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Fringeli Y, Linas I, Kessler U, Zehetner J. Exploring the feasibility and safety of laparoscopic anti-reflux surgery with the new RefluxStop™ device: a retrospective cohort study of 40 patients. Swiss Med Wkly 2024; 154:3365. [PMID: 39137342 DOI: 10.57187/s.3365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
AIMS OF THE STUDY Anti-reflux surgery aims to restore the anti-reflux barrier and reduce the retrograde flow of stomach contents. However, traditional surgical techniques generally involve some degree of encircling of the oesophagus, which can result in adverse effects such as dysphagia and the inability to belch or vomit. Based on the first published results, a novel surgical technique - with the RefluxStop™ device - appears promising for treating gastroesophageal reflux disease (GERD) with minimal postoperative dysphagia. This study describes the initial clinical experience with this procedure in a cohort of patients with chronic gastroesophageal reflux disease to evaluate its feasibility and safety in clinical practice. METHODS This retrospective cohort study examined the first 40 patients who underwent laparoscopic anti-reflux surgery with the RefluxStop™ device at a private hospital in Switzerland. The procedure involves implanting a nonactive device on the outside of the gastric fundus to stabilise a narrow oesophagogastric plication. Feasibility was assessed based on the proportion of patients in whom the device could be successfully implanted, with a discussion of the operative details. Intraoperative and postoperative complications, adverse effects, and changes in gastroesophageal reflux disease-related quality of life (GERD-HRQL questionnaire) are also reported. RESULTS Between May 2020 and April 2022, 40 patients underwent elective surgery for laparoscopic hiatal hernia repair and RefluxStop™ device implantation. All patients had typical symptoms of gastroesophageal reflux disease, such as heartburn and regurgitation; 20 (50%) had preoperative dysphagia. Laparoscopic surgery was feasible in all patients except one who required laparotomy due to adhesions and associated bleeding when accessing the abdomen. The median operating time was 57.5 minutes (interquartile range = 51.75-64.25 minutes) with no device-related intraoperative or postoperative complications. All patients were imaged one day and three months postoperative, confirming the correct placement of the device. Reflux symptoms (heartburn and acid regurgitation) were significantly improved in all patients at three months (p <0.0001). CONCLUSION These preliminary results support the feasibility and safety of introducing this novel laparoscopic anti-reflux surgical treatment option in clinical practice.
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Affiliation(s)
- Yannick Fringeli
- Department of Visceral Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Ioannis Linas
- Department of Gastroenterology, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Ulf Kessler
- Department of Visceral Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Joerg Zehetner
- Department of Visceral Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland
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2
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Rapolti DI, Monrabal Lezama M, Manueli Laos EG, Schlottmann F, Masrur MA. Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies. J Laparoendosc Adv Surg Tech A 2024; 34:581-602. [PMID: 38568115 DOI: 10.1089/lap.2024.0111] [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] [Indexed: 07/26/2024] Open
Abstract
Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.
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Affiliation(s)
- Diana I Rapolti
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | | | | | - Francisco Schlottmann
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Mario A Masrur
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
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3
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Nehra D, Clements CDM, Bezzaa SL, Tabbakh Y, Walsh CM. Patient-reported outcomes of laparoscopic magnetic sphincter augmentation for gastro-oesophageal reflux disease. Ann R Coll Surg Engl 2024; 106:344-352. [PMID: 37609688 PMCID: PMC10981991 DOI: 10.1308/rcsann.2023.0051] [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] [Accepted: 06/19/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Gastro-oesophageal reflux disease (GORD) is a chronic progressive disease, associated with substantial clinical and economic burden. Proton pump inhibitors (PPIs) are considered first-line treatment; however, there are concerns around the long-term impact of their usage. Surgical treatment with Nissen fundoplication can be considered but, because of the potential side effects, few patients undergo surgery and there remains a substantial therapeutic gap within the current treatment pathway. Laparoscopic magnetic sphincter augmentation (MSA) using the LINX® device is an alternative surgical approach. METHODS The objective of this study was to investigate patient-reported outcomes following laparoscopic MSA surgery using the LINX® device in a UK setting. A retrospective questionnaire obtained data regarding postoperative symptoms, medication use and patient satisfaction. RESULTS Out of 131 patients surveyed, 97 responses were received, with a minimum follow-up time of 1 year. In those who reported heartburn and regurgitation preoperatively, improvement was reported in 93% (84/90) and 90% (86/96) of patients, respectively. Eighty-eight per cent (73/83) of patients were able to completely stop or reduce their medication by at least 75%. Seventy-seven per cent (73/95) of patients were "very satisfied" or "satisfied". CONCLUSIONS This study is the first to present patient-reported outcomes of MSA using the LINX® device for patients with GORD in the UK. It demonstrates that the device has favourable outcomes and could effectively bridge the current therapeutic gap that exists between PPI medication and Nissen fundoplication.
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Affiliation(s)
- D Nehra
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - CDM Clements
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - SL Bezzaa
- Epsom and St Helier University Hospitals NHS Trust, UK
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Shacker M, Latorre-Rodríguez AR, Mittal SK. Prevalence and severity of abdominal bloating in patients with gastroesophageal reflux disease. Dis Esophagus 2024; 37:doad058. [PMID: 37738150 DOI: 10.1093/dote/doad058] [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: 07/20/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/24/2023]
Abstract
Abdominal bloating (AB) is a common symptom among patients with gastroesophageal reflux disease (GERD); however, in clinical practice, its prevalence is likely underestimated due to the lack of objective tools to measure its frequency and severity. It is associated with dissatisfaction and worse quality of life, but data on its prevalence before and after mechanical control of GERD (i.e. fundoplication, magnetic sphincter augmentation, and antireflux mucosectomy) are lacking. To assess and determine the pre- and postoperative prevalence and severity of AB among patients with GERD, we conducted a structured literature search using MeSH and free-text terms in MEDLINE (via Pubmed), EMBASE, and Taylor & Francis Online between January 1977 and October 2022. Fifteen articles reporting the prevalence or severity of AB using quality-of-life questionnaires before or after antireflux surgery (ARS) were included. Overall, a high prevalence of AB before ARS was found. A decline in the prevalence and severity of AB was documented postoperatively in most cases independent of the surgical approach. Among surgical approaches, a complete fundoplication had the highest reported postoperative AB. Overall, patients reported less severe and less frequent AB after ARS than before. The traditional belief that postoperative bloating is a sequela of ARS should be reevaluated.
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Affiliation(s)
- Mark Shacker
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | | | - Sumeet K Mittal
- School of Medicine, Creighton University, Phoenix, AZ, USA
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Puri A, Steven S, Markar SR, Boyle N. Longer-term outcomes of gastroesophageal reflux disease treated with magnetic sphincter augmentation. Dis Esophagus 2023; 36:doad014. [PMID: 36942526 PMCID: PMC10789235 DOI: 10.1093/dote/doad014] [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: 09/18/2022] [Revised: 02/14/2023] [Accepted: 02/28/2023] [Indexed: 03/23/2023]
Abstract
Surgical intervention for gastroesophageal reflux disease (GERD) has historically been limited to fundoplication. Magnetic sphincter augmentation (MSA) is a less invasive alternative that was introduced 15 years ago, and it may have a superior side-effect profile. To date, however, there has been just a single published study reporting outcomes in a UK population. This study reports quality-of-life (QOL) outcomes and antacid use in patients undergoing MSA, with a particular focus on postoperative symptoms and those with severe reflux. A single-center cohort study was carried out to assess the QOL outcomes and report long-term safety outcomes in patients undergoing MSA. GERD-health-related quality of life (GERD-HRQL) and Reflux Symptom Index (RSI) scores were collected preoperatively, and immediately postoperatively, at 1-, 2-, 3-, and 5-year follow-up time points. All patients underwent preoperative esophagogastroduodenoscopy, impedance, and manometry. Two hundred and two patients underwent laparoscopic MSA over 9 years. The median preoperative GERD-HRQL score was 31, and the median RSI score was 17. There was a reduction in all scores from preoperative values to each time point, which was sustained at 5-year follow-up; 13% of patients had a preoperative DeMeester score of >50, and their median preoperative GERD-HRQL and RSI scores were 32 and 15.5, respectively. These were reduced to 0 at the most recent follow-up. There was a significant reduction in antacid use at all postoperative time points. Postoperative dilatation was necessary in 7.4% of patients, and the device was removed in 1.4%. Erosion occurred in no patients. MSA is safe and effective at reducing symptom burden and improving QOL scores in patients with both esophageal and laryngopharyngeal symptoms, including those with severe reflux.
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Affiliation(s)
- Aiysha Puri
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sue Steven
- Department of Surgery, Reflux UK, London, UK
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
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Eriksson SE, Zheng P, Sarici IS, Shen X, Jobe BA, Ayazi S. The impact of delayed gastric emptying as measured by gastric emptying scintigraphy on the outcome of magnetic sphincter augmentation. Surg Endosc 2023; 37:7144-7152. [PMID: 37328595 PMCID: PMC10462528 DOI: 10.1007/s00464-023-10190-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: 04/01/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The impact of delayed gastric emptying (DGE) on the outcome of anti-reflux surgery (ARS) is controversial. There is concern that poor gastric emptying diminishes outcomes. Magnetic sphincter augmentation (MSA) may have a comparatively mild impact on gastric physiology, but the relationship between DGE and MSA outcomes is unknown. This study aims to evaluate the relationship between objective DGE and MSA outcomes over time. METHODS Patients who completed gastric emptying scintigraphy (GES) prior to MSA between 2013 and 2021 were included. DGE was defined as a 4 h retention > 10% or half emptying time > 90 min on GES. Outcomes were compared between DGE and normal gastric emptying (NGE) groups at 6 months, 1 and 2 years. Sub-analysis of patients with severe (> 35%) DGE and correlation analysis between 4-h retention and symptom and acid-normalization were performed. RESULTS The study population consisted of 26 (19.8%) patients with DGE and 105 with NGE. DGE was associated with more 90-days readmissions (18.5 vs 2.9%, p = 0.009). At 6 months patients with DGE had higher median (IQR) GERD-HRQL total [17.0(10-29) vs 5.5(3-16), p = 0.0013], heartburn [1(1-3) vs 0(0-1), p = 0.0010) and gas-bloat [4(2-5) vs 2(1-3), p = 0.033] scores. Outcomes at 1 and 2 years follow-up were comparable (p > 0.05). From 6 months to 1-year the gas-bloat score decreased from 4(2-5) to 3(1-3), p = 0.041. Total and heartburn scores decreased, but not significantly. Severe DGE (n = 4) patients had lower antiacid medication freedom at 6 months (75 vs 87%, p = 0.014) and 1-year (50 vs 92%, p = 0.046). There were non-significant trends for higher GERD-HRQL scores, dissatisfaction, and removal rates in severe DGE at 6 months and 1-year. There was a weak correlation between 4-h retention and 6-month GERD-HRQL total score [R = 0.253, 95%CI (0.09-0.41), p = 0.039], but not acid-normalization (p > 0.05). CONCLUSION Outcomes after MSA are diminished early on in patients with mild-to-moderate DGE, but comparable by 1 year and durable at 2 years. Severe DGE outcomes may be suboptimal.
