesh-related complications are rare but known to be disastrous. To address another form of crural repair, polypropylene strips are suggested. This study aimed to assess peri- and postoperative complications of reinforcement of cruroplasty with polypropylene strips. METHODS From 2013 to 2020, patients with a primary or recurrent type 2, 3, or 4 paraesophageal hernia that underwent cruroplasty with polypropylene strips were retrospectively reviewed. Intra- and postoperative complications were graded according to the Clavien-Dindo classification. The incidence of symptomatic recurrent hiatal hernia (CT or endoscopy proven) and hospital stay were assessed. RESULTS One hundred fifty-eight patients were included. Mean age was 65 years (standard deviation 10.4), and 119 patients were female (75.3%). Almost 50% of surgeries took place between 2018 and 2020. Median follow-up was 7 months (interquartile range 17.5). Mean operation time in the primary hernia group was 159 min (standard deviation 39.0), and length of stay was 4.4 days. In 3/158 patients (2.0%), intraoperative complications occurred. Two patients developed a grade 4 and seven patients a grade 3 postoperative complication. No mortality was recorded. Twelve recurrences (8.2%) were detected in the primary hernia group and one (9.1%) in the recurrent hernia group. CONCLUSION There were no mesh-related complications seen and symptomatic recurrence rate was low, but longer follow-up is needed.
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Affiliation(s)
| | - Gijs H J De Smet
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Aziz Mamound
- Department of Surgery, Alrijne Ziekenhuis, Leiderdop, The Netherlands
| | - Johan Lange
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Willem Hueting
- Department of Surgery, Alrijne Ziekenhuis, Leiderdop, The Netherlands
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38
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Giulini L, Razia D, Mittal SK. Redo fundoplication and early Roux-en-Y diversion for failed fundoplication: a 3-year single-center experience. Surg Endosc 2021; 36:3094-3099. [PMID: 34231073 DOI: 10.1007/s00464-021-08610-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Redo fundoplication (RF) and Roux-en-Y diversion (RNY) are both accepted surgical treatments after failed fundoplication. However, due to higher reported morbidity, RNY is more commonly performed only after several surgical failures. In our experience, RNY at an earlier point of the disease progression seems to be related with better outcomes. The aim of this study was to investigate this aspect by comparing the results between RF and RNY performed by a single surgeon over 3 years at our institution. METHODS A prospectively maintained database was reviewed to identify patients who underwent RF or RNY at our institution between 2016 and 2019 by a single surgeon (author SKM). Patients with previous bariatric surgery were excluded. RESULTS Of 43 patients, 28 underwent RF and 15 underwent RNY (mean body mass index 28.6 and 32.7 kg/m2, respectively, p = 0.01). The number of previous antireflux surgeries for the RF and RNY groups was 1 (82% vs 80%, p > 0.99), 2 (18% vs 7%, p = 0.4), and more than 2 (0% vs 13%, p = 0.1). RNY took longer than RF (median, 165 vs 137 min, p = 0.02), but both groups had a median estimated blood loss of 50 ml (p = 0.82). There was no difference in intraoperative complications (25% vs 20% for RF and RYN, respectively, p > 0.99). Postoperative complications were more common in the RF than in the RYN group (21% vs 7%, p = 0.39). Median hospital stay was 3 days for both groups (p = 0.78). At short-term follow-up, the mean quality of life score was similar for the RF and RYN groups (11.5 vs 12.2, p = 0.8). CONCLUSIONS RNY diversion, if performed by experienced hands and at an earlier point of disease progression, has comparable perioperative morbidity to RF and should be considered as a feasible and safe option for definitive treatment of failed antireflux surgery.
