Network meta-analysis of surgical management of gastro-oesophageal reflux disease in adults

Acute gastric volvulus complicated by gastric perforation following laparoscopic Nissen fundoplication; A case report

INTRODUCTION

Laparoscopic Nissen Fundoplication is an effective standard surgical procedure for treatment of severe GERD. While it is generally safe and effective, a rare but potentially fatal complication known as acute gastric volvulus can occur following this procedure.

CASE PRESENTATION

A 28-year-old male, ten months post Laparoscopic Nissen Fundoplication presented with a one-day history of severe epigastric pain, abdominal distention, unproductive retching, and difficulty in breathing. Examination revealed tachypnea, subcutaneous emphysema and a tender distended abdomen. Imaging studies showed a left pneumothorax, pneumoperitoneum, and a grossly distended stomach. Emergency exploratory laparotomy confirmed organoaxial gastric volvulus, necrosis of the greater curvature and gastric perforation. Partial gastrectomy and anterior gastropexy were performed. A left thoracostomy tube was placed to drain the left pneumothorax. He recovered fully post-operatively with complete resolution of all symptoms.

DISCUSSION

Acute Gastric volvulus post Laparoscopic Nissen Fundoplication is attributed to adhesions, gastrostomy tubes, and foreign bodies like sutures. Life-threatening complications, such as gastric perforation, can ensue, underscoring the need for swift diagnosis and treatment.

CONCLUSION

Acute gastric volvulus following Laparoscopic Nissen Fundoplication is a rare condition, and is difficult to diagnose. Given the steadily increasing rates of laparoscopic Nissen fundoplications performed in Uganda, maintaining a high index of suspicion is crucial for favorable patient outcomes among patients with this potentially fatal complication.

Results of the ARROW survey of anti-reflux practice in the United Kingdom

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.

Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials

BACKGROUND

In the surgical management of GERD, the traditional procedure is laparoscopic total (Nissen) fundoplication. However, partial fundoplication has been advocated as providing similar reflux control while potentially minimizing dysphagia. The comparative outcomes of different approaches to fundoplication are a topic of ongoing debate and long-term outcomes remain uncertain. This study aims to compare long-term gastroesophageal reflux disease (GERD) related outcomes following different fundoplication procedures.

METHODS

MEDLINE, EMBASE, PubMed, and CENTRAL databases were searched up to November 2022 to identify randomized controlled trials (RCTs) comparing different types of fundoplications reporting long-term (> 5 years) outcomes. The primary outcome was incidence of dysphagia. Secondary outcomes included incidence of heartburn/reflux, regurgitation, inability to belch, abdominal bloating, reoperation, and patient satisfaction. DataParty, which uses Python 3.8.10 was used to perform the network meta-analysis. We evaluated the overall certainty of evidence with the GRADE framework.

RESULTS

13 RCTs were included, with 2063 patients across Nissen (360°), Dor (anterior 180°-200°), and Toupet (posterior 270°) fundoplications. Network estimates demonstrated that Toupet had lower incidence of dysphagia compared to Nissen (OR 0.285; 95% CrI 0.06-0.958). There were no differences in dysphagia between Toupet and Dor (OR 0.473, 95% CrI 0.072-2.835) or between Dor and Nissen (OR 1.689, 95% CrI 0.403-7.699). The three fundoplication types were comparable in all other outcomes.

CONCLUSIONS

All three approaches of fundoplication share similar long-term outcomes, with the Toupet fundoplication likely providing the best long-term durability with lowest odds of developing postoperative dysphagia.

Laparoscopic Nissen fundoplication versus 90° and 180° fundoplication for gastroesophageal reflux disease

Background

Laparoscopic Nissen fundoplication (LNF) is standard care for surgical treatment of gastroesophageal reflux disease (GERD) in adults. The main disadvantage is the compression of the food passageway, affecting the ability to belch and vomit, and causing swallowing difficulties. Therefore, partial fundoplication methods encircling esophagus as little as 90° and 180° have been developed. Previous studies have been inconclusive. The aim was to assess the effectiveness of LNF compared to laparoscopic anterior 90° and 180° fundoplication.