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Affiliation(s)
- Sven E Eriksson
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Inanc S Sarici
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Xinxin Shen
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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Asti E, Milito P, Froiio C, Milani V, Bonavina L. Comparative outcomes of Toupet fundoplication and magnetic sphincter augmentation. Dis Esophagus 2023; 36:doac090. [PMID: 36544397 DOI: 10.1093/dote/doac090] [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: 08/31/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
Laparoscopic fundoplication is the current surgical gold standard for the treatment of refractory gastroesophageal reflux disease (GERD). Magnetic sphincter augmentation (MSA) is a less invasive, standardized, and reversible option to restore competency of the lower esophageal sphincter. A comparative cohort study was conducted at a tertiary-care referral center on patients with typical GERD symptoms treated with systematic crural repair combined with Toupet fundoplication or MSA. Primary study outcome was decrease of Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Between January 2014 and December 2021, a total of 199 patients (60.3% female, median [Q1-Q3] age: 51.0 [40.0-61.0]) underwent MSA (n = 130) or Toupet fundoplication (n = 69). Operative time and hospital stay were significantly shorter in MSA patients (P < 0.0001). At a median follow-up of 12.0 [12.0-24.0] months, there was a statistically significant decrease of GERD-HRQL score in both patient groups (P = 0.001). The mean delta values did not significantly differ between groups (P = 0.7373). The incidence of severe gas bloating symptoms was similar in the two groups (P = 0.7604), but the rate of persistent postoperative dysphagia was greater in MSA patients (P = 0.0009). Six (8.7%) patients in the Toupet group had recurrent hiatal hernia requiring revisional surgery in one (1.4%). In the MSA group, eight (7.9%) patients necessitated through-the-scope balloon dilation for relief of dysphagia, and six patients had the device removed (4.6%) because of persistent dysphagia (n = 3), device disconnection (n = 1), persistent reflux (n = 1) or need of magnetic resonance (n = 1). Toupet and MSA procedures provide similar clinical outcomes, but MSA is associated with a greater risk of reoperation. Randomized clinical trials comparing fundoplication and MSA are eagerly awaited.
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Affiliation(s)
- Emanuele Asti
- University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery and Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, Milan, Italy
| | - Pamela Milito
- University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery and Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, Milan, Italy
| | - Caterina Froiio
- University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery and Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, Milan, Italy
| | - Valentina Milani
- University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery and Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, Milan, Italy
| | - Luigi Bonavina
- University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery and Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, Milan, Italy
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Reiter AJ, Farina DA, Fronza JS, Komanduri S. Magnetic sphincter augmentation: considerations for use in Barrett's esophagus. Dis Esophagus 2023; 36:doac096. [PMID: 36575922 PMCID: PMC10267686 DOI: 10.1093/dote/doac096] [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: 09/08/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 12/29/2022]
Abstract
Barrett's esophagus (BE) occurs in 5-15% of patients with gastroesophageal reflux disease (GERD). While acid suppressive therapy is a critical component of BE management to minimize the risk of progression to esophageal adenocarcinoma, surgical control of mechanical reflux is sometimes necessary. Magnetic sphincter augmentation (MSA) is an increasingly utilized anti-reflux surgical therapy for GERD. While the use of MSA is listed as a precaution by the United States Food and Drug Administration, there are limited data showing effective BE regression with MSA. MSA offers several advantages in BE including effective reflux control, anti-reflux barrier restoration and reduced hiatal hernia recurrence. However, careful patient selection for MSA is necessary.
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Affiliation(s)
- Audra J Reiter
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Domenico A Farina
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeffrey S Fronza
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Srinadh Komanduri
- Department of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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9
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Patel A, Gyawali CP. The role of magnetic sphincter augmentation (MSA) in the gastroesophageal reflux disease (GERD) treatment pathway: the gastroenterology perspective. Dis Esophagus 2023:7034219. [PMID: 36776100 DOI: 10.1093/dote/doad005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/18/2023] [Indexed: 02/14/2023]
Abstract
Magnetic sphincter augmentation (MSA) is a surgical intervention for well-characterized gastroesophageal reflux disease (GERD), where the esophagogastric junction barrier is augmented using a bracelet of magnetized titanium beads. MSA could be an attractive option for patients with documented GERD who wish to avoid long-term pharmacologic therapy or whose symptoms are not adequately managed with lifestyle modifications and pharmacologic therapy. The 'ideal' MSA patient is one with prominent regurgitation, without dysphagia or esophageal motor dysfunction, with objective evidence of GERD on upper endoscopy and/or ambulatory reflux monitoring. Appropriate candidates with significant hiatus hernia may pursue MSA with concomitant hiatus hernia repair. The increasing adoption of MSA in the GERD treatment pathway reflects research that shows benefits in long-term outcomes and healthcare costs compared with other established therapies in appropriate clinical settings.
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Affiliation(s)
- Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham VA Medical Center, Durham, NC, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
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10
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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: 20] [Impact Index Per Article: 20.0] [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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11
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Froiio C, Tareq A, Riggio V, Siboni S, Bonavina L. Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review. Eur Surg 2023. [DOI: 10.1007/s10353-022-00789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Summary
Background
The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force.
Methods
An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence.
Results
Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia.
Conclusion
A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.
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12
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Vivek A, Latorre-Rodríguez AR, Mittal SK. Magnetic sphincter augmentation for gastroesophageal reflux in overweight and obese patients. Dis Esophagus 2023:6974776. [PMID: 36617946 DOI: 10.1093/dote/doac104] [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: 09/02/2022] [Revised: 11/29/2022] [Accepted: 12/04/2022] [Indexed: 01/10/2023]
Abstract
Magnetic sphincter augmentation (MSA) is a successful treatment option for chronic gastroesophageal reflux disease; however, there is a paucity of data on the efficacy of MSA in obese and morbidly obese patients. To assess the relationship between obesity and outcomes after MSA, we conducted a literature search using MeSH and free-text terms in MEDLINE, EMBASE, Cochrane and Google Scholar. The included articles reported conflicting results regarding the effect of obesity on outcomes after MSA. Prospective observational studies with larger sample sizes and less statistical bias are necessary to understand the effectiveness of MSA in overweight and obese patients.
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Affiliation(s)
- Anjali Vivek
- Creighton University School of Medicine, Phoenix, AZ, USA
| | | | - Sumeet K Mittal
- Creighton University School of Medicine, Phoenix, AZ, USA.,Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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13
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Sarici IS, Dunn CP, Eriksson SE, Jobe BA, Ayazi S. Long-term clinical and functional results of magnetic sphincter augmentation. Dis Esophagus 2022:6965898. [PMID: 36585776 DOI: 10.1093/dote/doac109] [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: 11/20/2022] [Indexed: 01/01/2023]
Abstract
Magnetic sphincter augmentation (MSA) was introduced in 2007 as an alternative surgical procedure for patients with gastroesophageal reflux disease (GERD). The majority of data since MSA's introduction has focused on short and intermediate-term results, demonstrating safety and high efficacy in terms of reflux symptom control, freedom from proton pump inhibitor use and normalization of distal esophageal acid exposure. However, GERD is a chronic condition that demands a long-term solution. Limited available data from studies reporting outcomes at 5 years or later following MSA demonstrate that the promising short- and mid-term efficacy and safety profile of MSA remains relatively constant in the long term. Compared with Nissen fundoplication, MSA has a much lower rate of gas-bloat and inability to belch at a short-term follow-up, a difference that persists in the long-term. The most common complaint after MSA at a short-term follow-up is dysphagia. However, limited data suggest dysphagia rates largely decrease by 5 years. Dysphagia is the most common indication for dilation and device removal in both early- and long-term studies. However, the overall rates of dilation and removal are similar in short- and long-term reports, suggesting the majority of these procedures are performed in the short-term period after device implantation. The indications and standard practices of MSA have evolved over time. Long-term outcome data currently available are all from patient cohorts who were selected for MSA under early restricted indications and outdated regimens. Therefore, further long-term studies are needed to corroborate the preliminary, yet encouraging long-term results.
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Affiliation(s)
- Inanc S Sarici
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Colin P Dunn
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Sven E Eriksson
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Blair A Jobe
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.,Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.,Department of Surgery, Drexel University, Philadelphia, PA, USA
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14
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O'Neill SM, Jalilvand AD, Colvin JS, Haisley KR, Perry KA. S148: Long-term patient-reported outcomes of laparoscopic magnetic sphincter augmentation versus Nissen fundoplication: a 5-year follow-up study. Surg Endosc 2022; 36:6851-6858. [PMID: 35041056 DOI: 10.1007/s00464-022-09015-1] [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: 09/02/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Laparoscopic magnetic sphincter augmentation (MSA) has emerged as an alternative to laparoscopic Nissen fundoplication (LNF) for the management of symptomatic gastroesophageal reflux disease (GERD). While short-term outcomes of MSA compare favorably to those of LNF, direct comparisons of long-term outcomes are lacking. We hypothesized that the long-term patient-reported outcomes of MSA would be similar to those achieved with LNF. METHODS We tested this hypothesis in a retrospective cohort undergoing primary LNF or MSA between March 2013 and July 2015. The primary outcome was GERD-Health Related Quality of Life (GERD-HRQL) score at long-term follow-up relative to baseline. Secondary outcomes included dysphagia and bloating scores, proton-pump inhibitor (PPI) cessation, reoperations, and overall satisfaction with surgery. RESULTS 70 patients (25 MSA, 45 LNF) met criteria for study inclusion. MSA patients had lower baseline BMI (median: 27.1 [IQR: 22.7-29.9] versus 30.4 [26.4-32.8], p = 0.02), lower total GERD-HRQL (26 [19-32] versus 34 [25-40], p = 0.02), and dysphagia (2 [0-3] versus 3 [1-4], p = 0.02) scores. Median follow-up interval exceeded 5 years (MSA: 68 [65-74]; LNF: 65 months [62-69]). Total GERD-HRQL improved from 26 to 9 after MSA (p < 0.001) and from 34 to 7.5 after LNF (p < 0.01); these scores did not differ between groups (p = 0.68). Dysphagia (MSA: 1 [0-2]; LNF: 0 [0-2], p = 0.96) and bloating (MSA: 1.5 [0.5-3.0]; LNF: 3.0 [1.0-4.0], p = 0.08) scores did not show any statistically significant differences. Device removal was performed in 4 (16%) MSA patients and reoperation in 3 (7%) LNF patients. Eighty-nine percent of LNF patients reported satisfaction with the procedure, compared to 70% of MSA patients (p = 0.09). CONCLUSIONS MSA appears to offer similar long-term improvement in disease-specific quality of life as LNF. For MSA, there was a trend toward reduced long-term bloating compared to LNF, but need for reoperation and device removal may be associated with patient dissatisfaction.
