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Siemssen B, Hentschel F, Ibach MJ. Long-term results after laparoscopic revision fundoplication: a retrospective, single-center analysis in 194 patients with recurrent hiatal hernia. Esophagus 2024; 21:390-396. [PMID: 38709415 DOI: 10.1007/s10388-024-01060-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/11/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND After laparoscopic fundoplication, 10-20% of patients experience symptom recurrence-often due to resurgence of the hiatal hernia. The standard surgical treatment for such cases remains laparoscopic revision fundoplication. However, there is little data on the time frame and anatomic patterns of failed fundoplications. Additionally, few large studies exist on the long-term efficacy and safety of laparoscopic revision fundoplication. METHODS In a single-center, retrospective analysis of 194 consecutive revision fundoplications for recurrent reflux disease due to hiatal hernia, we collected data on time to failure and patterns of failure of the primary operation, as well as on the efficacy and safety of the revision. RESULTS The median time to failure of the primary fundoplication was 3 years. Most hiatal defects were smaller than 5 cm and located anteriorly or concentric around the esophagus. Laparoscopic redo fundoplication was technically successful in all cases. The short-term complication rate was 9%, mainly dysphagia requiring endoscopic intervention. At a mean follow-up of 4.7 years, 77% of patients were symptom-free, 14% required daily PPI, and 9% underwent secondary revision. Cumulative failure rates were 9%, 23%, and 31% at 1, 5, and 10 years. CONCLUSION The majority of failed fundoplications occur within 3 years of primary surgery, with most patients exhibiting anterior or concentric defects. For these patients, laparoscopic revision fundoplication is a safe procedure with a low rate of short-term complications and satisfactory long-term results.
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Affiliation(s)
- Björn Siemssen
- Department of Surgery, MIC Klinik, Kurstr. 11, 14129, Berlin, Germany.
| | - Florian Hentschel
- Medizinische Hochschule Brandenburg, Zentrum für Innere Medizin Universitätsklinikum Brandenburg an der Havel, Brandenburg, Germany
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Hanna NM, Kumar SS, Collings AT, Pandya YK, Kurtz J, Kooragayala K, Barber MW, Paranyak M, Kurian M, Chiu J, Abou-Setta A, Ansari MT, Slater BJ, Kohn GP, Daly S. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc 2024; 38:2917-2938. [PMID: 38630179 DOI: 10.1007/s00464-024-10816-9] [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: 01/30/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia. METHODS We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively. RESULTS We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery. CONCLUSIONS The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
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Affiliation(s)
- Nader M Hanna
- Department of Surgery, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Yagnik K Pandya
- Department of Surgery, MetroWest Medical Center, Framingham, MA, USA
| | - James Kurtz
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | | | - Meghan W Barber
- Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA
| | - Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Marina Kurian
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | | | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | | | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, Australia
- Melbourne Upper GI Surgical Group, Melbourne, Australia
| | - Shaun Daly
- Department of Surgery, University of California Irvine, Irvine, USA
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Lee J, Lee I, Oh Y, Kim JW, Kwon Y, Alromi A, Eledreesi M, Khalid A, Aljarbou W, Park S. Current Status of Anti-Reflux Surgery as a Treatment for GERD. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:518. [PMID: 38541244 PMCID: PMC10972421 DOI: 10.3390/medicina60030518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/01/2024] [Accepted: 03/20/2024] [Indexed: 06/29/2024]
Abstract
Anti-reflux surgery (ARS) is an efficient treatment option for gastroesophageal reflux disease (GERD). Despite growing evidence of the efficacy and safety of ARS, medications including proton pump inhibitors (PPIs) remain the most commonly administered treatments for GERD. Meanwhile, ARS can be an effective treatment option for patients who need medications continuously or for those who are refractory to PPI treatment, if proper candidates are selected. However, in practice, ARS is often regarded as a last resort for patients who are unresponsive to PPIs. Accumulating ARS-related studies indicate that surgery is equivalent to or better than medical treatment for controlling typical and atypical GERD symptoms. Furthermore, because of overall reduced medication expenses, ARS may be more cost-effective than PPI. Patients are selected for ARS based on endoscopic findings, esophageal acid exposure time, and PPI responsiveness. Although there is limited evidence, ARS may be expanded to include patients with normal acid exposure, such as those with reflux hypersensitivity. Additionally, other factors such as age, body mass index, and comorbidities are known to affect ARS outcomes; and such factors should be considered. Nissen fundoplication or partial fundoplication including Dor fundoplication and Toupet fundoplication can be chosen, depending on whether the patient prioritizes symptom improvement or minimizing postoperative symptoms such as dysphagia. Furthermore, efforts to reduce and manage postoperative complications and create awareness of the long-term efficacy and safety of the ARS are recommended, as well as adequate training programs for new surgeons.
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Affiliation(s)
- Jooyeon Lee
- Department of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Inhyeok Lee
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Youjin Oh
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Jeong Woo Kim
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Yeongkeun Kwon
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Ahmad Alromi
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- The Jordanian Ministry of Health, Department of General Surgery, Princes Hamzh Hospital, Amman 11947, Jordan
| | - Mohannad Eledreesi
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- Taif Armed Forces Hospital, Taif 26792, Saudi Arabia
| | - Alkadam Khalid
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Wafa Aljarbou
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- Dr. Sulaiman Al Habib Hospital, Riyadh 34423, Saudi Arabia
| | - Sungsoo Park
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
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Nurminen NMJ, Järvinen TKM, Kytö VJ, Salo SAS, Egan CE, Andersson SE, Räsänen JV, Ilonen IKP. Malpractice claims after antireflux surgery and paraesophageal hernia repair: a population-based analysis. Surg Endosc 2024; 38:624-632. [PMID: 38012443 PMCID: PMC10830758 DOI: 10.1007/s00464-023-10572-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts. METHODS A population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register. RESULTS During the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery. CONCLUSIONS The rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications.
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Affiliation(s)
- Nelli M J Nurminen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Tommi K M Järvinen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Ville J Kytö
- Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Silja A S Salo
- Gastrointestinal Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Caitlin E Egan
- Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA
| | | | - Jari V Räsänen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Ilkka K P Ilonen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland
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Ovaere S, Depypere L, Van Veer H, Moons J, Nafteux P, Coosemans W. The Belsey Mark IV procedure in the era of minimally invasive antireflux surgery. Dis Esophagus 2023; 36:doad042. [PMID: 37408470 DOI: 10.1093/dote/doad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Different surgical techniques exist in the treatment of giant and complex hiatal hernia. The aim of this study was to identify the role of the Belsey Mark IV (BMIV) antireflux procedure in the era of minimally invasive techniques. METHODS A single-center, retrospective cohort study was conducted. All patients who underwent an elective BMIV procedure aged 18 years or older, during a 15-year period (January 1, 2002 until December 31, 2016), were included. Demographics, pre-, per- and postoperative data were analyzed. Three groups were compared. Group A: BMIV as first procedure-group B: BMIV as a second procedure (first redo intervention)-group C: patients who had two or more previous antireflux interventions. RESULTS A total of 216 patients were included for analysis (group A n = 127; group B n = 51; group C n = 38). Median follow-up in groups A, B and C was 28, 48 and 56 months, respectively. Patients in group A were older and had a higher American Society of Anesthesiologists score compared to groups B and C. There was zero mortality in all groups. The severe complication rate of 7.9% in group A was higher compared with the 2.9% in group B and 3.9% in group C. Long-term outcome showed true recurrence, defined as both radiographic recurrence as well as associated symptoms, in 9.5% of cases in group A, 24.5% in group B and 44.7% in group C. CONCLUSIONS The BMIV procedure is a safe procedure with good results, moreover in the aging and comorbid patient with primary repair of a giant hiatal hernia.
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Affiliation(s)
- Sander Ovaere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
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Liu DS, Allan Z, Wong DJ, Goh SK, Stevens S, Aly A, Bright T, Watson DI. Pre-existing hiatal mesh increases morbidity during and after revisional antireflux surgery: A retrospective multicenter study. Surgery 2023; 174:549-557. [PMID: 37369605 DOI: 10.1016/j.surg.2023.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Revisional antireflux surgery, including hiatus hernia repair, is increasingly common. Mesh-augmented hiatal closure at the time of index operation is controversial but commonly performed. Although a meta-analysis of randomized data has demonstrated no additional benefit of routine mesh placement, it is unclear whether this practice results in harm, particularly at the time of revisional antireflux surgery. We determined whether pre-existing mesh at the hiatus increases morbidity during and after revisional antireflux surgery. METHODS Analysis of prospectively-maintained databases of all elective revisional antireflux surgery cases in 36 hospitals across Australia took place over 10 years. Intraoperative and postoperative outcomes of patients with and without prior hiatal mesh were compared. Propensity score-matched analysis was used to validate primary findings. RESULTS A total of 346 revisional cases (35 with pre-existing mesh) were analyzed. The 2 groups had comparable baseline characteristics. In total, 77 (22.2%) patients had 148 intraoperative adverse events. Pre-existing mesh was associated with a higher risk of intraoperative complications (48.6% vs 22.5%, odds ratio 3.25, 95% confidence interval 1.63-6.38, P = .002), secondary to bleeding, and lacerations to pleura, lung, and liver. Overall, 63 (18.2%) patients developed postoperative complications. Pre-existing mesh was associated with increased postoperative morbidity (37.1% vs 16.1%, odds ratio 3.09, 95% confidence interval 1.50-6.43, P = .005), particularly due to bleeding and respiratory complications. Importantly, pre-existing mesh independently predicted the occurrence of intraoperative and postoperative complications. CONCLUSION Prior hiatal mesh significantly increases morbidity during and after revisional antireflux surgery. Given that revisional surgery is increasingly being performed, our findings discourage routine mesh use during primary antireflux surgery.