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Affiliation(s)
- Luca Giulini
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Deepika Razia
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Sumeet K Mittal
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, 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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39
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Paranyak M, Patel R, Grubnyk V, Grubnik V. Influence of Wrap Fixation Technique on the Results of Fundoplication. Surg Laparosc Endosc Percutan Tech 2021; 31:663-668. [PMID: 34183570 DOI: 10.1097/sle.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Different techniques of wrap fixation in laparoscopic Nissen fundoplication (LNF) have been proposed with of the aim to reduce the complications, but the optimal technique is yet to be determined. The aim of our prospective study was to evaluate several techniques of wrap fixation and determine whether the application of a combined approach to perform wrap fixation reduces the failure rate in short-term and long-term follow-up. MATERIALS AND METHODS One hundred two patients with sliding or paraesophageal hiatal hernia (type I or type II), who underwent antireflux surgery were randomized into 2 groups. In group I, LNF was supplemented with suturing the wrap to the diaphragmatic crura (35 patients) or to the body of stomach (16 patients). This was dependent on the strength of the crura (defined as weak or strong). The control group (51 patients) underwent LNF without wrap fixation. All patients were assessed using a validated symptom and quality of life (gastroesophageal reflux disease-Health Related Quality of Life) questionnaire, 24-hour impedance-pH monitoring, and barium swallow. RESULTS At the 48-month follow-up, the overall rate of complications was not significantly different between the 2 groups; however, there was a tendency toward a lower frequency of reoperations in the first group (P=0.059). Fixation of the fundoplication of wrap was noted to lead to significantly lower rates of postoperative dysphagia (P<0.05). These patients (group I) were also found to have significant improvement in gastroesophageal reflux disease-Health Related Quality of Life score (from 19.3±13.2 to 4.3±3.9 vs. from 18.7±11.9 to 9.3±7.7). CONCLUSION Fixation of the Nissen fundoplication wrap has been shown to have a positive impact on the reduction of postoperative dysphagia and leads to an improvement in disease-specific quality of life.
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Affiliation(s)
- Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv
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40
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Luppi F, Kalluri M, Faverio P, Kreuter M, Ferrara G. Idiopathic pulmonary fibrosis beyond the lung: understanding disease mechanisms to improve diagnosis and management. Respir Res 2021; 22:109. [PMID: 33865386 PMCID: PMC8052779 DOI: 10.1186/s12931-021-01711-1] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/11/2021] [Indexed: 02/07/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive disorder with an estimated median survival time of 3–5 years after diagnosis. This condition occurs primarily in elderly subjects, and epidemiological studies suggest that the main risk factors, ageing and exposure to cigarette smoke, are associated with both pulmonary and extrapulmonary comorbidities (defined as the occurrence of two or more disorders in a single individual). Ageing and senescence, through interactions with environmental factors, may contribute to the pathogenesis of IPF by various mechanisms, causing lung epithelium damage and increasing the resistance of myofibroblasts to apoptosis, eventually resulting in extracellular matrix accumulation and pulmonary fibrosis. As a paradigm, syndromes featuring short telomeres represent archetypal premature ageing syndromes and are often associated with pulmonary fibrosis. The pathophysiological features induced by ageing and senescence in patients with IPF may translate to pulmonary and extrapulmonary features, including emphysema, pulmonary hypertension, lung cancer, coronary artery disease, gastro-oesophageal reflux, diabetes mellitus and many other chronic diseases, which may lead to substantial negative consequences in terms of various outcome parameters in IPF. Therefore, the careful diagnosis and treatment of comorbidities may represent an outstanding chance to improve quality of life and survival, and it is necessary to contemplate all possible management options for IPF, including early identification and treatment of comorbidities.
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Affiliation(s)
- Fabrizio Luppi
- Respiratory Unit, University of Milano Bicocca, S. Gerardo Hospital, ASST Monza, Monza, Italy
| | - Meena Kalluri
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, 3-134 Clinical Sciences Building, 11304 83 Ave., Edmonton, AB, T6G 2G3, Canada
| | - Paola Faverio
- Respiratory Unit, University of Milano Bicocca, S. Gerardo Hospital, ASST Monza, Monza, Italy
| | - Michael Kreuter
- Centre for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, University of Heidelberg, German Center for Lung Research, ThoraxklinikHeidelberg, Germany
| | - Giovanni Ferrara
- Sensory Motor Adaptive Rehabilitation Technology (SMART) Network, University of Alberta, Edmonton, AB, Canada. .,Division of Pulmonary Medicine, Department of Medicine, University of Alberta, 3-134 Clinical Sciences Building, 11304 83 Ave., Edmonton, AB, T6G 2G3, Canada.