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Affiliation(s)
- Sean M O'Neill
- Division of Minimally Invasive Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anahita D Jalilvand
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jennifer S Colvin
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kelly R Haisley
- Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Kyle A Perry
- Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, USA.
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15
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Callahan ZM, Amundson J, Su B, Kuchta K, Ujiki M. Outcomes after anti-reflux procedures: Nissen, Toupet, magnetic sphincter augmentation or anti-reflux mucosectomy? Surg Endosc 2022; 37:3944-3951. [PMID: 35999311 DOI: 10.1007/s00464-022-09544-9] [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: 03/17/2022] [Accepted: 08/07/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Surgical treatment options of gastroesophageal reflux disease have changed significantly in the last 50 years. Magnetic Sphincter Augmentation (MSA) and Anti-reflux Mucosectomy (ARMs) are gaining traction but there is a paucity of literature comparing these novel options to Toupet fundoplication and gold standard Nissen fundoplication. METHODS This is a retrospective review of a prospectively maintained database, evaluating patients undergoing Nissen, Toupet, MSA, and ARMs. Pre-operative, intra-operative, and post-operative variables including Reflux symptom index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire (GERD-HRQL), and Dysphagia scores were compared between groups. RESULTS During the study period, 649 patients underwent anti-reflux surgery. Patients who underwent Nissen or Toupet were younger than those undergoing MSA or ARMs (65 ± 12 and 67 ± 14 years vs 56 ± 14 and 56 ± 18 years, P < 0.01). Average operative time for Nissen was 127 ± 40 min which was similar to a Toupet at 122 ± 32 min. These durations were significantly longer than for MSA, averaging 79 ± 29, and ARMs, at a mean 35 ± 3 min (all P < 0.001). Length of stay was significantly different among all four groups with Nissen, Toupet, MSA, and ARMs patients staying a median of 31, 24, 7, and 3 h post operatively, respectively (all P < 0.001). Complications and re-admissions were similarly low among all groups. Despite minor differences in RSI and GERD-HRQL scores at isolated follow-up time points, quality of life scores seems to be similar overall at up to 5 years follow-up. Gas bloat and dysphagia did not differ among groups at any time point. CONCLUSIONS Novel anti-reflux surgery options provide similar GERD-related quality of life compared to traditional full or partial fundoplications with the added benefit of shorter operative time and faster recovery.
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Affiliation(s)
- Zachary M Callahan
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
| | - Julia Amundson
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Bailey Su
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
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16
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Bortolotti M. Magnetic challenge against gastroesophageal reflux. World J Gastroenterol 2021; 27:8227-8241. [PMID: 35068867 PMCID: PMC8717015 DOI: 10.3748/wjg.v27.i48.8227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/07/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023] Open
Abstract
Almost 15 years have passed since the first paper on the possibility of using magnets to prevent gastro-esophageal reflux (GER) was published and so it is time to assess the results obtained with the first magnetic device available on the market, the Linx magnetic sphincter augmentation (MSA) and to consider what other options are forthcoming. MSA demonstrated an anti-reflux activity similar to that of Nissen fundoplication, considered the “gold standard” surgical treatment for GER disease, and caused less gas-bloating and a better ability to allow vomiting and belching. However, unlike Nissen fundoplication, this magnetic device is burdened by complications, which are roughly similar to those of the non-magnetic anti-reflux Angelchik prosthesis, that, after considerable use in the eighties, was shelved due to these complications. It is interesting to note that some of these complications show the same pathophysiological mechanism in both devices. The upcoming new magnetic devices should avoid these complications, as their anti-reflux magnetic mechanism is completely different. The experiments in animals regarding these new magnetic appliances were examined, remarking their advantages and drawbacks, but the way to apply them in surgical practice is long and difficult, although worthy, as they represent the future of magnetic surgery.
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Affiliation(s)
- Mauro Bortolotti
- Department of Internal Medicine and Gastroenterology, S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna 40138, Italy
- Via Massarenti 48, Bologna 40138, Italy
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17
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Wu H, Attaar M, Wong HJ, Campbell M, Kuchta K, Ungerleider S, Denham W, Linn J, Ujiki MB. Impedance planimetry (EndoFLIP) measurements persist long term after anti-reflux surgery. Surgery 2021; 171:628-634. [PMID: 34865861 DOI: 10.1016/j.surg.2021.08.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE The functional lumen imaging probe provides objective measurements of the gastroesophageal junction during laparoscopic anti-reflux surgery. There is a lack of data on how functional lumen imaging probe measurements change at follow-up. We aim to describe our institutional experience in performing functional lumen imaging probe during postoperative endoscopy after laparoscopic anti-reflux surgery. METHODS A prospectively maintained database was queried. Patients who had postoperative endoscopic functional lumen imaging probe measurements between March 2018 and June 2021 were assessed at different time points from their index laparoscopic anti-reflux surgery using paired t test. Standardized quality of life questionnaires were collected for up to 2 years. Group comparisons were made using the Wilcoxon rank-sum test. RESULTS Fifty-eight patients who underwent laparoscopic anti-reflux surgery (magnetic sphincter augmentation or fundoplication) had postoperative functional lumen imaging probe. Thirty-two intraoperative functional lumen imaging probe values were compared with their postoperative functional lumen imaging probe. Fundoplication values did not differ. Postoperative functional lumen imaging probe distensibility index for magnetic sphincter augmentation patients was decreased (P = .04). Functional lumen imaging probe measurements for all postoperative endoscopies showed that magnetic sphincter augmentation had the lowest distensibility index (P < .01). Dysphagia as a reason for endoscopy had a decrease in distensibility index (P = .03). CONCLUSION Functional lumen imaging probe measurements after fundoplication persist at long-term follow up while patients may have a tighter gastroesophageal junction after magnetic sphincter augmentation. Functional lumen imaging probe has the potential to assess the success or failure after laparoscopic anti-reflux surgery and optimize patient outcomes.
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Affiliation(s)
- Hoover Wu
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL.
| | - Mikhail Attaar
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | - Harry J Wong
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | - Michelle Campbell
- Department of Surgery, NorthShore University Health System, Evanston, IL; Department of Surgery, University of Chicago Medical Center, Chicago, IL
| | | | | | - Woody Denham
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - John Linn
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, IL
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18
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Zhuang QJ, Tan ND, Chen SF, Zhang MY, Xiao YL. Magnetic sphincter augmentation in treating refractory gastroesophageal reflux disease: A systematic review and meta-analysis. J Dig Dis 2021; 22:695-705. [PMID: 34693633 DOI: 10.1111/1751-2980.13063] [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: 05/07/2021] [Revised: 09/13/2021] [Accepted: 10/20/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE In this systematic review and meta-analysis we aimed to determine the efficacy and safety of magnetic sphincter augmentation (MSA) in the management of refractory gastroesophageal reflux disease (rGERD). METHODS Literature search was conducted in PubMed, the Cochrane Library, EMBASE, Web of Science, OpenGrey and ClincalTrials.gov for single-arm studies evaluating the efficacy and safety of MSA in rGERD or comparative studies with proton pump inhibitor (PPI) or laparoscopic Nissen fundoplication (LNF) serving as the control published until April 2020. Primary outcome was the rate of postoperative PPI use, and secondary outcomes included postoperative GERD-health-related quality of life (GERD-HRQL), normalization of acid exposure time (AET) and incidence of procedure-related adverse events (AE). RESULTS Ten single-arm studies, one randomized controlled trial and three cohort studies involving 1138 participants were included. Post-MSA PPI withdrawal, significant GERD-HRQL improvement and AET normalization were achieved in 87.0%, 88.0% and 75.0% of the patients, respectively. The incidence of postoperative dysphagia was 29% and endoscopic dilation was required in 7.4% of patients undergoing MSA. MSA showed a better efficacy in symptom control than PPI (PPI cessation: 91% vs 0%; GERD-HRQL improvement: 81% vs 8%) and similar effectiveness but a lower risk of gas-bloat syndrome (risk ratio [RR] 0.69, 95% confidence interval [CI] 0.51-0.93, P = 0.01) and better reserved ability to belch (RR 1.48, 95% CI 0.76-2.86, P = 0.25) compared with LNF. CONCLUSIONS MSA was an effective and safe therapy for rGERD. Well-designed randomized trials that compare the efficacy of MSA with other therapies are needed.
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Affiliation(s)
- Qian Jun Zhuang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Nian Di Tan
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Song Feng Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Meng Yu Zhang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ying Lian Xiao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
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James TJ, Burke JF, Putnam LR, Pan J, Bildzukewicz NA, Bell R, Lipham JC. Loosening the belt on magnetic sphincter augmentation indications: does body mass index matter? Surg Endosc 2021; 36:4878-4884. [PMID: 34750701 DOI: 10.1007/s00464-021-08839-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is an effective treatment for gastroesophageal reflux disease (GERD). However, the impact of obesity on MSA outcomes is unknown. The objective of this study was to evaluate the effectiveness of MSA in patients with GERD and obesity. METHODS A retrospective cohort study was performed of consecutive patients who underwent laparoscopic MSA at three high-volume centers from 2016 to 2019. Patients were grouped into four cohorts according to the World Health Organization body mass index (BMI) classification: BMI < 25 (normal weight), BMI 25-29.9 (overweight), BMI 30-34.9 (obese class I), and BMI > 35 (obese class II-III). Preoperative, operative, and postoperative data were compared between groups. RESULTS A total of 621 patients underwent laparoscopic MSA during the study period. Follow-up with endoscopy or video esophagram was available for 361 patients (58%) with a median follow-up of 15.4 months. Baseline characteristics of the groups were similar except the BMI > 35 group had more females and a higher preoperative median DeMeester score. There were no significant differences in outcomes between normal weight, overweight, and obese patient groups undergoing MSA. All groups experienced significant reductions in acid suppressive medication use, low GERD-HRQL scores, low DeMeester scores, few intraoperative and postoperative complications, and low rates of hiatal hernia recurrence after MSA. CONCLUSIONS Magnetic sphincter augmentation is safe and effective in improving GERD symptoms, reducing esophageal acid exposure, and preventing hiatal hernia recurrence, irrespective of patient BMI. MSA should be considered an acceptable treatment option for obese patients with GERD.
