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Walker R, Currie A, Wiggins T, Markar SR, Blencowe NS, Underwood T, Hollyman M. Results of the ARROW survey of anti-reflux practice in the United Kingdom. Dis Esophagus 2023; 36:doad021. [PMID: 37019630 PMCID: PMC10543366 DOI: 10.1093/dote/doad021] [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] [Received: 07/25/2022] [Revised: 02/14/2023] [Indexed: 04/07/2023]
Abstract
Gastro-esophageal reflux disease (GERD) is a common, significant health burden. United Kingdom guidance states that surgery should be considered for patients with a diagnosis of GERD not suitable for long-term acid suppression. There is no consensus on many aspects of patient pathways and optimal surgical technique, and an absence of information on how patients are currently selected for surgery. Further detail on the delivery of anti-reflux surgery (ARS) is required. A United Kingdom-wide survey was designed to gather surgeon opinion regarding pre-, peri- and post-operative practice of ARS. Responses were received from 155 surgeons at 57 institutions. Most agreed that endoscopy (99%), 24-hour pH monitoring (83%) and esophageal manometry (83%) were essential investigations prior to surgery. Of 57 units, 30 (53%) had access to a multidisciplinary team to discuss cases; case-loads were higher in those units (median 50 vs. 30, P < 0.024). The most popular form of fundoplication was a Nissen posterior 360° (75% of surgeons), followed by a posterior 270° Toupet (48%). Only seven surgeons stated they had no upper limit of body mass index prior to surgery. A total of 46% of respondents maintain a database of their practice and less than a fifth routinely record quality of life scores before (19%) or after (14%) surgery. While there are areas of consensus, a lack of evidence to support workup, intervention and outcome evaluation is reflected in the variability of practice. ARS patients are not receiving the same level of evidence-based care as other patient groups.
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Affiliation(s)
| | - Robert Walker
- Guys and St Thomas’ Oesophago-Gastric Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
| | - Andrew Currie
- Service de Chirurgie Digestive A Pôle Digestif, CHU de Montpellier, Montpellier, France
| | - Tom Wiggins
- Department of Bariatric Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Sheraz R Markar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Natalie S Blencowe
- Population Health Sciences, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tim Underwood
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
| | - Marianne Hollyman
- Upper Gastrointestinal Surgery Department, Musgrove Park Hospital, Taunton, UK
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2
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Rausa E, Ferrari D, Kelly ME, Aiolfi A, Vitellaro M, Rottoli M, Bonitta G, Bona D. Efficacy of laparoscopic Toupet fundoplication compared to endoscopic and surgical procedures for GERD treatment: a randomized trials network meta-analysis. Langenbecks Arch Surg 2023; 408:52. [PMID: 36680602 DOI: 10.1007/s00423-023-02774-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/27/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE We aim to review and quantitatively compare laparoscopic Toupet fundoplication (LTF), Nissen fundoplication (LNF), anterior partial fundoplication (APF), magnetic augmentation sphincter (MSA), radiofrequency ablation (RFA), transoral incisionless fundoplication (TIF), proton pump inhibitor (PPI), and placebo for the treatment of GERD. A number of meta-analyses compared the efficacy of surgical and endoscopic procedures for recalcitrant GERD, but considerable debate on the effectiveness of operative strategies remains. METHODS A systematic review of MEDLINE databases, EMBASE, and Web of Science for randomized controlled trials (RCTs) comparing the aforementioned surgical and endoscopic GERD treatments was performed. Risk ratio and weighted mean difference were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to assess relative inference. RESULTS Thirty-three RCTs were included. Surgical and endoscopic treatments have similar RR for heartburn, regurgitation, bloating. LTF has a lower RR of post-operative dysphagia when compared to APF (RR 3.3; Crl 1.4-7.1) and LNF (RR 2.5; Crl 1.3-4.4). The pooled network meta-analysis did not observe any significant improvement regarding LES pressure and pH < from baseline. LTF, APF, LNF, MSA, RFA, and TIF had have a similar post-operative PPI discontinuation rate. CONCLUSION LTF has a lower rate of post-operative dysphagia when compared to APF and LNF. The pre-post effects, such as GERD-HQRL, LES pressure, and pH <4, should be avoided in meta-analyses because results may be biased. Last, a consensus about the evaluation of GERD treatments' efficacy and their outcomes is needed.