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Affiliation(s)
- David S Liu
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia; General and Gastrointestinal Surgery Research and Trials Group, The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia.
| | - Zexi Allan
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Darren J Wong
- General and Gastrointestinal Surgery Research and Trials Group, The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia; Department of Gastroenterology, Austin Health, Heidelberg, Victoria, Australia
| | - Su Kah Goh
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Sean Stevens
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia; General and Gastrointestinal Surgery Research and Trials Group, The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia
| | - Ahmad Aly
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia; The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia
| | - Tim Bright
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia; Discipline of Surgery, College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - David I Watson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia; Discipline of Surgery, College of Medicine and Public Health, Flinders University, South Australia, Australia
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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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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9
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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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10
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Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review. J Robot Surg 2023:10.1007/s11701-023-01546-6. [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] [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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Ghosh G, Choi AY, Dbouk M, Greenberg J, Zarnegar R, Murray M, Janu P, Thosani N, Dayyeh BKA, Diehl D, Nguyen NT, Chang KJ, Canto MI, Sharaiha R. Transoral incisionless fundoplication for recurrent symptoms after laparoscopic fundoplication. Surg Endosc 2023; 37:3701-3709. [PMID: 36650353 DOI: 10.1007/s00464-023-09880-4] [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: 10/22/2022] [Accepted: 01/08/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Revision of a failed laparoscopic fundoplication carries higher risk of complication and lower chance of success compared to the original surgery. Transoral incisionless fundoplication (TIF) may be an endoscopic alternative for select GERD patients without need of a moderate/large hiatal hernia repair. The aim of this study was to assess feasibility, efficacy, and safety of TIF 2.0 after failed laparoscopic Nissen or Toupet fundoplication (TIFFF). METHODS This is a multicenter retrospective cohort study of patients who underwent TIFFF between September 2017 and December 2020 using TIF 2.0 technique (EsophyX Z/Z+) performed by gastroenterologists and surgeons. Patients were included if they had (1) recurrent GERD symptoms, (2) pathologic reflux based upon pH testing or Grade C/D esophagitis or Barrett's esophagus, and (3) hiatal hernia ≤ 2 cm. The primary outcome was improvement in GERD Health-Related Quality of Life (GERD-HRQL) post-TIFFF. The TIFFF cohort was also compared to a similar surgical re-operative cohort using propensity score matching. RESULTS Twenty patients underwent TIFFF (median 4.1 years after prior fundoplication) and mean GERD-HRQL score improved from 24.3 ± 22.9 to 14.75 ± 21.6 (p = 0.014); mean Reflux Severity Index (RSI) score improved from 14.1 ± 14.6 to 9.1 ± 8.0 (p = 0.046) with 8/10 (80%) of patients with normal RSI (< 13) post-TIF. Esophagitis healed in 78% of patients. PPI use decreased from 85 to 55% with 8/20 (45%) patients off of PPI. Importantly, mean acid exposure time decreased from 12% ± 17.8 to 0.8% ± 1.1 (p = 0.028) with 9/9 (100%) of patients with normalized pH post-TIF. There were no statistically significant differences in clinical efficacy outcomes between TIFFF and surgical revision, but TIFFF had significantly fewer late adverse events. CONCLUSION Endoscopic rescue with TIF is a safe and efficacious alternative to redo laparoscopic surgery in symptomatic patients with appropriate anatomy and objective evidence of persistent or recurrent reflux.
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Affiliation(s)
- Gaurav Ghosh
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1283 York Ave, 9th Floor, New York, NY, 10065, USA.
| | - Alyssa Y Choi
- HH Chao Comprehensive Digestive Disease Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jacques Greenberg
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | | | - Peter Janu
- Fox Valley Surgical Associates, Affinity Health Systems, Appleton, WI, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA, USA
| | - Ninh T Nguyen
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Kenneth J Chang
- HH Chao Comprehensive Digestive Disease Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1283 York Ave, 9th Floor, New York, NY, 10065, USA
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12
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Jaruvongvanich VK, Matar R, Reisenauer J, Janu P, Mavrelis P, Ihde G, Murray M, Singh S, Kolb J, Nguyen NT, Thosani N, Wilson EB, Zarnegar R, Chang K, Canto MI, Abu Dayyeh BK. Hiatal hernia repair with transoral incisionless fundoplication versus Nissen fundoplication for gastroesophageal reflux disease: A retrospective study. Endosc Int Open 2023; 11:E11-E18. [PMID: 36618876 PMCID: PMC9812651 DOI: 10.1055/a-1972-9190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/19/2022] [Indexed: 01/06/2023] Open
Abstract
Background and study aims Concomitant hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) is a therapeutic option for patients with HH > 2 cm and gastroesophageal reflux disease (GERD). Data comparing this approach with laparoscopic Nissen fundoplication (LNF) are lacking. We performed an exploratory analysis to compare these two approaches' adverse events (AEs) and clinical outcomes. Patients and methods This was a multicenter retrospective cohort study of HH repair followed by LNF versus HH repair followed by TIF in patients with GERD and moderate HH (2-5 cm). AEs were assessed using the Clavien-Dindo classification. Symptoms (heartburn/regurgitation, bloating, and dysphagia) were compared at 6 and 12 months. Results A total of 125 patients with HH repair with TIF and 70 with HH repair with LNF were compared. There was no difference in rates of discontinuing or decreasing proton pump inhibitor use, dysphagia, esophagitis, disrupted wrap, and HH recurrence between the two groups ( P > 0.05). The length of hospital stay (1 day vs. 2 days), 30-day readmission rate (0 vs. 4.3 %), early AE rate (0 vs. 18.6 %), and early serious AE rate (0 vs. 4.3 %) favored TIF (all P < 0.05). The rate of new or worse than baseline bloating was lower in the TIF group at 6 months (13.8 % vs. 30.0 %, P = 0.009). Conclusions Concomitant HH repair with TIF is feasible and associated with lower early and serious AEs compared to LNF. Further comparative efficacy studies are warranted.
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Affiliation(s)
| | - Reem Matar
- Mayo Clinic – Gastroenterology and Hepatology, Rochester, Minnesota, United States
| | | | - Peter Janu
- Fox Valley Technical College, ThedaCare Regional Medical System, Appleton, Wisconsin, United States
| | - Peter Mavrelis
- Methodist Hospitals Inc. – Surgery, Gary, Indiana, United States
| | - Glenn Ihde
- Matagorda Regional Medical Center – Matagorda Medical Group, Bay City, Texas, United States
| | - Michael Murray
- UNRMed – University of Nevada, Reno, Nevada, United States
| | - Sneha Singh
- Mayo Clinic – Gastroenterology and Hepatology, Rochester, Minnesota, United States
| | - Jennifer Kolb
- UCIrvine – Gastroenterology, Irvine, California, United States
| | | | - Nirav Thosani
- University of Texas McGovern Medical School – Gastroenterology, Hepatology and Nutrition, Houston, Texas, United States
| | - Erik B. Wilson
- University of Texas McGovern Medical School – Surgery, Houston, Texas, United States
| | - Rasa Zarnegar
- Weill Cornell Medical College – Surgery, New York, New York, United States
| | - Kenneth Chang
- UCIrvine – Gastroenterology, Irvine, California, United States
| | - Marcia I. Canto
- Johns Hopkins Hospital and Health System – Gastroenterology, Baltimore, Maryland, United States
| | - Barham K. Abu Dayyeh
- Mayo Clinic – Gastroenterology and Hepatology, Rochester, Minnesota, United States
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13
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Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution. Surg Endosc 2023; 37:624-630. [PMID: 35713721 DOI: 10.1007/s00464-022-09359-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/16/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. METHODS A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis. RESULTS One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. CONCLUSION Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.