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Affiliation(s)
- Tayler J James
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Jocelyn F Burke
- Institute of Esophageal and Reflux Surgery, Englewood, CO, USA
| | - Luke R Putnam
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Jennifer Pan
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Nikolai A Bildzukewicz
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Reginald Bell
- Institute of Esophageal and Reflux Surgery, Englewood, CO, USA
| | - John C Lipham
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA.
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20
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Siboni S, Ferrari D, Riva CG, Sozzi M, Lazzari V, Milani V, Bonavina L. Reference high-resolution manometry values after magnetic sphincter augmentation. Neurogastroenterol Motil 2021; 33:e14139. [PMID: 33772949 PMCID: PMC8596403 DOI: 10.1111/nmo.14139] [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] [Received: 12/04/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 12/06/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is an innovative antireflux procedure that can improve lower esophageal sphincter (LES) competency and reduce symptoms of gastroesophageal reflux disease (GERD). Some patients report postoperative dysphagia. To date, no studies have described reference high-resolution manometry (HRM) values after MSA implantation. METHODS High-resolution manometry was performed in patients free of dysphagia after MSA with or without concurrent crura repair. Reference values for all parameters of the Chicago Classification were defined as those between the 5th and 95th percentiles. The contribution of concurrent crura repair to LES competency and to reference values was also analyzed. KEY RESULTS Eighty-four patients met the study inclusion criteria. The upper limit of normality for integrated relaxation pressure (IRP) and intrabolus pressure (IBP) was 20.2 mmHg and 30.3 mmHg, respectively. Both variables were higher after MSA compared to normative Chicago Classification v3.0 values. The Distal Contractile Integral upper limit was in the range of normality. Patients undergoing crura repair had a significantly higher IRP (p = 0.0378) and lower GERDQ-A scores (p = 0.0374) and Reflux Symptom Index (p = 0.0030) compared to those who underwent MSA device implantation alone. CONCLUSION & INFERENCES This study provides HRM reference values for patients undergoing successful MSA implantation. Crural repair appears to be a key component of LES augmentation and is associated with improved clinical outcomes.
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Affiliation(s)
- Stefano Siboni
- Division of General and Foregut SurgeryDepartment of Biomedical Sciences for HealthIRCCS Policlinico San DonatoUniversity of MilanMilanItaly
| | - Davide Ferrari
- Division of General and Foregut SurgeryDepartment of Biomedical Sciences for HealthIRCCS Policlinico San DonatoUniversity of MilanMilanItaly
| | - Carlo Galdino Riva
- Division of General and Foregut SurgeryDepartment of Biomedical Sciences for HealthIRCCS Policlinico San DonatoUniversity of MilanMilanItaly
| | - Marco Sozzi
- Division of General and Foregut SurgeryDepartment of Biomedical Sciences for HealthIRCCS Policlinico San DonatoUniversity of MilanMilanItaly
| | - Veronica Lazzari
- Division of General and Foregut SurgeryDepartment of Biomedical Sciences for HealthIRCCS Policlinico San DonatoUniversity of MilanMilanItaly
| | | | - Luigi Bonavina
- Division of General and Foregut SurgeryDepartment of Biomedical Sciences for HealthIRCCS Policlinico San DonatoUniversity of MilanMilanItaly
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21
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Nikolic M, Matic A, Kristo I, Paireder M, Asari R, Osmokrovic B, Semmler G, Schoppmann SF. Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up. Surg Endosc 2021; 36:3019-3027. [PMID: 34159461 PMCID: PMC9001554 DOI: 10.1007/s00464-021-08598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 06/06/2021] [Indexed: 01/19/2023]
Abstract
Background Various technical modifications of Nissen fundoplication (NF) that aim to improve patients’ outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF. Methods 283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed. Results Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively. Conclusion Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF.
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Affiliation(s)
- Milena Nikolic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Aleksa Matic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Matthias Paireder
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Reza Asari
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bogdan Osmokrovic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Semmler
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sebastian F Schoppmann
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Chandan S, Mohan BP, Khan SR, Jha LK, Dhaliwal AJ, Bilal M, Aziz M, Canakis A, Arora S, Malik S, Kassab LL, Ponnada S, Bhat I, Hewlett AT, Sharma N, McDonough S, Adler DG. Clinical efficacy and safety of magnetic sphincter augmentation (MSA) and transoral incisionless fundoplication (TIF2) in refractory gastroesophageal reflux disease (GERD): a systematic review and meta-analysis. Endosc Int Open 2021; 9:E583-E598. [PMID: 33869732 PMCID: PMC8043814 DOI: 10.1055/a-1352-2944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/09/2020] [Indexed: 10/27/2022] Open
Abstract
Abstract
Background and study aims Proton pump inhibitors (PPI) are effective medical therapy options for gastro-esophageal reflux disease (GERD). However, 20 % to 40 % of patients report symptoms despite taking daily PPI. Transoral incisionless fundoplication (TIF2) and magnetic sphincter augmentation (MSA) are less invasive options for the treatment of refractory GERD and are increasingly gaining popularity.
Methods We conducted a comprehensive search of several databases to identify relevant studies. Our primary aim was to compare the efficacy of both interventions reported as improvement in Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score, overall patient satisfaction, improvement in post-procedure regurgitation, and fraction of patients completely off PPI therapy at follow up.
Results Twenty-four studies with 1942 patients were included in the final analysis. Both MSA and TIF2 had comparable technical success and clinical success based on improvement in GERD-HRQL scores i. e. 98.8 % (CI 95.6,99.7) vs 98.5 % (CI 95.7,99.5) and 80.4 % (CI 66,89.6) vs 77.7 % (CI 64.1,87.2), respectively. A significantly greater proportion of patients reported improvement in regurgitation, i. e. 91.1 % (CI 83.8,95.3) vs 73.1 % (CI 62.5,81.7) and were able to completely discontinue PPI therapy with MSA compared to TIF2 i. e. 91.3 % (CI 81.5,96.2) vs 63.8 % (CI 51.6,74.4). Patients’ BMI and presence of a hiatal hernia did not have any effect on procedural outcomes.
Conclusion Both procedures performed at par when comparing clinical success in terms of improvement in GERD-HRQL scores. In terms of overall patient satisfaction, post procedure regurgitation and cumulative number of patients off PPI therapy, MSA outperforms TIF2.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Shahab R. Khan
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Lokesh K. Jha
- Gastroenterology, Parkview Health, Fort Wayne, Indianapolis, United States
| | - Amaninder J. Dhaliwal
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Mohammad Bilal
- Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Muhammad Aziz
- Internal Medicine, University of Toledo, Toledo, Ohio, United States
| | - Andrew Canakis
- Internal Medicine, Boston University Medical Center, Boston, Massachusetts, United States
| | - Sumant Arora
- Gastroenterology & Hepatology, University of Iowa, Iowa City, Iowa, United States
| | - Sarah Malik
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Lena L. Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Suresh Ponnada
- Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, United States
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Alexander T. Hewlett
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Neil Sharma
- Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Stephanie McDonough
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
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Friedman AJ, Elseth AJ, Brockmeyer JR. Proton Pump Inhibitors, Associated Complications, and Alternative Therapies: A Shifting Risk Benefit Ratio. Am Surg 2021; 88:20-27. [PMID: 33560890 DOI: 10.1177/0003134821991988] [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: 01/19/2023]
Abstract
OBJECTIVE Our goal was to compile the most recent and accurate data on the side effects of proton pump inhibitors (PPI). We also compared the efficacy of PPI to the efficacy of different surgical options for acid reflux control. BACKGROUND Proton pump inhibitors are the primary therapy for chronic control of gastroesophageal reflux disease (GERD), but newer studies demonstrate deleterious side effects. Collating this information and contrasting it with surgical therapy for GERD provides evidence for possible practice changes in treatment. METHODS A literature search utilizing PubMed was performed evaluating for PPI and anti-reflux surgery (ARS), focusing on articles that reflected information regarding the usage and efficacy of symptom control of both PPI and ARS. Search terms included "ARS, fundoplication, MSA, acute interstitial nephritis, acute kidney injury, chronic kidney disease, meta-analysis, PPI, H2 blocker, cardiovascular risk, and gut dysbiosis." We evaluated 271 articles by title, abstract, and data for relevance and included 70. RESULTS Long-term control of GERD with PPI may have a greater than expected side effect profile than initially thought. Surgical options may provide greater symptom control than PPI without the side effects of long-term medical therapy. CONCLUSIONS Anti-reflux control can be safely achieved with either PPI or surgical options; however, the long-term side effects noted in the review such as increased risk of cardiovascular events, renal disease, and gut dysbiosis may suggest surgical anti-reflux control as a better long-term option.