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Affiliation(s)
- E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - D Ferrari
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M E Kelly
- Department of Surgery, St. James Hospital, School of Medicine-Trinity College Dublin, Dublin, Ireland
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Marco Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - G Bonitta
- General Surgery, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - D Bona
- General Surgery, Istituto Clinico Sant'Ambrogio, Milano, Italy
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Cheng F, Liang H, Zhang Y, Zeng H, Gao X, Tan L, He H. Tension-free hiatal hernia repair with biological mesh: A real-world experience. Medicine (Baltimore) 2022; 101:e31782. [PMID: 36397386 PMCID: PMC9666108 DOI: 10.1097/md.0000000000031782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Laparoscopic Nissen fundoplication and esophagoplasty are the standards for gastroesophageal reflux disease (GERD) and hiatal hernia (HH) repair. Biologically derived mesh is also associated with reduced recurrence. This study attempted to evaluate the effectiveness of a biological mesh in the 4K laparoscopic repair of HH. This retrospective study reviewed patients with a severe GERD complicated with HH from August 2019 to August 2020. All patients underwent the HH repair using a biological mesh under a 4K laparoscope accompanying Nissen fundoplication. Up to 16 months postoperatively, GERD-health-related quality-of-life (GERD-HRQL) scale, radiologic studies on HH recurrence, and symptoms were recorded. The mean surgical time and postoperative hospital stay were 70.9 ± 8.72 min, 4.8 ± 0.76 days, respectively. The postoperative symptom relief rate was 96.5%, and no recurrence exhibited during follow-up. Dysphagia occurred in 10 (9.43%) patients. There were no intraoperative vagus nerve injury or postoperative complications, mesh infection, and reoperation for mesh. The tension-free repair of HH with the biological mesh is an option for clinical use, with effectiveness and few short-term complications being reported.
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Affiliation(s)
- Fahui Cheng
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Hongyan Liang
- The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Yu Zhang
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Hui Zeng
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Xiao Gao
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Lipeng Tan
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Hengzheng He
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
- * Correspondence: Hengzheng He, Department of Mini-invastsurgery, Brain Hospital of Hunan Province, 427, third segment, Furong Zhong Road, Changsha, Hunan 410007, China (e-mail: )
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Markar S, Andreou A, Bonavina L, Florez ID, Huo B, Kontouli K, Low DE, Mavridis D, Maynard N, Moss A, Pera M, Savarino E, Siersema P, Sifrim D, Watson DI, Zaninotto G, Antoniou SA. UEG and EAES rapid guideline: Update systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on surgical management of GERD. United European Gastroenterol J 2022; 10:983-998. [PMID: 36196591 PMCID: PMC9731663 DOI: 10.1002/ueg2.12318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/17/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There are several options for the surgical management of GERD in adults. Previous guidelines and systematic reviews have compared the effects of total fundoplication versus pooled effects of different techniques of partial fundoplication. OBJECTIVE To develop evidence-informed, trustworthy, pertinent recommendations on the use of total, posterior partial and anterior partial fundoplications for the management of GERD in adults. METHODS We performed an update systematic review, network meta-analysis, and evidence appraisal using the GRADE and the Confidence in Network Meta-Analysis methodologies. An international, multidisciplinary panel of surgeons, gastroenterologists, and a patient representative reached unanimous consensus through an evidence-to-decision framework to select among multiple interventions, and a Delphi process to formulate the recommendation. The project was developed in an online authoring and publication platform (MAGICapp), and was overseen by an external auditor. RESULTS We suggest posterior partial fundoplication over total posterior or anterior 90° fundoplication in adult patients with GERD. We suggest anterior >90° fundoplication as an alternative, although relevant comparative evidence is limited (weak recommendation). The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/j20X4n. CONCLUSION This rapid guideline was developed in line with highest methodological standards and provides evidence-informed recommendations on the surgical management of GERD. It provides user-friendly decision aids to inform healthcare professionals' and patients' decision making.