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Surgical treatment of recalcitrant gastroesophageal reflux disease in patients with systemic sclerosis: a systematic review. Langenbecks Arch Surg 2021; 406:1353-1361. [PMID: 33611653 PMCID: PMC8370958 DOI: 10.1007/s00423-021-02118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/03/2021] [Indexed: 12/16/2022]
Abstract
Introduction Gastroesophageal reflux disease (GERD) is frequently seen in patients with systemic sclerosis (SSc). Long-standing GERD may cause esophagitis, long-segment strictures, and Barrett’s esophagus and may worsen pre-existing pulmonary fibrosis with an increased risk of end-stage lung disease. Surgical treatment of recalcitrant GERD remains controversial. The purpose of this systematic review was to summarize the current data on surgical treatment of recalcitrant GERD in SSc patients. Materials and methods A systematic literature review according to PRISMA and MOOSE guidelines. PubMed, EMBASE, and Web of Science databases were consulted. Results A total of 101 patients were included from 7 studies. The age ranged from 34 to 61 years and the majority were females (73.5%). Commonly reported symptoms were heartburn (92%), regurgitation (77%), and dysphagia (74%). Concurrent pulmonary disease was diagnosed in 58% of patients. Overall, 63 patients (62.4%) underwent open fundoplication, 17 (16.8%) laparoscopic fundoplication, 15 (14.9%) Roux en-Y gastric bypass (RYGB), and 6 (5.9%) esophagectomy. The postoperative follow-up ranged from 12 to 65 months. Recurrent symptoms were described in up to 70% and 30% of patients undergoing fundoplication and RYGB, respectively. Various symptoms were reported postoperatively depending on the type of surgical procedures, anatomy of the valve, need for esophageal lengthening, and follow-up. Conclusions The treatment of recalcitrant GERD in SSc patients is challenging. Esophagectomy should be reserved to selected patients. Minimally invasive RYGB appears feasible and safe with promising preliminary short-term results. Current evidence is scarce while a definitive indication about the most appropriate surgical treatment is lacking. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02118-8.
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Gefen R, Marom G, Brodie R, Elazary R, Mintz Y. Complete vs partial fundoplication: a laboratory measurement of functionality and effectiveness. MINIM INVASIV THER 2021; 31:635-641. [PMID: 33529074 DOI: 10.1080/13645706.2021.1878538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Complete or partial fundoplication remains controversial for the surgical treatment of GERD. While partial fundoplication is considered less effective, it is associated with less post-operative dysphagia and gas bloating compared with complete fundoplication. AIM To compare the mechanical efficiency of the three different types of fundoplication. MATERIAL AND METHOD Two studies of the LES were performed on explanted stomachs: distensibility and failure point. Measurements were taken before and after fundoplication. RESULTS There was no difference in distensibility between Nissen and Toupet fundoplication, however, the EGJ was more distensible following Dor fundoplication. According to failure point measurements, Nissen fundoplication was significantly more effective than Toupet, Toupet was significantly more effective than Dor (p = .016, p = .017, respectively). CONCLUSIONS There were significant differences in distensibility between Dor and both Nissen and Toupet, however no statistical difference between Toupet and Nissen. There was a significant difference in effectiveness between all three types of fundoplication according to the failure point. These laboratory findings demonstrate that the mechanical orientation of Nissen and Toupet have similar functionality suggesting that Toupet is as good as Nissen. While in clinical studies Toupet has fewer post-operative complications these findings support the proponents of Toupet for GERD. Abbreviation: GERD: Gastroesophageal reflux disease.