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14
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Pascotto B, Henrard A, Maillart JF, Arenas-Sanchez M, Postal A, Legrand M. Quality of life and gastric acid-suppression medication post-laparoscopic fundoplication: a ten years retrospective study. Acta Chir Belg 2022; 122:321-327. [PMID: 33534655 DOI: 10.1080/00015458.2020.1860551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background: Although medical treatment is the best approach for treating gastroesophageal reflux disease (GERD), surgery has a significant role to play not only in cases of failure of medical treatment but also as in a long-term approach, specifically in young patient. On the other hand, alarming reports have been published concerning the outcomes and usefulness of antireflux surgery (ARS). The aim of this study was to evaluate medium and long-term functional outcomes following ARS performed in our institution over a 10 year period.Methods: This was a retrospective review of patients in our department who underwent primary or redo laparoscopic fundoplication between 2005 and 2015. Evaluation of the outcomes was made using a validated questionnaire specifically dedicated to GERD (the Gastroesophageal Reflux Disease - Health-Related Quality of Life (GERD-HRQL) questionnaire) and by investigation about the continued use of proton-pump inhibitors (PPIs). Exclusion criteria were patients treated for GERD with Roux-en-Y gastric bypass, emergency reduction of hiatal hernia, patients missing from follow-up and patients deceased from unrelated causes.Results: 296 patients out of 309 met the inclusion criteria. Primary procedures included 214 Nissen, 35 Toupet, and 23 Collis gastroplasty; there were additionally 62 redo operations. Neither postoperative mortality nor conversion was observed. The mean follow-up was 8 years post-surgery, and contact was made with 96% of the original group. 85% of the patients had stopped PPI use since their operation (86% after Nissen, 73% after Toupet, 94% after Collis and 82% after redos). 90% of the patients had good to excellent functional results as reported by their GERD-HRQL score, and independent of the type of previous procedure. 31 patients were dissatisfied due to dysphagia in 7 and GERD recurrence in 24. Again 75% were extremely satisfied and 15% satisfied. Our own incidence of redo procedures was 11% but the functional result and satisfaction index were comparable between redo and primary procedures. The addition of Collis gastroplasty in cases of real short oesophagus did not alter the final result.Conclusions: Laparoscopic ARS presents a superior alternative to lifetime medication use and can provide long-term control of GERD symptoms in the majority of patients if it is performed skillfully and in carefully evaluated patients. Based on the present study, we believed that significant improvement in GERD health-related quality of life can be attained following both primary and reoperative ARS.
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Affiliation(s)
- Beniamino Pascotto
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
| | - Alexandre Henrard
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
| | | | | | - Alain Postal
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
| | - Marc Legrand
- Digestive Surgery Department, Regional Hospital Centre of Huy, Huy, Belgium
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15
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Fuchs KH, Breithaupt W, Varga G, Babic B, Eckhoff J, Meining A. How effective is laparoscopic redo-antireflux surgery? Dis Esophagus 2022; 35:6490086. [PMID: 34969079 DOI: 10.1093/dote/doab091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The failure-rate after primary antireflux surgery ranges from 3 to 30%. Reasons for failures are multifactorial. The aim of this study is to gain insight into the complex reasons for, and management of, failure after antireflux surgery. METHODS Patients were selected for redo-surgery after a diagnostic workup consisting of history and physical examination, upper gastrointestinal endoscopy, quality-of-life assessment, screening for somatoform disorders, esophageal manometry, 24-hour-pH-impedance monitoring, and selective radiographic studies such as Barium-sandwich for esophageal passage and delayed gastric emptying. Perioperative and follow-up data were compiled between 2004 and 2017. RESULTS In total, 578 datasets were analyzed. The patient cohort undergoing a first redo-procedure (n = 401) consisted of 36 patients after in-house primary LF and 365 external referrals (mean age: 62.1 years [25-87]; mean BMI 26 [20-34]). The majority of patients underwent a repeated total or partial laparoscopic fundoplication. Major reasons for failure were migration and insufficient mobilization during the primary operation. With each increasing number of required redo-operations, the complexity of the redo-procedure itself increased, follow-up quality-of-life decreased (GIQLI: 106; 101; and 100), and complication rate increased (intraoperative: 6,4-10%; postoperative: 4,5-19%/first to third redo). After three redo-operations, resections were frequently necessary (morbidity: 42%). CONCLUSIONS Providing a careful patient selection, primary redo-antireflux procedures have proven to be highly successful. It is often the final chance for a satisfying result may be achieved upon performing a second redo-procedure. A third revision may solve critical problems, such as severe pain and/or inadequate nutritional intake. When resection is required, quality of life cannot be entirely normalized.
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Affiliation(s)
- K H Fuchs
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany
| | - W Breithaupt
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - G Varga
- AGAPLESION Markus Krankenhaus, Department of General and Visceral Surgery, Frankfurt, Germany
| | - B Babic
- University of Cologne, Department of General-, Visceral-and Cancer Surgery, Cologne, Germany
| | - J Eckhoff
- University of Cologne, Department of General-, Visceral-and Cancer Surgery, Cologne, Germany
| | - A Meining
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany.,University of Würzburg, Zentrum Innere Medizin, Head of Gastroenterology, Würzburg, Germany
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16
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Gan SW, Lee N, Tan SE, Edwards SM, Kiroff GK, Myers JC. Quantification of fluoroscopic fundoplication anatomy: inter- and intraobserver reliability. Dis Esophagus 2022; 35:6313267. [PMID: 34215875 DOI: 10.1093/dote/doab045] [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: 11/03/2020] [Revised: 03/04/2021] [Accepted: 06/11/2021] [Indexed: 12/11/2022]
Abstract
The etiology of postfundoplication dysphagia remains incompletely understood. Subtle changes of gastroesophageal junction (GEJ) anatomy may be contributory. Barium swallows have potential for standardization to evaluate postsurgical anatomical features. Using structured barium swallows, we aim to identify reproducible, objectively measured postfundoplication anatomical features that will permit future comparison between patients with/without dysphagia. At 6-12 months of postfundoplication, 31 patients underwent structured barium swallow with video-fluoroscopy recording: standing anteroposterior; standing oblique (×2); prone oblique (×2); and prone oblique with continuous free drinking. A primary observer recorded 11 variables of GEJ anatomy for each view, repeated 3 months later, forming two datasets to assess intraobserver consistency. Interobserver reliability was determined using a dataset each from the primary observer and two medical students (after training). Intraclass correlation coefficients (ICC) were based on two-way mixed-effects model (ICC agreement: 0.40-0.59 'fair'; 0.60-0.74 'good'; 0.75-1.00 'excellent'). Interobserver reliability was good-excellent for 47 of 66 measurements. Measures of maximal esophageal diameter cf. wrap opening diameter and posterior esophageal angle showed high interobserver reproducibility on all views (ICC range 0.84-0.91; 0.68-0.80, respectively). Interobserver agreement was good-excellent for 5/6 views when measuring anterior GEJ displacement and axis deviation (ICC range 0.56-0.79; 0.41-0.77, respectively). Measures of wrap length showed lower reproducibility. Prone oblique measurements showed highest reproducibility (good-excellent agreement in 19/22 measurements). Intraobserver consistency was excellent for 98% of measurements (ICC range 0.74-0.99). Objective measurements of postfundoplication GEJ anatomy using structured barium swallow are reproducible and may allow further interrogation of anatomical features contributing to postfundoplication dysphagia.
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Affiliation(s)
- Siang Wei Gan
- Department of Surgery, The Queen Elizabeth Hospital & University of Adelaide, Adelaide, Australia
| | - Natalie Lee
- Adelaide Medical School, Faculty of Health & Sciences, University of Adelaide, Adelaide, Australia
| | - Siao En Tan
- Adelaide Medical School, Faculty of Health & Sciences, University of Adelaide, Adelaide, Australia
| | - Suzanne M Edwards
- Adelaide Health Technology Assessment, School of Public Health, University of Adelaide, Adelaide, Australia
| | - George K Kiroff
- Department of Surgery, The Queen Elizabeth Hospital & University of Adelaide, Adelaide, Australia
| | - Jennifer C Myers
- Department of Surgery, The Queen Elizabeth Hospital & University of Adelaide, Adelaide, Australia
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17
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Fuchs KH, Breithaupt W, Varga G, Babic B, Schulz T, Meining A. Primary laparoscopic fundoplication in selected patients with gastroesophageal reflux disease. Dis Esophagus 2022; 35:6277415. [PMID: 34002235 DOI: 10.1093/dote/doab032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite proton pump inhibitors being a powerful therapeutic tool, laparoscopic fundoplication (LF) has proven successful in the treatment of gastroesophageal reflux disease (GERD), through mechanical augmentation of a weak antireflux barrier and the advantages of minimally invasive access. A critical patient selection for LF, based on thorough preoperative assessment, is important for the management of GERD-patients. The purpose of this study is to provide an overview on the management of GERD-patients treated by primary LF in a specialized center and to illustrate the possible outcome after several years. METHODS Patients were selected after going through diagnostic workup consisting of patient's history and physical examination, upper gastrointestinal endoscopy, assessment of gastrointestinal Quality of Life Index, screening for somatoform disorders, functional assessment by esophageal manometry, (impedance)-24-hour-pH-monitoring, and selective radiographic studies. The indication for LF was based on EAES-guidelines. Either a floppy and short Nissen fundoplication was performed or a posterior Toupet-hemifundoplication was chosen. A long-term follow-up assessment was attempted after surgery. RESULTS In total, n = 1131 patients were evaluated (603 males; 528 females; mean age; 48.3 years; and mean body mass index: 27). The mean duration between onset of symptoms and surgery was 8 years. Nissen: n = 873, Toupet: n = 258; conversion rateerativ: 0.5%; morbidity 4%, mortality: 1 (1131). Mean follow-up (n = 898; 79%): 5.6 years; pre/post-op results: esophagitis: 66%/12.1%; Gastrointestinal Quality of Life Index: median: 92/119; daily proton pump inhibitors-intake after surgery: 8%; and operative revisions 4.3%. CONCLUSIONS In conclusion, our data show that careful patient selection for laparoscopic fundoplication and well-established technical concepts of mechanical sphincter augmentation can provide satisfying results in the majority of patients with severe GERD.