Methods

Randomized controlled trials were searched for in MEDLINE, Embase, CINAHL, the Cochrane Library, and Web of Science, and in eligible studies’ reference lists and relevant reviews. Outcomes of interest were 5-year heartburn, medication use, dysphagia, reoperation, and satisfaction. Dichotomous data were calculated as risk ratios (RR). Subgroup analyses were performed to compare each comparator separately with LNF. The meta-analyses were conducted using a random-effects model with an inverse variance statistical method and a significance level of 0.05.

Results

Four eligible trials were included with 398 participants, of which half compared LNF with 90°. At 5 years there was higher risk of dysphagia for solids after LNF compared to 90° and 180° fundoplication (RR 1.68 [1.14, 2.49]). However, LNF was associated with a significantly lower risk of medication use compared to laparoscopic anterior 90° fundoplication (RR 0.23 [0.09, 0.58], subgroup analysis). No differences between treatments in terms of heartburn, reoperation, and satisfaction were found.

Conclusion

The limited evidence fails to provide an unequivocal method of choice, but rather indicates a trade-off between reflux control and complications.

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

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.

Laparoscopic Toupet Fundoplication for the Treatment of Laryngopharyngeal Reflux: Results at Medium-Term follow-Up

BACKGROUND

The effect of laparoscopic Toupet fundoplication (LTF) for the treatment of laryngopharyngeal reflux (LPR) is unclear. The purpose of this study is to investigate the feasibility and effectiveness of LTF for the treatment of LPR-related symptoms and disease-specific quality of life (QoL) up to 3-year follow-up.

MATERIALS AND METHODS

Observational cohort study (2015-2019). Patients suffering from LPR were included. Preoperative evaluation included esophagogastroduodenoscopy, esophageal manometry and 24-h pH/impedance study. Symptoms and QoL were measured with the reflux symptom index (RSI) and the laryngopharyngeal reflux-health-related quality of life (LPR-HRQL) validate questionnaires at baseline and during follow-up.

RESULTS

Eighty-six patients were included. Twenty-three (27%) patients had pure LPR while 63 (73%) presented with combined LPR/GERD. Cough (89.7%), dyspnea/choking (39.6%) and asthma (25.6%) were the most commonly reported extraesophageal symptoms. The median (interquartile range, IQR) total RSI score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 36.1 (10.3), 9.58 (12.3), 11.8 (10.2), 12.4 (9.6), 12.0 (13.1) and 10.1 (12.0), respectively. The median (IQR) total LPR-HRQL score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 57.4 (22.2), 13.4 (14.9), 15.2 (12.8), 11.4 (10.9) and 11.9 (13.5), respectively. The subscores "voice," "cough," "throat" and "swallow" showed a significant improvement after intervention. Compared to baseline, each per-year follow-up pairwise comparison was significantly improved (p < 0.001).

CONCLUSIONS

LTF seems feasible, effective and promising for the treatment of LPR with improved symptoms and disease-specific patients' quality of life perception up to 3-year follow-up.

Surgical treatment of recalcitrant gastroesophageal reflux disease in patients with systemic sclerosis: a systematic review

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.

Randomized Trial of Laparoscopic Nissen vs. Anterior 180 Degree Partial Fundoplication - Late Clinical Outcomes at 15-20 years

OBJECTIVE

To determine very late clinical outcomes at up to 20 years follow-up from a randomized controlled trial of Nissen vs. anterior 180-degree partial fundoplication.

SUMMARY BACKGROUND DATA

Nissen fundoplication for gastroesophageal reflux can be followed by troublesome side effects. To address this, partial fundoplications have been proposed. Previously reports from a randomized controlled trial of Nissen vs. anterior 180-degree partial fundoplication at up to 10 years follow-up showed good outcomes for both procedures.