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Affiliation(s)
- Sheraz Markar
- Nuffield Department of SurgeryUniversity of OxfordOxfordUK
- Department of Molecular Medicine and SurgeryKarolinska InstituteStockholmSweden
| | | | - Luigi Bonavina
- Department of Biomedical Sciences for HealthDivision of General and Foregut SurgeryIRCCS Policlinico San DonatoUniversity of MilanMilanItaly
| | - Ivan D. Florez
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Department of PediatricsUniversity of AntioquiaMedellinColombia
| | - Bright Huo
- Faculty of MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | | | - Donald E. Low
- Department of Thoracic Surgery and Surgical OncologyVirginia Mason Medical CenterSeattleWashingtonUSA
| | - Dimitris Mavridis
- Department of Primary EducationSchool of Education University of IoanninaIoanninaGreece
- Paris Descartes UniversitySorbonne Paris CitéFaculté de MédecineParisFrance
| | - Nick Maynard
- Nuffield Department of SurgeryUniversity of OxfordOxfordUK
| | | | - Manuel Pera
- Gastroesophageal Carcinogenesis Research GroupHospital del Mar Medical Research Institute (IMIM)BarcelonaSpain
- Section of Gastrointestinal SurgeryHospital Universitario del MarUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Edoardo Savarino
- Department of Surgery, Oncology and GastroenterologyGastroenterology UnitUniversity of PaduaPaduaItaly
| | - Peter Siersema
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Daniel Sifrim
- Wingate Institute of NeurogastroenterologyBlizard InstituteBarts and The London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - David I. Watson
- Flinders University Discipline of SurgeryFlinders Medical CentreBedford ParkSouth AustraliaAustralia
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Walker R, Wiggins T, Blencowe NS, Findlay JM, Wilson M, Currie AC, Hornby S, Markar SR, Rahman S, Lloyd M, Hollyman M, Jaunoo S. A multicenter prospective audit to investigate the current management of patients undergoing anti-reflux surgery in the UK: Audit & Review of Anti-Reflux Operations & Workup. Dis Esophagus 2021; 34:doaa129. [PMID: 33458741 PMCID: PMC8522793 DOI: 10.1093/dote/doaa129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/16/2020] [Accepted: 11/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are a variety of surgical and endoscopic interventions available to treat gastroesophageal reflux disease. There is, however, no consensus on which approach is best.The aim of this national audit is to describe the current variation in the UK clinical practice in relation to anti-reflux surgery (ARS) and to report adherence to available clinical guidelines. METHODS This national audit will be conducted at centers across the UK using the secure online web platform ALEA. The study will comprise two parts: a registration questionnaire and a prospective multicenter audit of ARS. All participating centers will be required to complete the registration questionnaire comprising details regarding pre-, peri-, and post-operative care pathways and whether or not these are standardized within each center. Following this, a 12-month multicenter prospective audit will be undertaken to capture data including patient demographics, predominant symptoms, preoperative investigations, surgery indication, intraoperative details, and postoperative outcomes within the first 90 days.Local teams will retain access to their own data to facilitate local quality improvement. The full dataset will be reported at national and international scientific congresses and will contribute to peer-reviewed publications and national quality improvement initiatives. CONCLUSIONS This study will identify and explore variation in the processes and outcomes following ARS within the UK using a collaborative cohort methodology. The results generated by this audit will facilitate local and national quality improvement initiatives and generate new possibilities for future research in anti-reflux interventions.
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Affiliation(s)
| | - Rob Walker
- Cancer Sciences, University of Southampton, Southampton,
UK
| | - Tom Wiggins
- Cancer Sciences, University of Southampton, Southampton,
UK
| | | | - John M Findlay
- Cancer Sciences, University of Southampton, Southampton,
UK
| | - Michael Wilson
- Cancer Sciences, University of Southampton, Southampton,
UK
| | | | - Steve Hornby
- Cancer Sciences, University of Southampton, Southampton,
UK
| | | | - Saqib Rahman
- Cancer Sciences, University of Southampton, Southampton,
UK
| | - Megan Lloyd
- Cancer Sciences, University of Southampton, Southampton,
UK
| | | | - Shameen Jaunoo
- Cancer Sciences, University of Southampton, Southampton,
UK
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6
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Ishii D, Miyamoto K, Hirasawa M, Miyagi H. Preferential performance of Thal fundoplication for gastroesophageal reflux disease: a single institution experience. Pediatr Surg Int 2021; 37:191-196. [PMID: 33388959 PMCID: PMC7847459 DOI: 10.1007/s00383-020-04804-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Nissen fundoplication (NF) is the most commonly used surgical treatment for persistent gastroesophageal reflux disease (GERD). We introduced to the alternative Thal fundoplication (TF) (partial anterior wrapping) in 1998. The purpose of this paper is to review and report on the effectiveness of TF in our department. METHODS We retrospectively analyzed cases of 281 patients who underwent TF for GERD at our hospital from 1998 to 2019. RESULTS Average age, 16.3 ± 18.1 years; average body weight, 21.0 ± 16.0 kg; average operative time, 89.1 ± 43.0 min; average volume of bleeding, 11.6 ± 29.2 g; enteral feeding commenced after an average of 3.4 ± 1.3 postoperative days (PODs), and average postoperative full enteral feeding was 6.3 ± 1.4 PODs. Five patients (1.8%) had Clavien-Dindo classification III or higher; average hospital stay duration was 10.3 ± 6.0 days, with symptom recurrence affecting 17 patients (6.1%). CONCLUSION TF may be an effective and simple treatment for GERD that has few recurrences and avoids complications common to NF, but further studies to compare it with other techniques are needed.