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Affiliation(s)
- Alexander J Friedman
- General Surgery Department, 19911Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Anna J Elseth
- General Surgery Department, 19911Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Joel R Brockmeyer
- General Surgery Department, 19911Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
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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: 0.3] [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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Vaezi MF, Shaheen NJ, Muthusamy VR. State of Evidence in Minimally Invasive Management of Gastroesophageal Reflux: Findings of a Scoping Review. Gastroenterology 2020; 159:1504-1525. [PMID: 32621903 DOI: 10.1053/j.gastro.2020.05.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/30/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUNDS & AIMS Endoscopic management of gastroesophageal reflux disease (GERD) is being employed increasingly. The aim of this scoping review was to assess the volume of available evidence on the benefits of endoscopic and minimally invasive surgical therapies for GERD. METHODS criteria were used to perform an extensive literature search of data regarding the reported benefit of endoscopic therapies in GERD. Randomized controlled studies were utilized when available; however, data from observational studies were also reviewed. RESULTS A formal review of evidence was performed in 22 studies. Inclusion and exclusion criteria and study duration were noted and tabulated. Assessment of outcomes was based on symptoms and objective criteria reported by investigators. Reported outcomes for the interventions were tabulated under the heading of subjective (symptom scores, quality of life metrics, and change in proton pump inhibitor use) and objective metrics (pH parameters, endoscopic signs, and lower esophageal sphincter pressure changes). Adverse events were noted and tabulated. The majority of studies showed symptomatic and objective improvement of GERD with the device therapies. Adverse events were minimal. However, normalization of acid exposure occurred in about 50% of patients and, for some modalities, long-term durability is uncertain. CONCLUSIONS This scoping review revealed that the endoluminal and minimally invasive surgical devices for GERD therapy are a promising alternative to proton pump inhibitor therapy. Their place in the treatment algorithm for GERD will be better defined when important clinical parameters, especially durability of effect, are better understood.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Nicholas J Shaheen
- Division of Gastroenterology, Hepatology, and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California
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Kim MS, Oh Y, Lee JH, Park JM, Kim JJ, Song KY, Ryu SW, Seo KW, Kim HI, Kim DJ, Park S, Han SU. Trends in laparoscopic anti-reflux surgery: a Korea nationwide study. Surg Endosc 2020; 35:4241-4250. [PMID: 32875418 DOI: 10.1007/s00464-020-07909-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 08/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND In 2014, the results derived from the nationwide data of the Korean Anti-reflux Surgery Study (KARS) demonstrated short-term feasibility and safety of anti-reflux surgery. This study aimed to update the longer-term safety and feasibility of laparoscopic anti-reflux surgery up to 1-year follow-up with the KARS nationwide cohort. METHODS The data of 310 patients with GERD who received anti-reflux surgery up to 2018 were analyzed. Baseline patient characteristics, postoperative symptom resolution, and postoperative complications were evaluated at postoperative 3 months and 1 year using the questionnaire designed by KARS. We divided the patients into two groups according to the operation period (up to and after 2014) to identify changes in the trends of the characteristics of surgical patients and operative qualities. RESULTS The typical preoperative symptoms were present in 275 patients (91.7%), and atypical symptoms were present in 208 patients (71.0%). Ninety-seven (35.5%) and 124 patients (46.1%) had inadequate PPI responses and hiatal hernia, respectively. At postoperative 1 year, typical and atypical symptoms were either completely or partially controlled in 90.3% and 73.5.0% of patients, respectively. Moderate-to-severe dysphagia, inability to belch, gas bloating, and flatulence at postoperative 1 year were identified in 23.5%, 29.4%, 23.2%, and 22.0% of patients, respectively. The number of surgical patients continuously increased from 2011 to 2018 in Korea. The proportion of patients with hiatal hernia and comorbidities increased (p < 0.01, p = 0.053), and the operation time decreased significantly (p < 0.01) in the late period (2015-2018) as compared with the early period (2011-2014). Symptom control and complication rate were equivalent between the two periods. CONCLUSIONS Anti-reflux surgery was effective with > 90% of typical symptom resolution and posed a comparable postoperative complication rate with those in Western studies with mid-term to long-term follow-up. This result supports the feasibility and safety of anti-reflux surgery as a treatment for GERD in the Korean population.
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Affiliation(s)
- Min Seo Kim
- Korea University College of Medicine, Seoul, Republic of Korea
| | - Youjin Oh
- Korea University College of Medicine, Seoul, Republic of Korea
| | - Jun-Hyun Lee
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jin-Jo Kim
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Kyo Young Song
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Seung Wan Ryu
- Department of Surgery, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Kyung Won Seo
- Department of Surgery, Kosin University College of Medicine, Busan, Republic of Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Kim
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Sungsoo Park
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Inchon-ro 73, Seongbuk-gu, Seoul, 136-705, Republic of Korea.
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, 206 WorldCup-ro, Yeongtong-gu, Suwon, 443-749, Republic of Korea.
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Three-year clinical experience with magnetic sphincter augmentation and laparoscopic fundoplication. Surg Endosc 2020; 35:3449-3458. [PMID: 32676727 PMCID: PMC8195805 DOI: 10.1007/s00464-020-07792-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is a surgical intervention for gastroesophageal reflux disease (GERD) which has been evaluated in numerous studies and has shown beneficial effects. Long-term effectiveness data for MSA as well as laparoscopic fundoplication (LF) in patients with GERD are needed. OBJECTIVE The objective of this study was to evaluate the 3-year outcomes for MSA and LF in patients with GERD. METHODS This prospective, multi-center, observational registry study evaluated MSA and LF in clinical practice over 3 years (ClinicalTrials.gov identifier: NCT01624506). Data collection included baseline characteristics, reflux symptoms, medication use, satisfaction and complications. Post-surgical evaluations were collected at yearly intervals. RESULTS Between December 2009 and December 2014, 631 patients (465 MSA and 166 LF) were enrolled in the registry. Both MSA and LF resulted in improvements in total GERD-HRQL score (mean reduction in GERD-HRQL from baseline to 3 years post-surgery: MSA 22.0 to 4.6 and LF 23.6 to 4.9) and in satisfaction (GERD-HRQL satisfaction increase from baseline to 3 years: MSA 4.6% to 78.2% and LF 3.7% to 76.5%). Most patients were able to belch as needed with both therapies (MSA 97.6% and LF 91.7% at 3 years). MSA allowed a higher percentage of patients the ability to vomit as needed (MSA 91.2% and LF 68.0% at 3 years). PPI usage declined from baseline to 3 years for both groups after surgery (MSA 97.8% to 24.2% and LF 95.8% to 19.5%). The mean procedure time was shorter for MSA than for LF. Intraoperative and procedure-related complication rates (≤ 2%) were low for both therapies. CONCLUSIONS This 3-year prospective observational registry study contributes to the mounting evidence for the effectiveness of MSA and LF. Despite the more severe nature of GERD in the LF group, the clinical outcomes for MSA and LF were favorable from an effectiveness and safety standpoint.
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Bellorin O, Dolan P, Vigiola-Cruz M, Al Hussein Alawamlh O, Pomp A, Dakin G, Afaneh C. Robotic-assisted approaches to GERD following sleeve gastrectomy. Surg Endosc 2020; 35:3033-3039. [PMID: 32572629 DOI: 10.1007/s00464-020-07753-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most common bariatric operation in the United States but increases the incidence of gastroesophageal reflux disease (GERD). The aim of our study was to describe our experience with robotic-assisted management of intractable GERD after SG. METHODS A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted magnetic sphincter augmentation placement after sleeve gastrectomy (MSA-S group) or conversion to Roux-en-Y gastric bypass (RYGB group) for GERD from 2015 to 2019 at our tertiary- care bariatric center. These were compared to a consecutive group of patients undergoing robotic-assisted magnetic sphincter augmentation placement (MSA group) for GERD without a history of bariatric surgery from 2016 to 2019. The primary outcome was perioperative morbidity. Secondary outcomes were operative time (OT), 90-day re-intervention rate, length of stay, symptom resolution and weight change. RESULTS There were 51 patients included in this study; 18 patients in the MSA group, 13 patients in the MSA-S group, and 20 patients in the RYGB group. There was no significant difference in age, gender, ASA score, preoperative endoscopic findings, or DeMeester scores (P > 0.05). BMI was significantly higher in patients undergoing RYGB compared to MSA or MSA-S (P < 0.0001). There were significant differences in OT between the MSA and RYGB groups (P < 0.0001) and MSA-S and RYGB groups (P = 0.009), but not MSA group to MSA-S group (P = 0.51). There was no significant difference in intraoperative and postoperative morbidity (P = 1.0 and P = 0.60, respectively). 30-day morbidity: 5.6% (MSA), 15.4% (MSA-S) and 15% (RYGB). There was no difference on PPI discontinuation among groups, with more than 80% success rate in all. CONCLUSIONS The use of the robotic platform in the different approaches available for treatment of GERD after SG appears to be a feasible option with low morbidity and high success rate. Further data is needed to support our findings.
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Affiliation(s)
- Omar Bellorin
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Patrick Dolan
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Mariana Vigiola-Cruz
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | | | - Alfons Pomp
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Gregory Dakin
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Cheguevara Afaneh
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA.
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Tsai C, Steffen R, Kessler U, Merki H, Lipham J, Zehetner J. Postoperative Dysphagia Following Magnetic Sphincter Augmentation for Gastroesophageal Reflux Disease. Surg Laparosc Endosc Percutan Tech 2020; 30:322-326. [DOI: 10.1097/sle.0000000000000785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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30
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Dunn C, Bildzukewicz N, Lipham J. Magnetic Sphincter Augmentation for Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:325-342. [PMID: 32146949 DOI: 10.1016/j.giec.2019.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Magnetic sphincter augmentation is an effective and safe surgical method for the treatment of gastroesophageal reflux disease (GERD). The device has been compared with twice-daily proton pump inhibitor therapy and laparoscopic fundoplication (in randomized trials and prospective cohort studies, respectively). Magnetic sphincter augmentation was superior to medical therapy and equivalent to surgery for the relief of GERD symptoms. Recent research focuses on implanting the device into more complex patients, such as those with larger hiatal hernias or those with Barrett's esophagus. Additional novel research topics include cost analysis and predicting and minimizing postoperative dysphagia.
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Affiliation(s)
- Colin Dunn
- General Surgery Rutgers NJMS, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101, USA
| | - Nikolai Bildzukewicz
- The Advanced GI/MIS Fellowship, Keck Medical Center of USC, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA 90033-4612, USA
| | - John Lipham
- Upper GI Cancer, Keck Medical Center of USC, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA 90033-4612, USA.
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Spann MD, Harrison NJ, English WJ, Bolduc AR, Aher CV, Williams DB, Hawkins AT. Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass. Am Surg 2020. [DOI: 10.1177/000313482008600336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.
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Affiliation(s)
- Matthew D. Spann
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noah J. Harrison
- Vanderbilt University School of Medicine, Nashville, Tennessee; and
| | - Wayne J. English
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron R. Bolduc
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chetan V. Aher
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D. Brandon Williams
- Department of Surgery, Section of Bariatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander T. Hawkins
- Department of Surgery, Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Riva CG, Siboni S, Sozzi M, Lazzari V, Asti E, Bonavina L. High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease. Neurogastroenterol Motil 2020; 32:e13750. [PMID: 31633258 DOI: 10.1111/nmo.13750] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/13/2019] [Accepted: 10/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation with the Linx® system is a novel laparoscopic procedure for the treatment of gastro-esophageal reflux disease (GERD). Only few data are available regarding the impact of Linx on high-resolution manometry (HRM) variables. METHODS The prospectively collected database of patients who underwent Linx procedure at a single institution was queried. All patients who completed pre- and postoperative HRM, GERD health-related quality of life (GERD-HRQL) questionnaire, and functional outcome swallowing scale (FOSS) questionnaire were included in the study. KEY RESULTS Forty-five out of 304 patients were included. At a median follow-up of 12 months (IQR 10) after surgery, a statistically significant increase of lower esophageal sphincter (LES) total length (P = .002), intra-abdominal length (P = .001), integrated relaxation pressure (IRP), intrabolus pressure (IBP), and esophagogastric contractile integral (EGJ-CI) was noted (P < .001). Distal esophageal amplitude (P = .004), mean distal contractile integral (DCI) (P < .001), post multiple repeated swallows DCI (P = .001), and the percent of normal peristalsis increased (P = .040). All patients were relieved of reflux symptoms. Ineffective esophageal motility reversed to normal in 36% of patients after surgery. The only factor significantly associated with postoperative dysphagia was preoperative dysphagia (P = .006). Postoperatively, a significant correlation between IRP and DCI (r = 0.361 and P = .019) and between IBP and DCI (r = 0.443 and P = .003) was found. CONCLUSIONS AND INFERENCES The Linx procedure had a remarkable effect on esophageal motility in the short-term follow-up. It appears that the overall postoperative increase of IRP and IBP may justify the higher DCI values. Preoperative dysphagia was the only factor associated with postoperative dysphagia.