METHODS

107 participants were randomized to Nissen vs. anterior 180-degree partial fundoplication. 15-20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardized questionnaire with 0-10 analogue scores and yes/no questions to determine reflux symptoms, side-effects and satisfaction with surgery.

RESULTS

After anterior fundoplication heartburn (mean score 3.2 vs 1.4, p = 0.001) and proton pump inhibitor use (41.7% vs 17.1%, p = 0.023) were higher, offset by less dysphagia for solids (mean score 1.8 vs 3.3, p = 0.015), and better ability to belch (84.2% vs 65.9%, p = 0.030). Measures of overall outcome were similar for both groups (mean satisfaction score 8.4 vs 8.0, p = 0.444; 86.8% vs 90.2% satisfied with outcome). Six participants underwent revision following anterior fundoplication (Nissen conversion for reflux - 6), and 7 underwent revision following Nissen fundoplication (Nissen to partial fundoplication for dysphagia - 5; redo Nissen for reflux - 1; paraesophageal hernia -1).

CONCLUSIONS

At 15-20 years follow-up Nissen and anterior 180-degree partial fundoplication achieved similar success, but with trade-offs between better reflux control vs. more side-effects after Nissen fundoplication.

Changes in the disease-specific quality of life following Dor fundoplication. A multicentre cross-sectional study

Background

Gastrooesophageal reflux disease (GERD) is a spectrum of symptoms arising from the laxity of the cardio-oesophageal junction. Anti-reflux surgery is reserved for patients with refractory GERD. Anterior partial fundoplication (Dor) is a regularly performed anti-reflux surgery in Malaysia. We intend to determine the improvement in disease-specific quality of life in our patients after surgery.

Methods

A multicentre cross-sectional study was conducted to assess patients' improvement in disease-specific quality of life after Dor fundoplication. Ethics approval was obtained from our institutional review board. Patients between the ages of 18 and 65 years who underwent Dor fundoplication within the past five years were assessed using the GERD HRQL as well as the VISICK score via telephone interview. We excluded cases of revision surgery.

Results

Out of 129 patients screened, 55 patients were included. We found a significant improvement in patients' GERD HRQL score with the pre-operative mean score of 28.3 ± 9.39 and 6.55 ± 8.52 post-operatively, p < 0.01.50.9% of patients reported a VISICK score of 1. However, we noticed a deterioration in the GERD HRQL and VISICK score in patients followed up four years after surgery. This consisted of 25.5% of total patients.

Conclusion

Dor Fundoplication improves the overall disease-specific quality of life in patients with refractory GERD in the short term period. Recurrence of symptoms causing a deterioration in the quality of life is seen in patients followed up beyond four years of index surgery.

[Current aspects of surgical treatment of gastro-esophageal reflux disease]

Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of gastric content into the esophagus, pharynx, respiratory tract and oral cavity. In recent years, there has been a significant increase of the incidence of this disease, that significantly aggravates quality of life of the population. The 'gold standard' for treating GERD is anti-secretory therapy with proton pump inhibitors (PPIs). However, up to 40% of patients are unresponsive to PPIs even after dose adjustment. Advantages and disadvantages of modern surgical approaches for this pathology are reviewed. Laparoscopic fundoplication including Nissen (360°), Toupet (270°) and Dor procedures (180°) is the most common anti-reflux operation. In addition, new alternative surgical options are also discussed. For example, these are minimally invasive methods such as LINX reflux control system, electrical stimulation of the lower esophageal sphincter and transoral incisionless fundoplication (TIF). These methods are less aggressive and have less side effects. A comparative assessment of modern methods of surgical treatment of GERD is made.

Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis

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.

Single incision laparoscopic fundoplication: A systematic review of the literature

BACKGROUND

Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision (SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.

AIM

To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.

METHODS

The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases (Medline, Scopus and Web of Science) was performed.

RESULTS

Literature search resulted in the identification of 19 studies. Overall, 266, 137 and 110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.

CONCLUSION

Due to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.