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Affiliation(s)
- K H Fuchs
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany
| | - W Breithaupt
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - G Varga
- AGAPLESION Markus Krankenhaus, Department of General and Visceral Surgery, Frankfurt, Germany
| | - B Babic
- University of Cologne, Department of General-, Visceral-and Cancer Surgery, Cologne, Germany
| | - T Schulz
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - A Meining
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany.,University of Würzburg, Zentrum Innere Medizin, Head of Gastroenterology, Würzburg, Germany
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18
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Braghetto I, Korn O, Figueroa-Giralt M, Valenzuela C, Burgos AM, Mandiola C, Sotomayor C, Villa E. LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1678. [PMID: 36102488 PMCID: PMC9462863 DOI: 10.1590/0102-672020220002e1678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.
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19
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Bardini R, Battaglia S, Scarpa M, Savarino E. How a modified Nissen procedure works: a mechanistic study using intraoperative esophageal high-resolution manometry. Langenbecks Arch Surg 2021; 407:123-129. [PMID: 34564758 DOI: 10.1007/s00423-021-02317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed at demonstrating how a modified Nissen procedure works by analyzing intraoperatively the variations of the low esophageal sphincter pressure values using high resolution manometry. METHODS This study included 15 patients with documented gastroesophageal reflux disease who underwent a laparoscopic modified Nissen procedure. Data regarding the changes in the pressure values were recorded at each step of the procedures using high resolution manometry and after the progressive insufflation of air in the stomach. Categorical data were compared between the preoperative and postoperative periods using Fisher's test, and continuous data were compared using Mann-Whitney U non-parametric test. Preoperative versus postoperative variations in continuous data were assessed using Wilcoxon's non-parametric test for paired data. RESULTS Intraoperative manometric data showed a rise of basal LES pressure until the creation of the wrap. An evident increase of pressure values was recorded after gastric air insufflation, as consequence of the increase of intragastric pressure. No intraoperative and postoperative complications were observed. All patients experienced a significant reduction in terms of intensity and frequency of gastroesophageal reflux symptoms and no patients complained of dysphagia. CONCLUSIONS Intraoperative high resolution manometry was feasible in all patients and demonstrated that the modified Nissen procedure works by increasing the LES pressure in response to gastric distension, without impeding the progression of the bolus into the stomach.
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Affiliation(s)
- Romeo Bardini
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy. .,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy. .,Department of Surgery, Oncology and Gastroenterology - DiSCOG, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy.
| | - Silvia Battaglia
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Marco Scarpa
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Edoardo Savarino
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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20
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Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis. Ann Surg 2021; 274:78-85. [PMID: 33214483 DOI: 10.1097/sla.0000000000004639] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF). SUMMARY OF BACKGROUND DATA Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair. METHODS A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%). CONCLUSIONS LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.
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21
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Giulini L, Razia D, Mittal SK. Redo fundoplication and early Roux-en-Y diversion for failed fundoplication: a 3-year single-center experience. Surg Endosc 2021; 36:3094-3099. [PMID: 34231073 DOI: 10.1007/s00464-021-08610-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Redo fundoplication (RF) and Roux-en-Y diversion (RNY) are both accepted surgical treatments after failed fundoplication. However, due to higher reported morbidity, RNY is more commonly performed only after several surgical failures. In our experience, RNY at an earlier point of the disease progression seems to be related with better outcomes. The aim of this study was to investigate this aspect by comparing the results between RF and RNY performed by a single surgeon over 3 years at our institution. METHODS A prospectively maintained database was reviewed to identify patients who underwent RF or RNY at our institution between 2016 and 2019 by a single surgeon (author SKM). Patients with previous bariatric surgery were excluded. RESULTS Of 43 patients, 28 underwent RF and 15 underwent RNY (mean body mass index 28.6 and 32.7 kg/m2, respectively, p = 0.01). The number of previous antireflux surgeries for the RF and RNY groups was 1 (82% vs 80%, p > 0.99), 2 (18% vs 7%, p = 0.4), and more than 2 (0% vs 13%, p = 0.1). RNY took longer than RF (median, 165 vs 137 min, p = 0.02), but both groups had a median estimated blood loss of 50 ml (p = 0.82). There was no difference in intraoperative complications (25% vs 20% for RF and RYN, respectively, p > 0.99). Postoperative complications were more common in the RF than in the RYN group (21% vs 7%, p = 0.39). Median hospital stay was 3 days for both groups (p = 0.78). At short-term follow-up, the mean quality of life score was similar for the RF and RYN groups (11.5 vs 12.2, p = 0.8). CONCLUSIONS RNY diversion, if performed by experienced hands and at an earlier point of disease progression, has comparable perioperative morbidity to RF and should be considered as a feasible and safe option for definitive treatment of failed antireflux surgery.
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Affiliation(s)
- Luca Giulini
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Deepika Razia
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Sumeet K Mittal
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA.
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22
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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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23
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DeSantis AJ, Barry T, Saad AR, DuCoin C, Jacobs JW, Richter JE, Velanovich V. Etiology and Reoperative Management of Postoperative Recalcitrant Dysphagia after Nissen Fundoplication: Skipping the Ounce of Prevention Resulting in a Pound of Cure. J Gastrointest Surg 2021; 25:1559-1561. [PMID: 33169319 DOI: 10.1007/s11605-020-04856-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/31/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Anthony J DeSantis
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Tara Barry
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Christopher DuCoin
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - John W Jacobs
- Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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24
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Kivelä AJ, Kauppi J, Räsänen J, But A, Sintonen H, Vironen J, Kruuna O, Scheinin T. Long-Term Health-Related Quality of Life (HRQoL) After Redo-Fundoplication. World J Surg 2021; 45:1495-1502. [PMID: 33502565 PMCID: PMC8026436 DOI: 10.1007/s00268-021-05954-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND We aim to shed light on long-term subjective outcomes after re-operations for failed fundoplication. METHODS 1809 patients were operated on for hiatal hernia and/or gastroesophageal reflux disease (GERD) at the Helsinki University Hospital between 2000 and 2017. 111 (6%) of these had undergone a re-operation for a failed antireflux operation. Overall, HRQoL was assessed in 89 patients at the latest follow-up using the generic 15D© instrument. The results were compared to a sample of the general population, weighted to reflect the age and gender distribution of patients. Disease-specific HRQoL was assessed using the GERD-HRQoL questionnaire. We studied variation in the overall HRQoL with respect to disease-specific HRQoL and known patients' parameters using univariate and multivariable linear regression models. RESULTS The median postoperative follow-up period was 9.3 years. All patients were operated on laparoscopically (6% conversion rate), and 87% were satisfied with the re-operation. Postoperative complications were minimal (5%). Twelve patients (11%) underwent a second re-operation. The median GERD-HRQoL score was nine. In multivariable analysis, four variables were independently associated with the 15D score, suggesting a decrease in the 15D score with increasing GERD-HRQoL score, increasing Charlson Comorbidity Index (CCI) and the presence of chronic pain syndrome (CPS) and depression. CONCLUSION Re-do LF is a safe procedure in experienced hands and may offer acceptable long-term alleviation in patients with recurring symptoms after antireflux surgery. Decreased HRQoL in the long run is related to recurring GERD and co-morbidities.
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Affiliation(s)
- Antti J Kivelä
- Department of GI Surgery, Abdominal Centre, Helsinki University Hospital and Helsinki University, Jorvi Hospital, Turuntie 150, P.O. Box 800, FI 00029, Espoo, Helsinki, HUS, Finland.
| | - Juha Kauppi
- Department of General Thoracic and Esophageal Surgery, Lung and Heart Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Jari Räsänen
- Department of General Thoracic and Esophageal Surgery, Lung and Heart Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Anna But
- University of Helsinki, Helsinki, Finland
| | - Harri Sintonen
- Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jaana Vironen
- Department of GI Surgery, Abdominal Centre, Helsinki University Hospital and Helsinki University, Jorvi Hospital, Turuntie 150, P.O. Box 800, FI 00029, Espoo, Helsinki, HUS, Finland
| | - Olli Kruuna
- Department of GI Surgery, Abdominal Centre, Helsinki University Hospital and Helsinki University, Jorvi Hospital, Turuntie 150, P.O. Box 800, FI 00029, Espoo, Helsinki, HUS, Finland
| | - Tom Scheinin
- Department of GI Surgery, Abdominal Centre, Helsinki University Hospital and Helsinki University, Jorvi Hospital, Turuntie 150, P.O. Box 800, FI 00029, Espoo, Helsinki, HUS, Finland
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25
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Martins BC, Souza CS, Ruas JN, Furuya CK, Fylyk SN, Sakai CM, Ide E. ENDOSCOPIC EVALUATION OF POST-FUNDOPLICATION ANATOMY AND CORRELATION WITH SYMPTOMATOLOGY. ACTA ACUST UNITED AC 2021; 33:e1543. [PMID: 33470373 PMCID: PMC7812682 DOI: 10.1590/0102-672020200003e1543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/12/2020] [Indexed: 02/08/2023]
Abstract
Background:
Upper digestive endoscopy is important for the evaluation of patients
submitted to fundoplication, especially to elucidate postoperative symptoms.