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Affiliation(s)
- Carlo Galdino Riva
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Stefano Siboni
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Marco Sozzi
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Veronica Lazzari
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Emanuele Asti
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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Schizas D, Mastoraki A, Papoutsi E, Giannakoulis VG, Kanavidis P, Tsilimigras D, Ntourakis D, Lyros O, Liakakos T, Moris D. LINX ® reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies. World J Clin Cases 2020; 8:294-305. [PMID: 32047777 PMCID: PMC7000944 DOI: 10.12998/wjcc.v8.i2.294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/06/2019] [Accepted: 12/14/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication (LF) constitutes the gold-standard method. However, magnetic sphincter augmentation (MSA) using the LINX® Reflux Management System has recently emerged and disputes the standard therapeutic approach.
AIM To investigate the device’s safety and efficacy in resolving GERD symptoms.
METHODS This is a systematic review conducted in accordance to the PRISMA guidelines. We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019.
RESULTS Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor (PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups (e.g., bariatric or large hiatal-hernias) had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD.
CONCLUSION The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.
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Affiliation(s)
- Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Aikaterini Mastoraki
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Chaidari, Athens 11527, Greece
| | - Eleni Papoutsi
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Vassilis G Giannakoulis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Prodromos Kanavidis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Diamantis Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH 45830, United States
| | - Dimitrios Ntourakis
- Department of Surgery, School of Medicine, European University Cyprus, Nicosia 2404, Cyprus
| | - Orestis Lyros
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig 04103, Germany
| | - Theodore Liakakos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27705, United States
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Objective Evidence of Reflux Control After Magnetic Sphincter Augmentation: One Year Results From a Post Approval Study. Ann Surg 2020; 270:302-308. [PMID: 29697454 DOI: 10.1097/sla.0000000000002789] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To report 1-year results from a 5-year mandated study. SUMMARY BACKGROUND DATA In 2012, the United States Food and Drug Administration approved magnetic sphincter augmentation (MSA) with the LINX Reflux Management System (Torax Medical, Shoreview, MN), a novel device for the surgical treatment of gastroesophageal reflux disease (GERD). Continued assessment of safety and effectiveness has been monitored in a Post Approval Study. METHODS Multicenter, prospective study of patients with pathologic acid reflux confirmed by esophageal pH testing undergoing MSA. Predefined clinical outcomes were assessed at the annual visit including a validated, disease-specific questionnaire, esophagogastricduodenoscopy and esophageal pH monitoring, and use of proton pump inhibitors. RESULTS A total of 200 patients (102 males, 98 females) with a mean age of 48.5 years (range 19.7-71.6) were treated with MSA between March 2013 and August 2015. At 1 year, the mean total acid exposure time decreased from 10.0% at baseline to 3.6%, and 74.4% of patients had normal esophageal acid exposure time (% time pH<4 ≤5.3%). GERD Health-Related Quality of Life scores improved from a median score of 26.0 at baseline to 4.0 at 1 year, with 84% of patients meeting the predefined success criteria of at least a 50% reduction in total GERD Health-Related Quality of Life score compared with baseline. The device removal rate at 1 year was 2.5%. One erosion and no serious adverse events were reported. CONCLUSIONS Safety and effectiveness of magnetic sphincter augmentation has been demonstrated outside of an investigational setting to further confirm MSA as treatment for GERD.
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Nikolic M, Schwameis K, Paireder M, Kristo I, Semmler G, Semmler L, Steindl A, Mosleh BO, Schoppmann SF. Tailored modern GERD therapy - steps towards the development of an aid to guide personalized anti-reflux surgery. Sci Rep 2019; 9:19174. [PMID: 31844179 PMCID: PMC6914788 DOI: 10.1038/s41598-019-55510-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 11/28/2019] [Indexed: 12/11/2022] Open
Abstract
As the incidence of gastroesophageal reflux disease (GERD) is rising, surgical treatment is continuously advancing in an effort to minimize side effects, whilst maintaining efficacy. From a database of patients that underwent anti-reflux surgery at our institution between 2015 and 2018, the last 25 consecutive patients that underwent electrical stimulation (ES), magnetic sphincter augmentation (MSA) and Nissen fundoplication (NF), following a personalized treatment decision aid, were included in a comparative analysis. After preoperative evaluation each patient was referred for an ES, MSA or NF based on esophageal motility, hiatal hernia (HH) size and the patients’ preferences. Postoperative gastrointestinal symptoms and GERD-Health-related-Quality-of-Life were assessed. Preoperatively the median DCI (299 ES vs. 1523.5 MSA vs. 1132 NF, p = 0.001), HH size (0.5 cm ES vs. 1 cm MSA vs. 2 cm NF, p = 0.001) and presence of GERD-related symptoms differed significantly between the groups. The highest rate of postoperative dysphagia was seen after MSA (24%, p = 0.04), while the median GERD HRQL total score was equally distributed between the groups. The positive short-term postoperative outcome and patient satisfaction indicate that such an aid in treatment indication, based on esophageal motility, HH size and patient preference, represents a feasible tool for an ideal choice of operation and an individualized therapy approach.
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Affiliation(s)
- Milena Nikolic
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Katrin Schwameis
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Matthias Paireder
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Georg Semmler
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Lorenz Semmler
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Ariane Steindl
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Berta O Mosleh
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Sebastian F Schoppmann
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria.
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Kirkham EN, Main BG, Jones KJB, Blazeby JM, Blencowe NS. Systematic review of the introduction and evaluation of magnetic augmentation of the lower oesophageal sphincter for gastro-oesophageal reflux disease. Br J Surg 2019; 107:44-55. [PMID: 31800095 PMCID: PMC6972716 DOI: 10.1002/bjs.11391] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/13/2019] [Accepted: 09/11/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is reported to be an innovative alternative to antireflux surgery for patients with gastro-oesophageal reflux disease. Although used in practice, little is known about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of MSA and its introduction into clinical practice, in the context of guidelines (such as IDEAL) for evaluating innovative surgical devices. METHODS Systematic searches were used to identify all published studies reporting MSA insertion. Data collected included patient selection, governance arrangements, surgeon expertise, technique description and outcome reporting. RESULTS Searches identified 587 abstracts; 39 full-text papers were included (1 RCT 5 cohort, 3 case-control, 25 case series, 5 case reports). Twenty-one followed US Food and Drug Administration eligibility criteria for MSA insertion. Twenty-six documented that ethical approval was obtained. Two reported that participating surgeons received training in MSA; 18 provided information about how MSA insertion was performed, although techniques varied between studies. Follow-up ranged from 4 weeks to 5 years; in 14 studies, it was less than 1 year. CONCLUSION Most studies on MSA lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness.
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Affiliation(s)
- E N Kirkham
- Conformité Européenne Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK.,Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - B G Main
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,Conformité Européenne University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - K J B Jones
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - J M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,Conformité Européenne University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - N S Blencowe
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,Conformité Européenne University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Guidozzi N, Wiggins T, Ahmed AR, Hanna GB, Markar SR. Laparoscopic magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: systematic review and pooled analysis. Dis Esophagus 2019; 32:5487251. [PMID: 31069388 DOI: 10.1093/dote/doz031] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/27/2019] [Indexed: 02/07/2023]
Abstract
Magnetic sphincter augmentation (MSA) has been proposed as a less invasive, more appealing alternative intervention to fundoplication for the treatment of gastroesophageal reflux disease (GERD). The aim of this study was to evaluate clinical outcomes following MSA for GERD control in comparison with laparoscopic fundoplication. A systematic electronic search for articles was performed in Medline, Embase, Web of Science, and Cochrane Library for single-arm cohort studies or comparative studies (with fundoplication) evaluating the use of MSA. A random-effects meta-analysis for postoperative proton pump inhibitor (PPI) use, GERD-health-related quality of life (GERD-HRQOL), gas bloating, ability to belch, dysphagia, and reoperation was performed. The systematic review identified 6 comparative studies of MSA versus fundoplication and 13 single-cohort studies. Following MSA, only 13.2% required postoperative PPI therapy, 7.8% dilatation, 3.3% device removal or reoperation, and esophageal erosion was seen in 0.3%. There was no significant difference between the groups in requirement for postoperative PPI therapy (pooled odds ratio, POR = 1.08; 95%CI 0.40-2.95), GERD-HRQOL score (weighted mean difference, WMD = 0.34; 95%CI -0.70-1.37), dysphagia (POR = 0.94; 95%CI 0.57-1.55), and reoperation (POR = 1.23; 95%CI 0.26-5.8). However, when compared to fundoplication MSA was associated with significantly less gas bloating (POR = 0.34; 95%CI 0.16-0.71) and a greater ability to belch (POR = 12.34; 95%CI 6.43-23.7). In conclusion, magnetic sphincter augmentation achieves good GERD symptomatic control similar to that of fundoplication, with the benefit of less gas bloating. The safety of MSA also appears acceptable with only 3.3% of patients requiring device removal. There is an urgent need for randomized data directly comparing fundoplication with MSA for the treatment of GERD to truly evaluate the efficacy of this treatment approach.