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Affiliation(s)
- Rachel Gefen
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Gad Marom
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Israel
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Martins BC, Souza CS, Ruas JN, Furuya CK, Fylyk SN, Sakai CM, Ide E. ENDOSCOPIC EVALUATION OF POST-FUNDOPLICATION ANATOMY AND CORRELATION WITH SYMPTOMATOLOGY. ACTA ACUST UNITED AC 2021; 33:e1543. [PMID: 33470373 PMCID: PMC7812682 DOI: 10.1590/0102-672020200003e1543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/12/2020] [Indexed: 02/08/2023]
Abstract
Background:
Upper digestive endoscopy is important for the evaluation of patients
submitted to fundoplication, especially to elucidate postoperative symptoms.
However, endoscopic assessment of fundoplication anatomy and its
complications is poorly standardized among endoscopists, which leads to
inadequate agreement.
Aim:
To assess the frequency of postoperative abnormalities of fundoplication
anatomy using a modified endoscopic classification and to correlate
endoscopic findings with clinical symptoms.
Method:
This is a prospective observational study, conducted at a single center.
Patients were submitted to a questionnaire for data collection. Endoscopic
assessment of fundoplication was performed according to the classification
in study, which considered four anatomical parameters including the
gastroesophageal junction position in frontal view (above or at the level of
the pressure zone); valve position at retroflex view (intra-abdominal or
migrated); valve conformation (total, partial, disrupted or twisted) and
paraesophageal hernia (present or absent).
Results:
One hundred patients submitted to fundoplication were evaluated, 51% male
(mean age: 55.6 years). Forty-three percent reported postoperative symptoms.
Endoscopic abnormalities of fundoplication anatomy were reported in 46% of
patients. Gastroesophageal junction above the pressure zone (slipped
fundoplication), and migrated fundoplication, were significantly correlated
with the occurrence of postoperative symptoms. There was no correlation
between symptoms and conformation of the fundoplication (total, partial or
twisted).
Conclusion:
This modified endoscopic classification proposal of fundoplication anatomy is
reproducible and seems to correlate with symptomatology. The most frequent
abnormalities observed were slipped and migrated fundoplication, and both
correlated with the presence of symptoms.
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Affiliation(s)
| | | | | | | | | | | | - Edson Ide
- Endoscopy Unit, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil
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44
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Five-Year Outcome of Laparoscopic Fundoplication in Pediatric GERD Patients: a Multicenter, Prospective Cohort Study. J Gastrointest Surg 2021; 25:1412-1418. [PMID: 32700100 PMCID: PMC8203546 DOI: 10.1007/s11605-020-04713-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/22/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a common disease in children. When drug treatment fails, laparoscopic anti-reflux surgery (LARS) is considered. Short-term follow-up studies report high success rates; however, few studies report long-term results. The aim of this study was to describe the long-term effects of LARS in pediatric patients. METHODS A prospective, multicenter study of 25 laparoscopic fundoplication patients was performed. At 3 months and 1, 2, and 5 years postoperatively, patients and caregivers were asked to complete the gastroesophageal reflux symptom questionnaire to assess symptoms and the PedsQL™ to assess health-related quality of life (HRQoL). RESULTS Reflux symptom severity was still significantly improved 5 years after LARS compared with preoperative levels (p < 0.0001). However, 26% of patients reported moderate or severe reflux symptoms. Dysphagia was reported in 13% of patients 5 years after LARS and was more common in children with neurologic impairment and children who underwent a Nissen procedure. The increase in HRQoL 3 months postoperatively appears to decline over time: 5 years after surgery, HRQoL was lower, though not significantly, than 3 months postoperatively. HRQoL at 5 years was still higher, though also not significantly, than preoperative levels. The presence of reflux symptoms after surgery was not significantly associated with lower HRQoL. CONCLUSIONS LARS is effective for therapy-resistant GERD in children. Five years after surgery, reflux symptoms are still improved. However, we observed a decline in symptom-free patients over time. The initial increase in HRQoL shortly after LARS appears to decline over time. TRIAL REGISTRATION Dutch national trial registry Identifier: 2934 ( www.trialregister.nl ).