However, endoscopic assessment of fundoplication anatomy and its
complications is poorly standardized among endoscopists, which leads to
inadequate agreement.
Aim:
To assess the frequency of postoperative abnormalities of fundoplication
anatomy using a modified endoscopic classification and to correlate
endoscopic findings with clinical symptoms.
Method:
This is a prospective observational study, conducted at a single center.
Patients were submitted to a questionnaire for data collection. Endoscopic
assessment of fundoplication was performed according to the classification
in study, which considered four anatomical parameters including the
gastroesophageal junction position in frontal view (above or at the level of
the pressure zone); valve position at retroflex view (intra-abdominal or
migrated); valve conformation (total, partial, disrupted or twisted) and
paraesophageal hernia (present or absent).
Results:
One hundred patients submitted to fundoplication were evaluated, 51% male
(mean age: 55.6 years). Forty-three percent reported postoperative symptoms.
Endoscopic abnormalities of fundoplication anatomy were reported in 46% of
patients. Gastroesophageal junction above the pressure zone (slipped
fundoplication), and migrated fundoplication, were significantly correlated
with the occurrence of postoperative symptoms. There was no correlation
between symptoms and conformation of the fundoplication (total, partial or
twisted).
Conclusion:
This modified endoscopic classification proposal of fundoplication anatomy is
reproducible and seems to correlate with symptomatology. The most frequent
abnormalities observed were slipped and migrated fundoplication, and both
correlated with the presence of symptoms.
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Affiliation(s)
| | | | | | | | | | | | - Edson Ide
- Endoscopy Unit, Oswaldo Cruz German Hospital, São Paulo, SP, Brazil
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26
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Long-term outcomes of Roux-en-Y gastric diversion after failed surgical fundoplication in a large cohort and a systematic review. Surg Obes Relat Dis 2021; 17:161-169. [DOI: 10.1016/j.soard.2020.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/03/2020] [Accepted: 08/09/2020] [Indexed: 12/12/2022]
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27
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Köckerling F, Zarras K, Adolf D, Kraft B, Jacob D, Weyhe D, Schug-Pass C. What Is the Reality of Hiatal Hernia Management?-A Registry Analysis. Front Surg 2020; 7:584196. [PMID: 33195390 PMCID: PMC7642514 DOI: 10.3389/fsurg.2020.584196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/21/2020] [Indexed: 12/05/2022] Open
Abstract
Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions. Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010–2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010–2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared. Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of “other techniques” at 20.9%. For the paraesophageal hiatal hernias (types II–IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and “other techniques” of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates. Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the “classic” Nissen and Toupet fundoplication surgical techniques.
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Affiliation(s)
- Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany
| | - Konstantinos Zarras
- Department of Visceral, Minimally Invasive and Oncological Surgery, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Barbara Kraft
- Department of General and Visceral Surgery, Diakonie Hospital, Stuttgart, Germany
| | - Dietmar Jacob
- Chirurgisch-Orthopädischer PraxisVerbund (COPV)-Hernia Center, Berlin, Germany
| | - Dirk Weyhe
- Department of General and Visceral Surgery, University Hospital of Visceral Surgery, Pius Hospital Oldenburg, Oldenburg, Germany
| | - Christine Schug-Pass
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany
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Ellis R, Garwood G, Khanna A, Harmouch M, Miller CC, Banki F. Patient-related risk factors associated with symptomatic recurrence requiring reoperation in laparoscopic hiatal hernia repair. Surg Open Sci 2020; 1:105-110. [PMID: 32754702 PMCID: PMC7391889 DOI: 10.1016/j.sopen.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/17/2019] [Accepted: 06/03/2019] [Indexed: 11/29/2022] Open
Abstract
Background Recurrent hiatal hernia remains a challenge. Methods For initial repairs at our center: patients with 1 repair were compared to those who required reoperation for symptomatic recurrence. Subsequently, patients who had 1 repair at our center were compared to all patients who required reoperation (including initial repair at another center). Results There were 401 repairs: 308 primary repairs at our center and 93 reoperations, 287/308 (93%) required 1 repair and 21/308 (7%) required reoperation. Comparing 1 repair versus 21 reoperations, risk factors were abdominoplasty odds ratio = 32.0 (4.1-250.6), P < .001, postoperative lifting/vomiting odds ratio = 11.6 (3.2-42.1), P < .0002, tubal ligation odds ratio = 4.9 (1.1-22.6), P < .04 and height < 160 cm odds ratio = 3.9 (1.1-13.3) P < 0.03. Comparing 287 with 1 repair versus all 93 reoperations, risk factors were post-operative vomiting odds ratio = 22.7 (2.3-218.0), P < .007, abdominoplasty odds ratio = 5.6 (1.0-31.4), P < .0495, post-operative lifting odds ratio = 5.4 (2.2-12.9), P < .0002, age < 52 odds ratio = 3.6 (1.8-7.3), P < .0003, tubal ligation odds ratio = 3.2 (1.2-8.7), P < 0.019 and height < 160 cm odds ratio = 3.0 (1.5-6.1), P < 0.003. Conclusions Younger age, shorter stature, heavy lifting or vomiting after surgery, abdominoplasty and tubal ligation are risk factors associated with symptomatic recurrence requiring reoperation.
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Affiliation(s)
- Ryan Ellis
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Grant Garwood
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Anshu Khanna
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Maamoun Harmouch
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Charles C Miller
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Farzaneh Banki
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth).,Memorial Hermann Southeast Esophageal Disease Center
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29
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Kim M, Navarro F, Eruchalu CN, Augenstein VA, Heniford BT, Stefanidis D. Minimally Invasive Roux-en-Y Gastric Bypass for Fundoplication failure offers Excellent Gastroesophageal Reflux Control. Am Surg 2020. [DOI: 10.1177/000313481408000726] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) may represent a superior alternative to reoperative fundoplication in patients with symptomatic failure. Our goal was to assess early outcomes of patients after RYGB for failed fundoplication. Records of patients who underwent fundoplication takedown and RYGB from March 2007 to June 2013 were reviewed for demographics, comorbidities, operative findings, and perioperative outcomes. Data are reported as medians (range). Forty-five patients who had undergone 64 prior antireflux procedures (range, one to three fundoplications) were identified. Median patient age was 56 years (range, 25 to 72 years) with a body mass index of 33 kg/m2 (range, 22 to 51 kg/m2). Most patients had comorbidities: hypertension (60%), anxiety/ depression (44.4%), dyslipidemia (33.3%), asthma (31%), obstructive sleep apnea (26.7%), arthritis (22.2%), and diabetes (11.1%). Median symptom-free interval was 3 years (range, 0 to 25 years). All patients had an anatomic reason for failure: 83 per cent had a hiatal hernia and 35 per cent had a slipped Nissen fundoplication. The procedures were accomplished laparoscopically in 28, robotically in 13, and open in four cases. Median operative time was 367 minutes (range, 190 to 600 minutes) and estimated blood loss averaged 100 mL (range, 25 to 500 mL). Five patients (11%) required reoperation: one for an anastomotic leak, one for anastomotic obstruction, and three for early obstruction resulting from adhesions. Two patients developed respiratory failure requiring prolonged mechanical ventilation. Length of stay averaged four days (range, 1 to 33 days) with two readmissions: one for melena and one for vomiting and dehydration; neither required intervention. There was no mortality. At 11 months of follow-up (range, 2.3 to 54 months), 93.3 per cent of patients were symptom-free. When primary fundoplication for gastroesophageal reflux disease fails, fundoplication takedown and RYGB can be accomplished safely with minimally invasive techniques. The conversion to a RYGB has an acceptable perioperative morbidity and excellent early symptom control, and, therefore, should be considered for reoperative patients gastroesophageal reflux disease.
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Affiliation(s)
- Mimi Kim
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Fernando Navarro
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Chukwuma N. Eruchalu
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Vedra A. Augenstein
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dimitrios Stefanidis
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina
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30
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Abstract
Minimally invasive endoscopic antireflux therapies are critical for bridging the gap between medical and surgical treatments for gastroesophageal reflux disease (GERD). Although multiple endoscopic devices have been developed, perhaps some of the most exciting options that are currently evolving are the full-thickness suturing techniques using widely available and low-cost platforms. Full-thickness endoscopic suturing can allow for a highly durable recreation of the anatomic and functional components of a lower esophageal sphincter, which are deficient in patients with GERD. Proper patient selection, endoscopic hiatal hernia evaluation, and standardized suturing methods are necessary to ensure success of endoscopic suturing for antireflux therapy.