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Affiliation(s)
- Nadia Guidozzi
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Tom Wiggins
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Ahmed R Ahmed
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, United Kingdom
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Pandolfino J, Lipham J, Chawla A, Ferko N, Hogan A, Qadeer RA. A budget impact analysis of a magnetic sphincter augmentation device for the treatment of medication-refractory mechanical gastroesophageal reflux disease: a United States payer perspective. Surg Endosc 2019; 34:1561-1572. [PMID: 31559575 DOI: 10.1007/s00464-019-06916-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Medication-refractory gastroesophageal reflux disease (GERD) is sometimes treated with laparoscopic Nissen fundoplication (LNF); however, this is a non-reversible procedure associated with important side effects and the need for repeat surgery. Removable magnetic sphincter augmentation (MSA) devices are an alternative, effective, and safe treatment option for such patients who have some lower esophageal sphincter function. The objective of this study was to assess the economic impact of introducing MSA technology (i.e., LINX Reflux Management System) into current practice from a US-payer perspective. METHODS An economic budget impact model was developed over a 1-year time horizon that compared current treatment of GERD patients who are medically managed (but refractory) or receiving LNF to future treatment of GERD patients that included a mix of patients treated with medical management only, LNF, or MSA. Resources included within the analyses were index procedures (inpatient and outpatient use), reoperations (revisions and removals), readmissions, healthcare visits, diagnostic tests, procedures, and medications. Medicare payment rates were typically used to inform unit costs. RESULTS Assuming a hypothetical commercial insurance population of 1 million members, the base-case analysis estimated a net cost savings of $111,367 with introduction of the MSA. This translates to a savings of $0.01 per member per month. Results were largely driven by avoided inpatient procedures with use of the MSA device. Alternative analyses exploring the potential impact of increasing surgical volumes predicted that results would remain cost saving if the proportion of MSA market share taken from LNF was ≥ 90%. CONCLUSIONS This study predicts that the introduction of the MSA device would lead to favorable budget impact results for the treatment of medication-refractory mechanical GERD for commercial payers. Future analyses will benefit from inclusion of middle-ground treatments as well as longer time horizons.
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Affiliation(s)
- John Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair, Chicago, IL, 60611, USA.
| | - John Lipham
- Department of Surgery, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA
| | | | - Nicole Ferko
- Cornerstone Research Group Inc, Burlington, ON, Canada
| | - Andrew Hogan
- Cornerstone Research Group Inc, Burlington, ON, Canada
| | - Rana A Qadeer
- Cornerstone Research Group Inc, Burlington, ON, Canada
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Buckley FP, Havemann B, Chawla A. Magnetic sphincter augmentation: Optimal patient selection and referral care pathways. World J Gastrointest Endosc 2019; 11:472-476. [PMID: 31523378 PMCID: PMC6715569 DOI: 10.4253/wjge.v11.i8.472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/13/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
Outcomes associated with magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD) have been reported, however the optimal population for MSA and the related patient care pathways have not been summarized. This Minireview presents evidence that describes the optimal patient population for MSA, delineates diagnostics to identify these patients, and outlines opportunities for improving GERD patient care pathways. Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018. Clinical experts contextualized the evidence based on clinical experience. The optimal MSA population may be the 2.2-2.4% of GERD patients who, despite optimal medical management, continue experiencing symptoms of heartburn and/or uncontrolled regurgitation, have abnormal pH, and have intact esophageal function as determined by high resolution manometry. Diagnostic work-ups include ambulatory pH monitoring, high-resolution manometry, barium swallow, and esophagogastroduodenoscopy. GERD patients may present with a range of typical or atypical symptoms. In addition to primary care providers (PCPs) and gastroenterologists (GIs), other specialties involved may include otolaryngologists, allergists, pulmonologists, among others. Objective diagnostic testing is required to ascertain surgical necessity for GERD. Current referral pathways for GERD management are suboptimal. Opportunities exist for enabling patients, PCPs, GIs, and surgeons to act as a team in developing evidence-based optimal care plans.
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Affiliation(s)
- F Paul Buckley
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, United States
| | | | - Amarpreet Chawla
- Department of Health Economics and Market Access, Ethicon Inc. (Johnson and Johnson), Cincinnati, OH 45242, United States
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How to choose among fundoplication, magnetic sphincter augmentation or transoral incisionless fundoplication. Curr Opin Gastroenterol 2019; 35:371-378. [PMID: 31033771 DOI: 10.1097/mog.0000000000000550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW To examine current trends and research in nonmedical approaches to the treatment of gastroesophageal reflux disease (GERD). RECENT FINDINGS Long-term studies of GERD patients treated with transoral incisionless fundoplication (TIF) have found that a large portion of patients resume proton pump inhibitor therapy. In patients with uncomplicated GERD, magnetic sphincter augmentation (MSA) shows excellent short-term results in both patient satisfaction and physiologic measures of GERD, with fewer postoperative side-effects than fundoplication, although dysphagia can be problematic. SUMMARY Fundoplication remains the standard of care for patients with GERD complicated by hiatal hernias more than 2 cm, Barrett's esophagus and/or grade C and D erosive esophagitis. For the patient with uncomplicated GERD, MSA appears to be a viable alternative that has greater technical standardization and fewer postoperative side-effects than fundoplication. TIF remains an option for patients with refractory GERD who refuse surgical intervention.
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Kuckelman JP, Phillips CJ, Hardin MO, Martin MJ. Standard vs Expanded Indications for Esophageal Magnetic Sphincter Augmentation for Reflux Disease. JAMA Surg 2019; 152:890-891. [PMID: 28593252 DOI: 10.1001/jamasurg.2017.1606] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John P Kuckelman
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Tacoma, Washington
| | - Cody J Phillips
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Tacoma, Washington
| | - Mark O Hardin
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Tacoma, Washington
| | - Matthew J Martin
- Department of Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Tacoma, Washington
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Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is a modern treatment option for gastroesophageal reflux disease (GERD); however, laparoscopic fundoplication remains the gold standard. The aim of the study was to evaluate outcomes of MSA patients at a reflux center. METHODS A retrospective review was performed of all patients that underwent MSA between March 2012 and November 2017. Out of 110 patients, 68 with a follow-up >3 months were included. Postoperative gastrointestinal symptoms, proton pump inhibitor (PPI) intake, GERD-Health-related Quality of Life (GERD-HRQL) and alimentary satisfaction (AS) were assessed. Postoperative esophageal functioning tests were performed in 50% of patients. RESULTS Sixty-eight patients underwent MSA; hiatal repair was performed in 31 cases. The median OR time was 27 min, and no intraoperative complications occurred. The median follow-up was 13 months (IQR 4.2-45). Endoscopic dilatation was performed in 2 patients (3%) and device removal in another 2 cases. The postoperative GERD-HRQL score was significantly reduced (3 vs. 24; p < 0.001) and the median AS was 8/10. Preoperative experienced heartburn, regurgitations and dysphagia were eliminated in 92, 96 and 100%. Postoperative new-onset difficulties swallowing with solids only were reported to occur occasionally by 16% and rarely by 21% of patients. Satisfaction with heartburn relief was 95%, and the overall outcome was rated excellent/good in 89%. PPI dependency was eliminated in 87%. The median total percentage pH < 4 and number of reflux episodes were significantly reduced. Postoperative pH results were negative or slightly above the norm in 79% and 12%, respectively. CONCLUSION Sphincter augmentation results in significantly reduced reflux symptoms, increased GERD-specific Quality of Life and excellent alimentary satisfaction with low perioperative morbidity. This procedure should be considered an excellent alternative to fundoplication in the treatment of GERD.
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Antiporda M, Jackson C, Smith CD, Bowers SP. Short-Term Outcomes Predict Long-Term Satisfaction in Patients Undergoing Laparoscopic Magnetic Sphincter Augmentation. J Laparoendosc Adv Surg Tech A 2018; 29:198-202. [PMID: 30556776 DOI: 10.1089/lap.2018.0598] [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] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Laparoscopic magnetic sphincter augmentation (MSA) has been shown to be efficacious therapy for gastroesophageal reflux disease (GERD) refractory to maximal medical management. Herein, we present our experience with this procedure and an analysis of our outcomes. MATERIALS AND METHODS Medical records were retrospectively reviewed of 98 patients who underwent laparoscopic MSA for GERD at a single institution from 2012 to 2016. Symptoms were assessed with gastroesophageal reflux disease-health-related quality of life (GERD-HRQL) questionnaire. Objective testing included pH testing, manometry, endoscopy, and upper GI series. Postimplantation interventions were recorded. Median follow-up was 46 months. RESULTS Median preoperative DeMeester score was 32 (interquartile range 21-46). Esophagitis was present in 18%. Hiatal hernia was present in 59%. Operation required full hiatal dissection in 16%. There were no intraoperative complications. Mean hospital stay postimplantation was 18 hours. Reoperative intervention with device explant was necessary in 5 cases, one of which was for intraluminal device erosion. Median GERD-HRQL scores were 25 preoperatively, 8 in short-term follow-up at median 1 month, and 5 in long-term follow-up at median 46 months. Improvement in GERD-HRQL scores was statistically significant with both short and long term compared with preoperative (P < .05), but no different between short- and long-term follow-up. Daily bothersome dysphagia was present in 19 patients preoperatively and in 9 at long-term follow-up. CONCLUSIONS Laparoscopic MSA is associated with excellent outcomes with decrease in GERD-HRQL scores in short term that are durable to longer term follow-up, and with low rates of new-onset dysphagia.
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Affiliation(s)
- Michael Antiporda
- 1 Department of Surgery, Mayo Clinic in Florida , Jacksonville, Florida
| | - Chloe Jackson
- 1 Department of Surgery, Mayo Clinic in Florida , Jacksonville, Florida
| | | | - Steven P Bowers
- 1 Department of Surgery, Mayo Clinic in Florida , Jacksonville, Florida
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Sandhu DS, Fass R. Current Trends in the Management of Gastroesophageal Reflux Disease. Gut Liver 2018; 12:7-16. [PMID: 28427116 PMCID: PMC5753679 DOI: 10.5009/gnl16615] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 01/06/2017] [Indexed: 12/13/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) characterized by heartburn and/or regurgitation symptoms is one of the most common gastrointestinal disorders managed by gastroenterologists and primary care physicians. There has been an increase in GERD prevalence, particularly in North America and East Asia. Over the past three decades proton pump inhibitors (PPIs) have been the mainstay of medical therapy for GERD. However, recently there has been an increasing awareness amongst physicians and patients regarding the side effects of the PPI class of drugs. In addition, there has been a marked decline in the utilization of surgical fundoplication as well as a rise in the development of nonmedical therapeutic modalities for GERD. This review focuses on different management strategies for GERD, optimal management of refractory GERD with special focus on available endoluminal therapies and the future directions.