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45
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Konstantinidou SK, Kostaras P, Anagnostopoulos GE, Markantonis SL, Karalis V, Konstantinidis K. A retrospective study on the evaluation of the symptoms, medications and improvement of the quality of life of patients undergoing robotic surgery for gastroesophageal reflux disease. Exp Ther Med 2020; 21:174. [PMID: 33456541 PMCID: PMC7792496 DOI: 10.3892/etm.2020.9605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/10/2020] [Indexed: 11/22/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder requiring lifestyle adaptations and administration of medications. Another approach is the surgical treatment of GERD through laparoscopic or robotic operations. The aim of the present study was to investigate the improvement of symptoms and quality of life of patients with GERD, before and after robotic surgical restoration using the Nissen robotic fundoplication technique. The potential effects of body weight, age and sex, as well as the response to medications and progress over time, were also assessed. A retrospective study was conducted in a tertiary hospital between October 2019 and March 2020. Data were collected and recorded from 144 patients who underwent robotic surgery, using the Nissen fundoplication technique, during the period 2009-2019. All patients involved in this analysis pre-operatively exhibited severe symptoms of heartburn and reflux, as well as poor quality of life. All of these symptoms were re-examined after surgery, and a marked decrease was observed with respect to their frequency and intensity. Improvement was not affected by body mass index, whereas older patients exhibited greater improvement. Women initially experienced more severe symptoms before the surgery, but they appeared to respond as well as the male patients. The long-term beneficial effects of surgery for up to the 10-year period studied were validated. After the robotic surgical rehabilitation, the vast majority of patients overcame the unpleasant symptoms of GERD and stayed off their medications. More than 4/5 of the patients were satisfied after surgery. In conclusion, restoration of GERD, using Nissen robotic fundoplication, led to the minimization of symptoms and to a marked improvement in the quality of life of patients.
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Affiliation(s)
| | - Penelope Kostaras
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece
| | | | - Sophia-Liberty Markantonis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece
| | - Vangelis Karalis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece
| | - Konstantinos Konstantinidis
- Department of General, Laparoscopic, Robotic and Bariatric Surgery, Athens Medical Center, 15125 Athens, Greece
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46
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Huynh P, Konda V, Sanguansataya S, Ward MA, Leeds SG. Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication. Surg Laparosc Endosc Percutan Tech 2020; 31:264-276. [PMID: 33347088 PMCID: PMC8154178 DOI: 10.1097/sle.0000000000000888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation. MATERIALS AND METHODS A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control. RESULTS Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH. CONCLUSIONS Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.
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Affiliation(s)
- Phuong Huynh
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
| | - Vani Konda
- Center for Esophageal Diseases, Baylor University Medical Center, Dallas
| | | | - Marc A. Ward
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
| | - Steven G. Leeds
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
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47
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Banting SP, Badgery HE, Read M, Mashimo H. Rethinking gastroesophageal reflux disorder. Ann N Y Acad Sci 2020; 1482:177-192. [PMID: 32875572 DOI: 10.1111/nyas.14478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/28/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a common clinical condition for which our understanding has evolved over the past decades. It is now considered a cluster of phenotypes with numerous anatomical and physiological abnormalities contributing to its pathophysiology. As such, it is important to first understand the underlying mechanism of the disease process for each patient before embarking on therapeutic interventions. The aim of our paper is to highlight the mechanisms contributing to GERD and review investigations and interpretation of these results. Finally, the paper reviews the available treatment modalities for this condition, ranging from medical intervention, endoscopic options through to surgery and its various techniques.
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Affiliation(s)
- Samuel P Banting
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Henry E Badgery
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Matthew Read
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, the University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Hiroshi Mashimo
- Department of Medicine, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
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48
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Shao JM, Elhage SA, Prasad T, Gersin K, Augenstein VA, Colavita PD, Heniford BT. Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion? Surg Endosc 2020; 35:3865-3873. [PMID: 32676728 DOI: 10.1007/s00464-020-07800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution. METHODS A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed. RESULTS 180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m2 (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m2 and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001). CONCLUSIONS RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.