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31
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Laparoscopic repeat surgery for gastro-oesophageal reflux disease: Results of the analyses of a cohort study of 117 patients from a multicenter experience. Int J Surg 2020; 76:121-127. [DOI: 10.1016/j.ijsu.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/20/2020] [Accepted: 03/03/2020] [Indexed: 01/21/2023]
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32
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Degrandi O, Laurent E, Najah H, Aldajani N, Gronnier C, Collet D. Laparoscopic Surgery for Recurrent Hiatal Hernia. J Laparoendosc Adv Surg Tech A 2020; 30:883-886. [PMID: 32208044 DOI: 10.1089/lap.2020.0118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Surgical treatment of hiatal hernia (HH) is well standardized. However, recurrence is observed in 15%-60% of cases, and is challenging to manage. The aim of this study was to analyze the causes of surgical failure and provide some guidelines for treatment. The symptoms of recurrent HH vary widely, and include persistent reflux, dysphagia, and permanent discomfort, leading to a marked change in the quality of life. Morphological and functional pretherapeutic evaluation is necessary to determine whether the symptoms are due to recurrent HH, and to understand the cause of failure. Redo surgery is technically difficult and challenging, and should only be used in symptomatic patients whose symptoms are definitively those of recurrent HH.
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Affiliation(s)
- Olivier Degrandi
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Eva Laurent
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Haythem Najah
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Nour Aldajani
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Caroline Gronnier
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Denis Collet
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
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Sanberg Ljungdalh J, Rubin KH, Durup J, Houlind KC. Long-term patient satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort: study protocol for a retrospective cohort study with development of a novel scoring system for patient selection. BMJ Open 2020; 10:e034257. [PMID: 32184312 PMCID: PMC7076240 DOI: 10.1136/bmjopen-2019-034257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Laparoscopic anti-reflux surgery is standard of care in surgical treatment of gastro-oesophageal reflux disease and is not without risks of adverse effects, including disruption of the fundoplication and postfundoplication dysphagia, in some cases leading to reoperation. Non-surgical factors such as pre-existing anxiety or depression influence postoperative satisfaction and symptom relief. Previous studies have focused on a short-term follow-up or only certain aspects of disease, such as reoperation or postoperative quality of life. The aim of this study is to evaluate long-term patient-satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort using a comprehensive multimodal follow-up, and to develop a clinically applicable scoring system usable in selecting patients for anti-reflux surgery. METHODS AND ANALYSIS The study is a retrospective cohort study utilising data from patient records and follow-up with patient-reported quality of life as well as registry-based data. The study population consists of all adult patients having undergone laparoscopic anti-reflux surgery at The Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital Denmark in an 11-year period. From electronic records; patient characteristics, preoperative endoscopic findings, reflux disease characteristics and details on type of surgery, will be identified. Disease-specific quality of life and dysphagia will be collected from a patient-reported follow-up. From Danish national registries, data on comorbidity, reoperative surgery, use of pharmacological anti-reflux treatment, mortality and socioeconomic factors will be included. Primary outcome of this study is treatment success at follow-up. ETHICS AND DISSEMINATION Study approval has been obtained from The Danish Patient Safety Agency, The Danish Health Data Authority and Statistics Denmark, complying to Danish and EU legislation. Inclusion in the study will require informed consent from participating subjects. The results of the study will be published in peer-reviewed medical journals regardless of whether these are positive, negative or inconclusive. TRIAL REGISTRATION NUMBER Clinicaltrials.gov (NCT03959020).
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Affiliation(s)
- Jonas Sanberg Ljungdalh
- Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Katrine Hass Rubin
- OPEN - Open Patient Data Explorative Network, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Jesper Durup
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Kim Christian Houlind
- Department of Regional Health Research, University of Southern Denmark, Odense, Syddanmark, Denmark
- Department of Vascular Surgery, Kolding Hospital, a part of Lillebaelt Hospital, Kolding, Denmark
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Kanani Z, Gould JC. Laparoscopic fundoplication for refractory GERD: a procedure worth repeating if needed. Surg Endosc 2020; 35:298-302. [PMID: 32016514 DOI: 10.1007/s00464-020-07396-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/28/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Laparoscopic fundoplication is the current gold standard for medically refractory gastroesophageal reflux disease. Over a 10-year period following surgery, 5-10% of primary laparoscopic fundoplication patients undergo reoperative surgery. Our objective was to compare the symptomatic outcomes and morbidity of primary and reoperative fundoplication procedures. METHODS This was a retrospective review of patients who underwent laparoscopic primary or reoperative fundoplication between 2011 and 2017. A single surgeon with a more than 10-year experience in reoperative foregut surgery performed all procedures. Patients in both groups completed the GERD health-related quality of life (GERD-HRQL) survey prior to surgery and postoperatively. Outcomes were reflected by the composite GERD-HRQL scores (0 to 50, with lower scores representing a better GERD-related quality of life), which were compared between groups postoperatively. Demographics, perioperative data, and complications were compared. Patient data were analyzed using Chi-Square tests and outcomes were analyzed using independent samples t tests and Mann-Whitney U tests. RESULTS There were 136 primary and 82 reoperative fundoplications. Prior to surgery, GERD-HRQL scores were similar for primary and reoperative patients. Both groups experienced significant improvement in GERD-related quality of life at 2 years, although this improvement was greater in primary patients (8.7 ± 7.8 primary vs. 14.3 ± 13.6 reoperative, p = 0.02). Operative time and length of stay were longer following reoperative cases. The rate of moderate to severe 30-day complications requiring radiologic, endoscopic, or surgical intervention was similar (2.9% primary vs. 1.2% reoperative, p = 0.65). CONCLUSIONS Patients who undergo reoperative fundoplication experience a significant improvement in their GERD-related symptoms, although not to the degree seen in primary antireflux surgery patients. Perioperative morbidity rates following reoperative and primary procedures can be similar in the hands of an experienced surgeon.
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Affiliation(s)
- Zia Kanani
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Jon C Gould
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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Myers JC, Jamieson GG, Szczesniak MM, Estremera-Arévalo F, Dent J. Asymmetrical elevation of esophagogastric junction pressure suggests hiatal repair contributes to antireflux surgery dysphagia. Dis Esophagus 2020; 33:5645215. [PMID: 31778151 DOI: 10.1093/dote/doz085] [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: 06/22/2019] [Revised: 07/24/2019] [Accepted: 08/31/2019] [Indexed: 12/11/2022]
Abstract
The radial distribution of esophago-gastric junction (EGJ) pressures with regard to troublesome dysphagia (TDysph) after antireflux surgery is poorly understood. Before and after antireflux surgery, end-expiratory and peak-inspiratory EGJ pressures were measured at eight angles of 45° radial separation in patients with reflux disease. All 34 patients underwent posterior crural repair, then either 90° anterior (N = 13) or 360° fundoplication (N = 21). Dysphagia was assessed prospectively using a validated questionnaire (score range 0-45) and TDysph defined as a dysphagia score that was ≥5 above pre-op baseline. Compared with before surgery, for 90° fundoplication, end-expiratory EGJ pressures were highest in the left-anterolateral sectors, the position of the partial fundoplication. In other sectors, pressures were uniformly elevated. Compared with 90° fundoplication, radial pressures after 360° fundoplication were higher circumferentially (P = 0.004), with a posterior peak. Nine patients developed TDysph after surgery with a greater increase in end-expiratory and peak-inspiratory EGJ pressures (P = 0.03 and 0.03, respectively) and significantly higher inspiratory pressure at the point of maximal radial pressure asymmetry (P = 0.048), compared with 25 patients without TDysph. Circumferential elevation of end-expiratory EGJ pressure after 90° and 360° fundoplication suggests hiatal repair elevates EGJ pressure by extrinsic compression. The highly localized focal point of elevated EGJ pressure upon inspiration in patients with TDysph after surgery is indicative of a restrictive diaphragmatic hiatus in the presence of a fundoplication.
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Affiliation(s)
- J C Myers
- Discipline of Surgery, The University of Adelaide, Adelaide, SA 5005, Australia.,Oesophageal Function, Surgery, Royal Adelaide Hospital and Queen Elizabeth Hospital, Adelaide, SA 5000, Australia
| | - G G Jamieson
- Discipline of Surgery, The University of Adelaide, Adelaide, SA 5005, Australia
| | - M M Szczesniak
- Department of Gastroenterology, University of NSW, Sydney, NSW 2052, Australia
| | - F Estremera-Arévalo
- Discipline of Surgery, The University of Adelaide, Adelaide, SA 5005, Australia
| | - J Dent
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
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Sowards KJ, Holton NF, Elliott EG, Hall J, Bajwa KS, Snyder BE, Wilson TD, Mehta SS, Walker PA, Chandwani KD, Klein CL, Rivera AR, Wilson EB, Shah SK, Felinski MM. Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience. Surg Endosc 2019; 34:2560-2566. [PMID: 31811451 DOI: 10.1007/s00464-019-07291-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 11/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs. METHODS Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer's exact test for categorical variables and the Mann-Whitney U test for continuous variables. RESULTS There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks. CONCLUSIONS Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.