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Affiliation(s)
- Daisuke Ishii
- Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaoka-Higashi, Asahikawashi, Hokkaido 078-8510 Japan
| | - Kazutoshi Miyamoto
- Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaoka-Higashi, Asahikawashi, Hokkaido 078-8510 Japan
| | - Masatoshi Hirasawa
- Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaoka-Higashi, Asahikawashi, Hokkaido 078-8510 Japan
| | - Hisayuki Miyagi
- Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaoka-Higashi, Asahikawashi, Hokkaido 078-8510 Japan
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7
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Laryngeal and Pharyngeal Squamous Cell Carcinoma After Antireflux Surgery in the 5 Nordic Countries. Ann Surg 2020; 276:e79-e85. [DOI: 10.1097/sla.0000000000004423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Doubova M, Gowing S, Robaidi H, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely AJE. Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia. Ann Thorac Surg 2020; 111:1717-1723. [PMID: 32891651 DOI: 10.1016/j.athoracsur.2020.06.095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 06/03/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood. METHODS Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation. RESULTS As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001). CONCLUSIONS These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.
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Affiliation(s)
- Maria Doubova
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Gowing
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Hassan Robaidi
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Farid M Shamji
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - R Sudhir Sundaresan
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick James Villeneuve
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew J E Seely
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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Håkanson BS, Lundell L, Bylund A, Thorell A. Comparison of Laparoscopic 270° Posterior Partial Fundoplication vs Total Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Randomized Clinical Trial. JAMA Surg 2020; 154:479-486. [PMID: 30840057 DOI: 10.1001/jamasurg.2019.0047] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance Restoration of the esophagogastric junction competence is critical for effective long-term treatment of gastroesophageal reflux disease. Surgical repair results in such restoration, but mechanical adverse effects seem unavoidable. Minimizing these adverse effects without jeopardizing reflux control is warranted. Objective To determine whether partial fundoplication (PF) or total fundoplication (TF) is superior in laparoscopic antireflux surgery. Design, Setting, and Participants In this double-blind, randomized clinical trial of 1171 patients scheduled for laparoscopic antireflux surgery at a single university-affiliated center between November 19, 2001, and January 24, 2006, 456 patients were randomized and followed up for 5 years. Data were collected from November 2001 to April 2012, and data were analyzed from April 2012 to September 2018. Interventions A 270° posterior PF or a 360° Nissen TF. Main Outcomes and Measures Esophageal acid exposure at 3 years after surgery. Result Of the 456 randomized patients, 268 (58.8%) were male, and the mean (SD) age was 49.0 (11.7) years. A total of 229 patients were randomized to PF, and 227 patients were randomized to TF. At 3 years postoperatively, the median (interquartile range) esophageal acid exposure was reduced from 14.6% (9.8-21.9) to 1.8% (0.7-4.4) after PF and from 16.0% (10.4-22.7) to 2.5% (0.8-6.8) after TF (P = .31). Likewise, reflux symptoms were equally and effectively controlled. Early postoperative dysphagia (6 weeks) was common in both groups but then decreased toward normality. A small but statistically significant difference in favor of PF was noted in the mean (SD) scoring of dysphagia for liquids at 6 weeks (PF, 1.6 [0.9]; TF, 1.9 [1.3]; P = .01) and for solid food at 12 months (PF, 1.3 [1.0]; TF, 1.9 [1.4]; P < .001) and 24 months (PF, 1.3 [0.9]; TF, 1.7 [1.2]; P = .001). Quality of life was reduced before surgery but increased to normal values after surgery and remained so over 5-year follow-up, with no difference between the groups. Conclusions and Relevance The results from this randomized clinical trial suggest that although PF and TF could be recommended for treatment of gastroesophageal reflux disease, PF might be superior by inducing less dysphagia. Trial Registration ClinicalTrials.gov identifier: NCT03659487.
