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Giulini L, Razia D, Latorre-Rodríguez AR, Shacker M, Csucska M, Mittal SK. Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center. J Gastrointest Surg 2023; 27:2308-2315. [PMID: 37715012 DOI: 10.1007/s11605-023-05829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/31/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues. METHODS After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed. RESULTS A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality. CONCLUSIONS HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.
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Affiliation(s)
- Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
- Department of General, Gastrointestinal and Thoracic Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Mark Shacker
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Mate Csucska
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA.
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Ceccarelli G, Valeri M, Amato L, De Rosa M, Rondelli F, Cappuccio M, Gambale FE, Fantozzi M, Sciaudone G, Avella P, Rocca A. Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review. J Robot Surg 2023; 17:1517-1524. [PMID: 36862348 PMCID: PMC9979125 DOI: 10.1007/s11701-023-01546-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review. METHODS We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery. RESULTS Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43-71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110-225) and the mean hospital stay was 3.2 days (range, 2-7). At a mean follow-up of 78 months (range, 18-192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien-Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage. CONCLUSION Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty.
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Affiliation(s)
- Graziano Ceccarelli
- General and Robotic Surgery Department, San Giovanni Battista Hospital, Foligno, Italy
| | - Manuel Valeri
- Department of Surgery, School of Medicine, University of Perugia, Perugia, Italy
| | - Lavinia Amato
- Department of Surgery, School of Medicine, University of Perugia, Perugia, Italy
| | - Michele De Rosa
- General and Robotic Surgery Department, San Giovanni Battista Hospital, Foligno, Italy
| | - Fabio Rondelli
- Department of Surgery, School of Medicine, University of Perugia, Perugia, Italy
| | - Micaela Cappuccio
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, 80131 Naples, Italy
| | - Francesca Elvira Gambale
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, Campobasso, Italy
| | | | - Guido Sciaudone
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, Campobasso, Italy
| | - Pasquale Avella
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, 80131 Naples, Italy
- Department of General Surgery, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | - Aldo Rocca
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, Campobasso, Italy
- Department of General Surgery, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
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Castillo-Larios R, Gunturu NS, Cornejo J, Trooboff SW, Giri AR, Bowers SP, Elli EF. Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-reflux surgery: which is better? Surg Endosc 2023:10.1007/s00464-023-10074-1. [PMID: 37130984 DOI: 10.1007/s00464-023-10074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/26/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Different techniques have been proposed for reoperation after failed anti-reflux surgery. However, there is no consensus on which should be preferred. We aim to report and compare the outcomes of different revisional techniques for failed anti-reflux surgery. METHODS We performed a retrospective analysis of patients who underwent redo fundoplication (RF) or Roux-en-Y gastric bypass (RYGB) conversion after a failed fundoplication at our institution between 2016 and 2021. The primary outcome was long-term presence of reflux or dysphagia following revisional surgery. Secondary outcomes included 30-day perioperative complications as well as long-term use of anti-reflux medication and radiographic recurrence of hiatal hernia (HH). RESULTS A total of 165 (median age 63 years, 73.9% female) patients were included. RF was performed in 120 (73 Toupet and 47 Nissen), RYGB in 38, and 7 patients had fundoplication takedown alone. The RYGB group had a significantly higher BMI, and more prior revisional surgeries compared to the other groups. Median operative time and length of stay were longer for RYGB. Twenty (12.1%) patients experienced postoperative complications, with the highest incidence in the RYGB group. Reflux and dysphagia improved significantly for the whole cohort, with the greatest improvement noted with reflux in the RYGB group (89.5% with preoperative reflux vs. 10.5% with postoperative reflux, p = < .001). On multivariable regression we found that prior re-operative surgery was associated with persistent reflux and dysphagia, whereas RYGB conversion was protective against reflux. CONCLUSION Conversion to RYGB may offer superior resolution of reflux than RF, especially for obese patients.
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Affiliation(s)
- Rocio Castillo-Larios
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Naga Swati Gunturu
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Jorge Cornejo
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Spencer W Trooboff
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | | | - Steven P Bowers
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Enrique F Elli
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Bhat S, Dubey N, Gan SW, Frampton C, Stranz C, Prasad S, Barazanchi AWH, Kanhere H. Efficacy and safety of laparoscopic Roux-en-Y gastric bypass in symptomatic patients following fundoplication failure: a meta-analysis. Esophagus 2023; 20:184-194. [PMID: 36348250 DOI: 10.1007/s10388-022-00969-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022]
Abstract
Revisional surgery may be required in a subset of patients who remain symptomatic despite undergoing laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD). While revisional LF (RLF) is feasible in these patients, laparoscopic Roux-en-Y gastric bypass (LRYGB) may serve as an alternative, although its efficacy and safety remains unknown. This study aimed to determine the outcomes of LRYGB in symptomatic patients following failed LF for GERD. MEDLINE, EMBASE, and PubMed databases were systematically searched for studies reporting LRYGB outcomes in symptomatic adults despite undergoing LF for GERD. Postoperative symptom resolution, recurrence of heartburn and dysphagia, proton pump inhibitor (PPI) use, and body mass index (BMI) reduction were assessed to determine LRYGB efficacy. Postoperative morbidity and mortality were used to evaluate LRYGB safety. Twenty-two studies with 1523 patients were included. Pooled rates of symptom resolution, recurrence of heartburn and dysphagia, PPI use, morbidity, and mortality were 71.6% (95% CI 59.4-86.4), 15.6% (8.9-27.3), 20.7% (12.5-34.3), 29.6% (18.8-46.5), 39.5% (29.9-52.3), and 2.2% (1.2-4.0), respectively, following LRYGB. Similar rates were observed after RLF. However, BMI reduction was significantly greater after LRYGB compared with RLF (mean difference 6.1 kg/m2, 4.8-7.4; p < 0.0001). LRYGB resulted in symptom relief in a majority of patients, and proved comparable to RLF regarding symptom recurrence and PPI use. Morbidity and mortality following LRYGB also did not differ from RLF. However, LRYGB was associated with considerably greater weight loss relative to RLF. Therefore, LRYGB is efficacious and an acceptable revisional procedure in symptomatic GERD patients who have previously undergone LF.
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Affiliation(s)
- Sameer Bhat
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, 1023, New Zealand
| | - Nandini Dubey
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, 1023, New Zealand
| | - Siang Wei Gan
- Department of General Surgery, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | | | - Conrad Stranz
- Department of General Surgery, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Shalvin Prasad
- Department of General Surgery, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Ahmed W H Barazanchi
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, 1023, New Zealand.
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
| | - Harsh Kanhere
- Department of General Surgery, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
- Division of Surgery, University of Adelaide, Adelaide, SA, 5005, Australia
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