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Affiliation(s)
- Kendell J Sowards
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Nicholas F Holton
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Ekatarina G Elliott
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - John Hall
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Kulvinder S Bajwa
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Brad E Snyder
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Todd D Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | | | | | - Kavita D Chandwani
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Connie L Klein
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Angielyn R Rivera
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Erik B Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Shinil K Shah
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA. .,Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX, USA.
| | - Melissa M Felinski
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
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Korwar V, Adjepong S, Pattar J, Sigurdsson A. Biological Mesh Repair of Paraesophageal Hernia: An Analysis of Our Outcomes. J Laparoendosc Adv Surg Tech A 2019; 29:1446-1450. [PMID: 31539310 DOI: 10.1089/lap.2019.0423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Symptomatic paraesophageal hernia (PEH) is an indication for surgical repair. Laparoscopic suture repair has high recurrence rates. Many surgeons prefer mesh repair to reduce PEH recurrence. Several types of mesh, synthetic and biological, are in use. Synthetic mesh has a risk of erosion and stricture, hence we preferred biological mesh repair. Our aim in this study is to assess medium-term outcomes of PEH repair with the use of biological mesh reinforcement over the cruroplasty. We also aimed to correlate clinical recurrences with radiological recurrences. Materials and Methods: This is a retrospective study of 154 consecutive patients from a single centre who underwent a standardized laparoscopic suture repair of the hiatus reinforced with an on-lay patch of Surgisis (porcine small intestine submucosa) and fundoplication. The mean age of the patients was 65 years. All patients were called for regular clinical follow-up and a barium study. Modified GERD-HRQL symptom severity instrument was used to assess postoperative symptoms and satisfaction. Results: The mean follow-up for barium swallow and clinical assessment were 28.42 ± 21.2 and 33.69 ± 23.46 months. The mean patient satisfaction score after surgery was 4.43 ± 1.09 (0-5). Follow-up barium swallow was performed in 122 (79.22%), 87 (56.49%) patients completed clinical follow-up questionnaire, and 77 (50%) had both. Symptomatic recurrence was noted in 25 (28.73%), recurrence on barium swallow 25(20.4%), and 10 (12.98%) had both. The reoperation rate was 3.25%. Mann-Whitney U test showed no statistical significance in reflux-related score between radiological recurrence group compared with no radiological recurrence (P = .06). Conclusions: Biological mesh repair of PEH is safe and well accepted by patients. There is significantly high PEH recurrence rate in long-term follow-up, even with mesh repair. Majority of these recurrences are small, asymptomatic, and the reoperation rate is very low.
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Affiliation(s)
- Vijay Korwar
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Samuel Adjepong
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Jayaprakash Pattar
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Audun Sigurdsson
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
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Cuenca-Abente F, Puma R, Ithurralde-Argerich J, Faerberg A, Rosner L, Ferro D. Non-Bariatric Roux-en-Y Gastric Bypass. J Laparoendosc Adv Surg Tech A 2019; 30:31-35. [PMID: 31539302 DOI: 10.1089/lap.2019.0476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Roux-en-Y gastric bypass (RYGB) is frequently performed for weight loss purposes in the morbidly obese population. The popularity and acceptance of this procedure have increased the knowledge of the physiological (anatomical and functional) changes that this technique produces in the organism. RYGB improves gastric emptying and gastroesophageal reflux symptoms. Materials and Methods: We analyzed 6 patients in whom an RYGB was performed for non-bariatric purposes. Symptom questionnaire was used to evaluate response. Results: None of the patients qualified for bariatric surgery, as all had a body mass index (BMI) <35 kg/m2. Five patients were operated on for severe gastroesophageal reflux disease symptoms, and one for gastroparesis. All patients had good to excellent results, with marginal modification of their BMI. Conclusion: Non-bariatric RYGB can be considered in patients with functional diseases of the upper gastrointestinal tract, regardless of their BMI.
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Affiliation(s)
- Federico Cuenca-Abente
- Foregut Surgery Unit, Digestive Tract Surgery Service, Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Rolando Puma
- Foregut Surgery Unit, Digestive Tract Surgery Service, Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Javier Ithurralde-Argerich
- Foregut Surgery Unit, Digestive Tract Surgery Service, Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Alejandro Faerberg
- Foregut Surgery Unit, Digestive Tract Surgery Service, Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Rosner
- Foregut Surgery Unit, Digestive Tract Surgery Service, Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Diego Ferro
- Foregut Surgery Unit, Digestive Tract Surgery Service, Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
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Giovannetti A, Craigg D, Castro M, Ross S, Sucandy I, Rosemurgy A. Laparoendoscopic Single-Site (LESS) versus Robotic “Redo” Hiatal Hernia Repair with Fundoplication: Which Approach is Better? Am Surg 2019. [DOI: 10.1177/000313481908500939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Only a small percentage of patients fail laparoscopic fundoplications undertaken for gastroesophageal reflux disease. But because many laparoscopic fundoplications have been undertaken, surgeons frequently encounter patients in need of “redo” operations. This study was undertaken to evaluate the robotic approach versus laparoendoscopic single-site (LESS) approach for redo fundoplications. With an Institutional Review Board approval, 64 patients undergoing LESS (n = 32) or robotic (n = 32) redo antireflux operations were prospectively followed up. Data are presented as median (mean + SD). For LESS versus robotic redo operations, the operative duration was 145 (143 ± 33.5) versus 196 (208 ± 76.7) minutes ( P < 0.01), estimated blood loss was 50 (80 ± 92.1) versus 20 (43 ± 57.1) mL ( P = 0.07), and length of stay was 1 (3 ± 5.4) versus 1 (2 ± 1.9) day ( P = 0.57); 1 LESS operation was converted to “open.” Operative duration was longer for men ( P = 0.01). Postoperative complications were not more frequent after Nissen (n = 36) or Toupet (n = 28) fundoplication, regardless of the approach. When matched by BMI, operative duration was prolonged by a large Type I to IV hiatal hernia ( P = 0.01). Symptoms improved dramatically and were similar with both approaches, and patient satisfaction was high. Robotic redo antireflux operations take longer than LESS operations. LESS and robotic redo antireflux operations are both safe and offer significant and similar amelioration of symptoms after failed fundoplications.
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Affiliation(s)
| | - Danielle Craigg
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Miguel Castro
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Sharona Ross
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Iswanto Sucandy
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
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Braghetto I, Csendes A. FAILURE AFTER FUNDOPLICATION: RE-FUNDOPLICATION? IS THERE A ROOM FOR GASTRECTOMY? IN WHICH CLINICAL SCENARIES? ACTA ACUST UNITED AC 2019; 32:e1440. [PMID: 31460600 PMCID: PMC6713057 DOI: 10.1590/0102-672020190001e1440] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/21/2019] [Indexed: 02/02/2023]
Abstract
Background: Re-fundoplication is the most often procedure performed after failed fundoplication, but re-failure is even higher. Aim: The objectives are: a) to discuss the results of fundoplication and re-fundoplication in these cases, and b) to analyze in which clinical situation there is a room for gastrectomy after failed fundoplication. Method: This experience includes 104 patients submitted to re-fundoplication after failure of the initial operation, 50 cases of long segment Barrett´s esophagus and 60 patients with morbid obesity, comparing the postoperative outcome in terms of clinical, endoscopic, manometric and 24h pH monitoring results. Results: In patients with failure after initial fundoplication, redo-fundoplication shows the worst clinical results (symptoms, endoscopic esophagitis, manometry and 24 h pH monitoring). In patients with long segment Barrett´s esophagus, better results were observed after fundoplication plus Roux-en-Y distal gastrectomy and in obese patients similar results regarding symptoms, endoscopic esophagitis and 24h pH monitoring were observed after both fundoplication plus distal gastrectomy or laparoscopic resectional gastric bypass, while regarding manometry, normal LES pressure was observed only after fundoplication plus distal gastrectomy. Conclusion: Distal gastrectomy is recommended for patients with failure after initial fundoplication, patients with long segment Barrett´s esophagus and obese patients with gastroesophageal reflux disease and Barrett´s esophagus. Despite its higher morbidity, this procedure represents an important addition to the surgical armamentarium.