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Affiliation(s)
- Bengt S Håkanson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Lars Lundell
- Department of Clinical Sciences, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Ami Bylund
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
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10
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Andreou A, Watson DI, Mavridis D, Francis NK, Antoniou SA. Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis. Surg Endosc 2020; 34:510-520. [PMID: 31628621 DOI: 10.1007/s00464-019-07208-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 10/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease. METHODS Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease. RESULTS Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270°, 360°, anterior 180° and anterior 90°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 270° (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180°, and anterior 90° were equally effective as 360° for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270° (OR 0.38, 95%, CI 0.24-0.60), anterior 90° (moderate quality evidence), and anterior 180° (low-quality evidence) compared to 360°. The odds for gas-bloat were lower after 270° (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90° compared to 360° (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence. CONCLUSION Laparoscopic 270° fundoplication achieves a better outcome than 360° total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective. REGISTRATION NO CRD42017074783.
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Affiliation(s)
- Alexandros Andreou
- Upper GI Department, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Foundation Trust, Hull, UK
| | - David I Watson
- Flinders University Discipline of Surgery, Flinders Medical Centre, Bedford Park, Australia
| | - Dimitrios Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
- Faculté de Médecine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - Stavros A Antoniou
- Department of Surgery, European University Cyprus, Nicosia, Cyprus.
- Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus.
- , Athens, Greece.
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11
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Esophageal Adenocarcinoma After Antireflux Surgery in a Cohort Study From the 5 Nordic Countries. Ann Surg 2019; 274:e535-e540. [DOI: 10.1097/sla.0000000000003709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maret-Ouda J, Wahlin K, Artama M, Brusselaers N, Färkkilä M, Lynge E, Mattsson F, Pukkala E, Romundstad P, Tryggvadóttir L, von Euler-Chelpin M, Lagergren J. Risk of Esophageal Adenocarcinoma After Antireflux Surgery in Patients With Gastroesophageal Reflux Disease in the Nordic Countries. JAMA Oncol 2019; 4:1576-1582. [PMID: 30422249 DOI: 10.1001/jamaoncol.2018.3054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Gastroesophageal reflux disease (GERD) is associated with a strong and severity-dependent increased risk of esophageal adenocarcinoma. Whether antireflux surgery prevents esophageal adenocarcinoma is a matter of uncertainty. Objectives To examine whether antireflux surgery is associated with reduced risk of esophageal adenocarcinoma and whether the risk is different between surgically and medically treated patients. Design, Setting, and Participants In this multinational, population-based retrospective cohort study from Denmark, Finland, Iceland, Norway, and Sweden, patients undergoing surgery were followed up for a median of 12.7 years, and a comparison group of patients receiving medication only were followed up for a median of 4.8 years. All patients with a registered diagnosis of GERD (or an associated disorder), including 48 414 individuals undergoing surgery and 894 492 receiving medication only, were included in the study. The study periods varied in the different countries depending on the year of initiation of registration and the date of data retrieval, from January 1, 1964, to December 21, 2014. Exposures Antireflux surgery for GERD. Main Outcomes and Measures The risk of esophageal adenocarcinoma over time after surgery was compared with that in a corresponding background population using standardized incidence ratios (SIRs) with 95% CIs and with patients with GERD who received medication using multivariable Cox proportional hazards regression, providing hazard ratios (HRs) with 95% CIs adjusted for confounders. Results In this study of 942 906 patients with GERD, 48 414 underwent antireflux surgery (median [interquartile range] age, 66.0 [58.0-73.0] years; 27 161 male [56.1%]) and 894 492 received medication only (median [interquartile range] age, 71.0 [62.0-78.0] years; 434 035 male [48.6%]). Among patients undergoing surgery, 177 developed esophageal adenocarcinoma. Esophageal adenocarcinoma risk decreased in a time-dependent manner after surgery compared with the background population (5 to <10 years after surgery: SIR, 7.63; 95% CI, 5.42-10.43; ≥15 years after surgery: SIR, 1.34; 95% CI, 0.98-1.80). Among patients with more severe and objectively determined GERD, the SIRs were 10.08 (95% CI, 6.98-14.09) at 5 to less than 10 years after surgery and 1.67 (95% CI, 1.15-2.35) at 15 years or more after surgery. The risk of esophageal adenocarcinoma did not change over time in surgical patients compared with patients who received medication only (5 to <10 years after surgery: HR, 2.02; 95% CI, 1.44-2.84; ≥15 years: HR, 1.80; 95% CI, 1.28-2.54). The risk remained stable over time in analyses restricted to severe reflux disease (5 to <10 years after surgery: HR, 1.81; 95% CI, 1.24-2.63; ≥15 years after surgery: HR, 1.69; 95% CI, 1.14-2.51). Conclusions and Relevance Medical and surgical treatment of GERD were associated with a similar reduced esophageal adenocarcinoma risk, with the risk decreasing to the same level as that in the background population over time, supporting the hypothesis that effective treatment of GERD might prevent esophageal adenocarcinoma.