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Affiliation(s)
- Jenny M Shao
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sharbel A Elhage
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Tanu Prasad
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Keith Gersin
- Atrium Health Weight Management, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
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49
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Postoperative Gastrointestinal Complaints After Laparoscopic Nissen Fundoplication. Surg Laparosc Endosc Percutan Tech 2020; 31:8-13. [PMID: 32649341 DOI: 10.1097/sle.0000000000000820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE To investigate the postoperative gastrointestinal complaints and their effects on the satisfaction level of patients after laparoscopic Nissen fundoplication (LNF). MATERIALS AND METHODS Over a 7-year period, 553 patients who underwent "floppy" LNF were evaluated for preoperative and postoperative complaints. For this purpose, a set of questions derived from gastroesophageal reflux disease-health-related quality-of-life questionnaire (GERD-HRQL) was used. A P-value of <0.05 was considered to show a statistically significant result. RESULTS The present study included 215 patients with a mean follow-up of 60 months. Reflux-related symptoms [regurgitation (17.7%), heartburn (17.2%), and vomiting (3.7%)] and nonspecific symptoms [bloating (50.2%), abdominal pain (15.3%), and belching (27%)] showed a significant decrease (P<0.001) after the surgery. Inability to belch (25.1%) and early satiety (29.3%) were the newly emerged symptoms. The percentage of patients with flatulence increased from 23.3% to 38.1% after LNF. There was no significant difference for dysphagia (25.6%) and diarrhea (15.3%) in the postoperative period. Of the patients, 15.3% had recurrent preoperative complaints and 9.8% were using drugs for that condition. Satisfaction level and preference for surgery were 82.8% and 91.6%, respectively. There was no significant difference in GERD-HRQL score according to body mass index. CONCLUSIONS This is the first study in which postoperative reflux-related and nonspecific gastrointestinal complaints are analyzed together for a long follow-up period. We found a significant decrease in many reflux-related and nonspecific symptoms. Although some disturbing complaints like inability to belch, early satiety, and flatulence emerged, the preference for surgery did not change.
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50
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Paroxysmal Laryngospasm: A Rare Condition That Respiratory Physicians Must Distinguish from Other Diseases with a Chief Complaint of Dyspnea. Can Respir J 2020; 2020:2451703. [PMID: 32695244 PMCID: PMC7361892 DOI: 10.1155/2020/2451703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/19/2020] [Accepted: 06/10/2020] [Indexed: 12/21/2022] Open
Abstract
Background In recent years, we have observed respiratory difficulty manifested as paroxysmal laryngospasm in a few outpatients, most of whom were first encountered in a respiratory clinic. We therefore explored how to identify and address paroxysmal laryngospasm from the perspective of respiratory physicians. Methods The symptoms, characteristics, auxiliary examination results, treatment, and prognosis of 12 patients with paroxysmal laryngospasm treated in our hospital from June 2017 to October 2019 were analyzed. Results Five males (42%) and 7 females (58%) were among the 12 Han patients sampled. The average age of the patients was 49.25 ± 13.02 years. The disease course ranged from 14 days to 8 years and was characterized by sudden dyspnea, an inability to inhale and exhale, a sense of asphyxia, and voice loss during an attack. Eight patients with gastroesophageal reflux were cured after antacid treatment. One case of upper respiratory tract infection (URI) was completely relieved after symptomatic treatment. One patient with left vocal cord paralysis experienced complete relief after specialist treatment by an otorhinolaryngologist. Episodes in 1 patient were significantly reduced after lifestyle improvement. One patient experienced spontaneous relief after rejecting treatment. Conclusions Paroxysmal laryngospasm is a rare laryngeal disease that generally occurs secondary to gastroesophageal reflux disease (GERD), and antireflux therapy is frequently effective for its treatment. A respiratory physician should master and identify the symptoms and differentiate this condition from hysterical stridor, reflux-related laryngospasm, and asthma. Timely referral to otolaryngologists, gastroenterologists, and other specialists for standardized examination and regular treatment should be provided when necessary.
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