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Affiliation(s)
- Dalbir S Sandhu
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Zadeh J, Andreoni A, Treitl D, Ben-David K. Spotlight on the Linx™ Reflux Management System for the treatment of gastroesophageal reflux disease: evidence and research. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2018; 11:291-300. [PMID: 30214323 PMCID: PMC6124788 DOI: 10.2147/mder.s113679] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The initial approach to gastroesophageal reflux disease (GERD) management typically involves lifestyle modification and medical therapy utilizing acid reducing agents such as histamine blockers and proton pump inhibitors. In severe cases refractory to such treatments, surgical therapy may be indicated. The gold standard for surgical treatment of GERD is the laparoscopic Nissen fundoplication. In recent years, a new technique known as magnetic sphincter augmentation (MSA) has been developed using the Linx™ Reflux Management System. This is an implantable ring of magnetic beads that is placed around the esophagus at the gastroesophageal junction to restore lower esophageal integrity. The aim of this review is to discuss the current literature regarding indications, surgical technique, efficacy, and complications of MSA using the Linx device. METHODS A standardized literature search was performed yielding 367 abstracts. After elimination due to duplicates between databases and irrelevance, 96 articles remained. The information found to be significant and non-redundant was included in this review. CONCLUSION After several years of clinical application, the Linx device has been shown to not only be effective for the management of GERD but also be as effective as fundoplication. With respect to safety, the most common complication of MSA is dysphagia. This often resolved without intervention, but esophageal dilation or device explanation are occasionally necessary. Not fully appreciated in earlier reviews, erosion of the device into the esophagus appears to be the most significant complication of the device after extended follow-up. While very rare, the potentially severe consequences of this phenomenon suggest that the device should be used with some restraint and that patients should be made aware of this potential morbidity. Fortunately, in the few cases of device erosion described in the literature reviewed, the Linx device was easily and safely removed.
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Affiliation(s)
- Jonathan Zadeh
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
| | - Anthony Andreoni
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
| | - Daniela Treitl
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
| | - Kfir Ben-David
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA,
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Alicuben ET, Bell RCW, Jobe BA, Buckley FP, Daniel Smith C, Graybeal CJ, Lipham JC. Worldwide Experience with Erosion of the Magnetic Sphincter Augmentation Device. J Gastrointest Surg 2018; 22:1442-1447. [PMID: 29667094 DOI: 10.1007/s11605-018-3775-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 04/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The magnetic sphincter augmentation device continues to become a more common antireflux surgical option with low complication rates. Erosion into the esophagus is an important complication to recognize and is reported to occur at very low incidences (0.1-0.15%). Characterization of this complication remains limited. We aim to describe the worldwide experience with erosion of the magnetic sphincter augmentation device including presentation, techniques for removal, and possible risk factors. MATERIALS AND METHODS We reviewed data obtained from the device manufacturer Torax Medical, Inc., as well as the Manufacturer and User Facility Device Experience (MAUDE) database. The study period was from February 2007 through July 2017 and included all devices placed worldwide. RESULTS In total, 9453 devices were placed and there were 29 reported cases of erosions. The median time to presentation of an erosion was 26 months with most occurring between 1 and 4 years after placement. The risk of erosion was 0.3% at 4 years after device implantation. Most patients experienced new-onset dysphagia prompting evaluation. Devices were successfully removed in all patients most commonly via an endoscopic removal of the eroded portion followed by a delayed laparoscopic removal of the remaining beads. At a median follow-up of 58 days post-removal, there were no complications and 24 patients have returned to baseline. Four patients reported ongoing mild dysphagia. CONCLUSIONS Erosion of the LINX device is an important but rare complication to recognize that has been safely managed via minimally invasive approaches without long-term consequences.
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Affiliation(s)
- Evan T Alicuben
- Department of Surgery, Keck Medicine of USC, University of Southern California, 1510 San Pablo St. #514, Los Angeles, CA, 90033, USA
| | | | - Blair A Jobe
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA, USA
- Temple University School of Medicine, Philadelphia, PA, USA
| | - F P Buckley
- Foregut & Reflux Surgery, Dell Medical School, The University of Texas-Austin, Austin, TX, USA
| | | | - Casey J Graybeal
- The Heartburn and Swallowing Center, Northeast Georgia Physicians Group, Gainesville, GA, USA
| | - John C Lipham
- Department of Surgery, Keck Medicine of USC, University of Southern California, 1510 San Pablo St. #514, Los Angeles, CA, 90033, USA.
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Magnetic sphincter augmentation for gastroesophageal reflux disease: review of clinical studies. Updates Surg 2018; 70:323-330. [DOI: 10.1007/s13304-018-0569-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023]
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Crural Closure improves Outcomes of Magnetic Sphincter Augmentation in GERD patients with Hiatal Hernia. Sci Rep 2018; 8:7319. [PMID: 29743599 PMCID: PMC5943411 DOI: 10.1038/s41598-018-24322-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/29/2018] [Indexed: 12/11/2022] Open
Abstract
Magnetic sphincter-augmentation (MSA) has been proven effective in the treatment of GERD. No consensus exists on whether crural closure should be performed. Our aim was to assess the impact of cruroplasty on reflux-control and quality of life. MSA-Patients treated between 03/2012-03/2017 were classified into those without hiatal hernia ("NHH"), those post-MSA (NHR) and those post-MSA/hiatal repair (HR). GERD-symptoms, PPI-intake, GERD-Health-related-Quality-of-Life (GERD-HRQL) and Alimentary Satisfaction were assessed. Sixty-eight patients underwent MSA, 26 patients had additional crural closure. PH-monitoring was negative in 80% of HR, 73% of NHR and 89% of NHH-patients. GERD-HRQL-total scores decreased significantly in all groups (p < 0.001). Alimentary satisfaction was 8/10 in HR/NHH and 10/10 in NHR-patients. Satisfaction with heartburn relief was high (HR: 96%, NR: 95%, NHH: 94%) as was the elimination of PPI-intake (HR/NHH: 87%, NR: 86%). Heartburn and regurgitations were eliminated in 100% of HR, 88% and 94% of NHR and 87% and 91% of NHH-patients. Endoscopic dilatation or device explantation was performed in 3% each. MSA leads to significant symptom relief, increased quality of life and alimentary satisfaction with low perioperative morbidity. Cruroplasty tends to result in better reflux control and symptom relief than exclusive MSA without increasing dysphagia rates.
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Aiolfi A, Asti E, Bernardi D, Bonitta G, Rausa E, Siboni S, Bonavina L. Early results of magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: Systematic review and meta-analysis. Int J Surg 2018; 52:82-88. [PMID: 29471155 DOI: 10.1016/j.ijsu.2018.02.041] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/16/2018] [Accepted: 02/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic Nissen and Toupet fundoplication (LF) are currently considered gold-standard surgical treatment for Gastroesophageal Reflux Disease (GERD). Magnetic Sphincter Augmentation (MSA) is an innovative surgical procedure that has been showed to be effective to control GERD symptoms and to reduce esophageal acid exposure. The aim of this systematic review and meta-analysis was to compare early outcomes of LF and MSA. MATERIALS AND METHODS PubMed, MEDLINE, Embase, and Cochrane databases were consulted matching the terms "Gastroesophageal reflux or heartburn", "LINX or magnetic sphincter augmentation" and "fundoplication". Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I2-index and Cochrane Q-test. Meta-regression was used to address the effect of potential confounders. RESULTS Seven observational cohort studies, published between 2014 and 2017, matched the inclusion criteria. Overall, 1211 patients, 686 MSA and 525 LF, were included. Postoperative morbidity ranged from 0 to 3% in the MSA group and from 0 to 7% in the LF group, and there was no mortality. Dysphagia requiring endoscopic dilatation occurred in 9.3% and 6.6% of patients respectively (OR = 1.56, 95% CI = 0.61-3.95, p = 0.119). The pooled OR of gas/bloat symptoms, ability to vomit, and ability to belch were 0.39 (95% CI 0.25-0.61; p < 0.001), 10.10 (95% CI 5.33-19.15; p < 0.001), and 5.53 (95% CI 3.73-8.19; p < 0.001), respectively. The postoperative GERD-HRQL was similar (p = 0.101). The pooled OR of PPI suspension, endoscopic dilation, and reoperation were similar in the two patients groups (p = 0.548, p = 0.119, p = 0.183, respectively). CONCLUSION Both anti-reflux procedures are safe and effective up to 1-year follow-up. PPI suspension rate, dysphagia requiring endoscopic dilatation, and disease-related quality of life are similar in the two patient groups. MSA is associated with less gas/bloat symptoms and increased ability to vomit and belch.
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Affiliation(s)
- Alberto Aiolfi
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Emanuele Asti
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Daniele Bernardi
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Gianluca Bonitta
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Emanuele Rausa
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Stefano Siboni
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Luigi Bonavina
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
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Rona KA, Tatum JM, Zehetner J, Schwameis K, Chow C, Samakar K, Dobrowolsky A, Houghton CC, Bildzukewicz N, Lipham JC. Hiatal hernia recurrence following magnetic sphincter augmentation and posterior cruroplasty: intermediate-term outcomes. Surg Endosc 2018; 32:3374-3379. [PMID: 29340828 DOI: 10.1007/s00464-018-6059-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/11/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND We have previously reported short-term outcomes after hiatal hernia repair (HHR) at the time of magnetic sphincter augmentation (MSA) for gastroesophageal reflux disease (GERD). Here we report intermediate-term outcomes and hernia recurrence rate after concomitant MSA and HHR. METHODS This is a retrospective cohort study of patients who underwent repair of a hiatal hernia 3 cm or larger at the time of MSA implantation between May 2009 and December 2015. The primary endpoint was hiatal hernia recurrence identified by routine postoperative videoesophagography or endoscopy. Recurrence was defined by a 2 cm or greater upward displacement of the stomach through the diaphragmatic esophageal hiatus. Secondary endpoints included cessation of proton-pump inhibitor (PPI), persistent dysphagia requiring intervention, and GERD health-related quality-of-life (HRQL) scores 1 year from surgery. RESULTS During the study period, 47 of 53 (89%) patients underwent concomitant MSA with HHR and complied with surveillance. Hiatal hernias ranged from 3 to 7 cm (mean 4 ± 1). Mean clinical follow-up time was 19 months (range 1-39). GERD-HRQL score decreased from 20.3 to 3.1 (p < .001), 89% of patients remained off PPIs, and 97% of patients reported improvement or resolution of symptoms. Two recurrent hiatal hernias were identified on surveillance imaging for a recurrence rate of 4.3% at a mean 18 (± 10) months after initial operation. Persistent dysphagia occurred in 13% (6/47) over the first year, which resolved after a single balloon dilation in 67% (4/6). Two patients elected for device removal due to dilation-refractory dysphagia and persistent reflux symptoms. CONCLUSION Concomitant magnetic sphincter augmentation and hiatal hernia repair in patients with gastroesophageal reflux disease and a moderate-sized hiatal hernia demonstrates durable subjective reflux control and an acceptable hiatal hernia recurrence rate at 1- to 2-year follow-up.
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Affiliation(s)
| | | | | | | | - Carol Chow
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | | | | | - Caitlin C Houghton
- Keck Hospital of USC, Los Angeles, CA, USA.,Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Nikolai Bildzukewicz
- Keck Hospital of USC, Los Angeles, CA, USA.,Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - John C Lipham
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA. .,Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA.
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