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Affiliation(s)
- John Maret-Ouda
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Karl Wahlin
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Miia Artama
- Impact Assessment Unit, Department of Health Protection, National Institute for Health and Welfare, Tampere, Finland
| | - Nele Brusselaers
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Science For Life Laboratory (SciLifeLab), Karolinska Institutet, Stockholm, Sweden
| | - Martti Färkkilä
- Clinic of Gastroenterology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Elsebeth Lynge
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Mattsson
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eero Pukkala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland.,Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Pål Romundstad
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Laufey Tryggvadóttir
- Icelandic Cancer Registry, Icelandic Cancer Society, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer Sciences, King's College London, London, United Kingdom
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Randomized Trial of Division Versus Nondivision of Short Gastric Vessels During Nissen Fundoplication: 20-Year Outcomes. Ann Surg 2019; 268:228-232. [PMID: 29303805 DOI: 10.1097/sla.0000000000002648] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate late outcomes from a randomized trial of division versus no division of short gastric vessels during laparoscopic Nissen fundoplication at up to 20 years follow-up. BACKGROUND Nissen fundoplication is an established procedure for the treatment of gastroesophageal reflux disease. Controversy about whether side effects such as dysphagia could be reduced by division of the short gastric vessels led to the establishment of a randomized trial in 1994. Early results showed equivalent reflux control and dysphagia, but more bloating after vessel division. METHODS A total of 102 patients underwent a laparoscopic Nissen fundoplication between May 1994 and October 1995, and were randomized to short gastric vessel division (50) versus nondivision (52). Follow-up was obtained yearly to 20 years using a standardized questionnaire administered by a blinded investigator. Clinical outcomes at 20 years or most recent follow-up were determined. RESULTS No significant differences for heartburn symptom and satisfaction scores or medication use were found between treatment groups. At 15 to 20 (mean 19.6) years follow-up, significant differences persisted for epigastric bloating: 26% versus 50% for nondivision versus division groups (P = 0.046). Heartburn symptom scores were low and not different for nondivision versus division groups (mean analog scores 1.4 vs 2.1/10, P = 0.152). Overall satisfaction after surgery was high in both groups (mean analog scores 8.1 vs 8.6/10, P = 0.989). CONCLUSIONS Although laparoscopic Nissen fundoplication has durable efficacy for heartburn symptom control at up to 20 years follow-up, division of short-gastric vessels failed to confer any reduction in side effects, and was associated with persistent epigastric bloat symptoms at late follow-up in this trial.
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Armijo PR, Hennings D, Leon M, Pratap A, Wheeler A, Oleynikov D. Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility. J Gastrointest Surg 2019; 23:36-42. [PMID: 30288691 DOI: 10.1007/s11605-018-3968-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients. METHODS A single-institution prospective database was reviewed (2007-2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05. RESULTS Fifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0 ± 18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1-7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia. CONCLUSIONS A tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.
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Affiliation(s)
- Priscila R Armijo
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA
| | - Dietric Hennings
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA.,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Melissa Leon
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA
| | - Akshay Pratap
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA.,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Austin Wheeler
- College of Medicine, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA
| | - Dmitry Oleynikov
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, 986246 Nebraska Medical Center, Omaha, NE, 68198-6246, USA. .,Department of Surgery, University of Nebraska Medical Center, 986245 Nebraska Medical Center, Omaha, NE, 68198-6245, USA.
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15
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Oor JE, Broeders JA, Roks DJ, Oors JM, Weusten BL, Bredenoord AJ, Hazebroek EJ. Reflux and Belching after Laparoscopic 270 degree Posterior Versus 180 degree Anterior Partial Fundoplication. J Gastrointest Surg 2018; 22:1852-1860. [PMID: 30030717 DOI: 10.1007/s11605-018-3874-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 07/03/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic 270 degree posterior, or Toupet (LTF), and 180 degree anterior partial fundoplication (LAF) ensure equal reflux control and reduce the risk of gas-related symptoms compared to 360 degree (Nissen) fundoplication. It is unclear which type of partial fundoplication is superior in preventing gas-related side-effects. The aim of this study was to determine differences in effect of LTF and LAF on reflux characteristics and belching patterns. METHODS Upper gastrointestinal endoscopy, esophageal manometry, and 24-h combined pH-impedance monitoring were performed before and 6 months after fundoplication (n = 10, LTF vs. n = 10, LAF). Observed changes after surgery (∆) were compared between the two procedures. RESULTS Symptomatic reflux control as well as the reduction in the mean number of acid (∆ - 58.5 vs. - 66.5; P = 0.912), liquid (∆ - 17.0 vs. - 43.5; P = 0.247), and mixed liquid gas reflux episodes (∆ - 38.0 vs. - 40.0; P = 0.579) were comparable following LTF and LAF. There were no differences in the mean number of weakly acidic reflux episodes after LTF and LAF (1.0 (0.8-4) vs. 1.0 (0-3), P = 0.436). The reduction in proximal (P = 1.000), mid-esophageal (P = 0.063), and distal reflux episodes (P = 0.315) was comparable. Both procedures equally reduced the number of gastric belches (P = 0.278) and supragastric belches (P = 0.123), with no significant reduction in the number of air swallows after either procedure (P = 0.278). CONCLUSION LTF and LAF provide similar reflux control, with a comparable effect on acidic, liquid, and gas reflux. Both procedures equally reduced the number of belches and supragastric belches. This study provides the physiological evidence for the published randomized trials reporting similar symptomatic outcome after both types of partial fundoplication.
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Affiliation(s)
- J E Oor
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
| | - J A Broeders
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - D J Roks
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - J M Oors
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - B L Weusten
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - E J Hazebroek
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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Outcome for Patients With Pathological Esophageal Acid Exposure After Laparoscopic Fundoplication. Ann Surg 2018; 267:1105-1111. [DOI: 10.1097/sla.0000000000002276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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17
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Randomized clinical trial comparing laparoscopic hiatal hernia repair using sutures versus sutures reinforced with non-absorbable mesh. Surg Endosc 2018; 32:4579-4589. [DOI: 10.1007/s00464-018-6211-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 05/09/2018] [Indexed: 12/21/2022]
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Gronnier C, Degrandi O, Collet D. Management of failure after surgery for gastro-esophageal reflux disease. J Visc Surg 2018; 155:127-139. [PMID: 29567339 DOI: 10.1016/j.jviscsurg.2018.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.
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Affiliation(s)
- C Gronnier
- Unité de chirurgie oeso-gastric et endocrinienne, service de chirurgie digestive, centre Magellan, centre hospitalier universitaire de Bordeaux, avenue de Magellan, 33600 Pessac, France; Faculté de médecine de Bordeaux, 33000 Bordeaux, France
| | - O Degrandi
- Unité de chirurgie oeso-gastric et endocrinienne, service de chirurgie digestive, centre Magellan, centre hospitalier universitaire de Bordeaux, avenue de Magellan, 33600 Pessac, France; Faculté de médecine de Bordeaux, 33000 Bordeaux, France
| | - D Collet
- Unité de chirurgie oeso-gastric et endocrinienne, service de chirurgie digestive, centre Magellan, centre hospitalier universitaire de Bordeaux, avenue de Magellan, 33600 Pessac, France; Faculté de médecine de Bordeaux, 33000 Bordeaux, France.
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