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Affiliation(s)
- Italo Braghetto
- Department of Surgery, Hospital Clínico "Dr. José J. Aguirre", Faculty of Medicine, University of Chile, Santiago Chile
| | - Attila Csendes
- Department of Surgery, Hospital Clínico "Dr. José J. Aguirre", Faculty of Medicine, University of Chile, Santiago Chile
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Panda N, Rattner DW, Morse CR. Third-time ("redo-redo") anti-reflux surgery: patient-reported outcomes after a thoracoabdominal approach. Surg Endosc 2019; 34:3092-3101. [PMID: 31388809 DOI: 10.1007/s00464-019-07059-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/31/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Approximately 3-6% of patients undergoing anti-reflux surgery require "redo" surgery for persistent gastroesophageal reflux disease (GERD). Further surgery for patients with two failed prior anti-reflux operations is controversial due to the morbidity of reoperation and poor outcomes. We examined our experience with surgical revision of patients with at least two failed anti-reflux operations. METHODS Adults undergoing at least a second-time revision anti-reflux surgery between 1999 and 2017 were eligible. The primary outcomes were general and disease-specific quality-of-life (QoL) scores determined by Short-Form-36 (SF36) and GERD-Health-Related QoL (GERD-HRQL) instruments, respectively. Secondary outcomes included perioperative morbidity and mortality. RESULTS Eighteen patients undergoing redo-redo surgery (13 with 2 prior operations, 5 with 3 prior operations) were followed for a median of 6 years [IQR 3, 12]. Sixteen patients (89%) underwent open revisions (14 thoracoabdominal, 2 laparotomy) and two patients had laparoscopic revisions. Indications for surgery included reflux (10 patients), regurgitation (5 patients), and dysphagia (3 patients). Intraoperative findings were mediastinal wrap herniation (9 patients), misplaced wrap (2 patients), mesh erosion (1 patient), or scarring/stricture (6 patients). Procedures performed included Collis gastroplasty + fundoplication (6 patients), redo fundoplication (5 patients), esophagogastrectomy (4 patients), and primary hiatal closure (3 patients). There were no deaths and 13/18 patients (72%) had no postoperative complications. Ten patients completed QoL surveys; 8 reported resolution of reflux, 6 reported resolution of regurgitation, while 4 remained on proton-pump inhibitors (PPI). Mean SF36 scores (± standard deviation) in the study cohort in the eight QoL domains were as follows: physical functioning (79.5 [± 19.9]), physical role limitations (52.5 [± 46.3]), emotional role limitations (83.3 [± 36.1]), vitality (60.0 [± 22.7]), emotional well-being (88.4 [± 8.7]), social functioning (75.2 [± 31.0]), pain (66.2 [± 30.9]), and general health (55.0 [± 39.0]). CONCLUSION An open thoracoabdominal approach in appropriately selected patients needing third-time anti-reflux surgery carries low morbidity and provides excellent results as reflected in QoL scores.
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Affiliation(s)
- Nikhil Panda
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA, 02114, USA.
| | - David W Rattner
- Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Abstract
PURPOSE OF REVIEW Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients. RECENT FINDINGS A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.
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Affiliation(s)
- Semeret Munie
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Hassan Nasser
- Department of General Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
| | - Jon C Gould
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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Minimally invasive Roux-en-Y reconstruction as a salvage operation after failed nissen fundoplication. Surg Endosc 2019; 34:2211-2218. [DOI: 10.1007/s00464-019-07010-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/19/2019] [Indexed: 12/28/2022]
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Brown AM, Nagle R, Pucci MJ, Chojnacki K, Rosato EL, Palazzo F. Perioperative Outcomes and Quality of Life after Repair of Recurrent Hiatal Hernia are Compromised Compared with Primary Repair. Am Surg 2019. [DOI: 10.1177/000313481908500535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Paraesophageal hernia repair (PEHR) is burdened by high recurrence rates that frequently lead to redo PEHR. Revisional surgery, because of higher complexity, higher risk of injury, and the intrinsic risk of recurrence, has increased likelihood of higher complication rates and decreased quality of life (QOL) postoperatively. We aimed to compare perioperative outcomes and QOL after revisional and primary PEHR. A retrospective review of all patients who underwent PEHR for a recurrent hernia between January 2011 and July 2016 was completed. These were matched with a contemporary cohort of patients who underwent primary PEHR by age, gender, and BMI. Perioperative measures were compared. The patients were invited to complete the Gastrointestinal Quality of Life Index (GIQLI) to assess response to surgical intervention. There were 24 patients (group 1) who underwent revisional PEHR, and they were matched to 48 patients (group 2) who had a primary hernia repair. Thirteen patients in group 1 responded to the survey (54%), whereas 21 patients’ responses were received from group 2 (44%). Conversion rates, LOS, and mean Gastrointestinal Quality of Life Index scores were significantly different between the two groups. Reoperative procedures for paraesophageal and hiatal hernias are burdened by higher conversion rates and length of stay, with similar overall complication rates. Patients who are undergoing repair of a recurrent hernia should be preoperatively counseled, and should have realistic expectations of their GI QOL after surgery.
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Affiliation(s)
- Andrew M. Brown
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ramzy Nagle
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael J. Pucci
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Karen Chojnacki
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ernest L. Rosato
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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46
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Left Transthoracic Approach for Magnetic Sphincter Augmentation Device LINX Implantation. Ann Thorac Surg 2019; 108:e225-e227. [PMID: 30885852 DOI: 10.1016/j.athoracsur.2019.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 01/31/2019] [Accepted: 02/05/2019] [Indexed: 12/22/2022]
Abstract
Magnetic sphincter augmentation with the LINX Reflux Management System (Torax Medical, St. Paul, MN) is a recently introduced surgical option with comparable therapeutic efficacy for medically refractory gastroesophageal reflux disease. An appropriately sized LINX device is usually placed around the gastroesophageal junction through a laparoscopic approach. In general, redo abdominal surgeries are technically challenging, with a higher risk of associated morbidity. This highlights the need to obtain feasible alternative access to place the LINX device for certain patient populations. In this case series, we described 2 patients who underwent LINX device implantation through left thoracotomy because of previous abdominal surgeries that prohibited a transabdominal approach.
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Miyano G, Yamoto M, Miyake H, Morita K, Kaneshiro M, Nouso H, Koyama M, Okawada M, Doi T, Koga H, Lane GJ, Fukumoto K, Yamataka A, Urushihara N. A Comparison of Laparoscopic Redo Fundoplications for Failed Toupet and Nissen Fundoplications in Children. J Indian Assoc Pediatr Surg 2019; 24:100-103. [PMID: 31105394 PMCID: PMC6417062 DOI: 10.4103/jiaps.jiaps_228_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs). Methods: Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0–3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome. Results: Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date. Conclusion: Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.
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Affiliation(s)
- Go Miyano
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan.,Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Keiichi Morita
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masakatsu Kaneshiro
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiroshi Nouso
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Mariko Koyama
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Manabu Okawada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Doi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
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Vilar A, Priego P, Puerta A, Cuadrado M, Angarita FG, GarcÍA-Moreno F, Galindo J. Redo Surgery after Failure of Antireflux Surgery. Am Surg 2018. [DOI: 10.1177/000313481808401142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surgery for refractory gastroesophageal reflux disease (GERD) has a satisfactory outcome for most patients; however, sometimes redo surgery is required. The Outcome and morbidity of a redo are suggested to be less successful than those of primary surgery. The aim of this study was to describe our experience, long-term results, and complications in redo surgery. From 2000 to 2016, 765 patients were operated on for GERD at our hospital. A retrospective analysis of 56 patients (7.3%) who underwent redo surgery was conducted. Large symptomatic recurrent hiatal hernia (50%) and dysphagia (28.6%) were the most frequent indications for redo. An open approach was chosen in 64.5 per cent of patients. Intraoperative and postoperative complication rates were 18 per cent and 14.3 per cent, respectively. Mortality rate was 1.8 per cent. Symptomatic outcome was successful in 71.3 per cent. Patients reoperated because of dysphagia and large recurrent hiatal hernia had a significantly higher failure rate (32.3% and 31.2%, respectively; P = 0.001). Complication rate was significantly lower in the laparoscopic group (0% vs 22.2%; P = 0.04). There were no statistical differences between expert and nonexpert surgeons. Laparoscopic approach has increased to 83.3 per cent in the last five years. Symptomatic outcome after redo surgery was less satisfactory than that after primary surgery. Complications were lower if a minimally invasive surgical approach was used.
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Affiliation(s)
- Alberto Vilar
- Division of Esophagogastric, Bariatric and Minimally Invasive Surgery, Madrid, Spain
- Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Pablo Priego
- Division of Esophagogastric, Bariatric and Minimally Invasive Surgery, Madrid, Spain
- Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Ana Puerta
- Division of Esophagogastric, Bariatric and Minimally Invasive Surgery, Madrid, Spain
- Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Marta Cuadrado
- Division of Esophagogastric, Bariatric and Minimally Invasive Surgery, Madrid, Spain
- Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Francisco GarcÍA Angarita
- Division of Esophagogastric, Bariatric and Minimally Invasive Surgery, Madrid, Spain
- Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Francisca GarcÍA-Moreno
- Division of Esophagogastric, Bariatric and Minimally Invasive Surgery, Madrid, Spain
- Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Julio Galindo
- Division of Esophagogastric, Bariatric and Minimally Invasive Surgery, Madrid, Spain
- Department of Surgery, Ramón y Cajal University Hospital, Madrid, Spain
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49
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Antiporda M, Jackson C, Smith CD, Thomas M, Elli EF, Bowers SP. Strategies for surgical remediation of the multi-fundoplication failure patient. Surg Endosc 2018; 33:1474-1481. [PMID: 30209604 DOI: 10.1007/s00464-018-6429-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/05/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Outcomes are not well studied in patients undergoing remediation for multi-fundoplication failure, that is, two or more prior failed fundoplications. Re-operation must balance reflux control and restoration of the ability to eat with the challenge of reconstructing a distorted hiatus and GE junction. The purpose of this study is to present our experience with surgical remediation for multi-fundoplication failure. METHODS Medical records were retrospectively reviewed of 91 patients who underwent third time or more esophagogastric operation for fundoplication failure at a single institution from 2007 to 2016. Dysphagia was present in 56% and heartburn in 51%. Median number of prior operations was 2 with range up to 6. Anatomic failure consisted of slipped wrap in 26 cases, wrap herniation in 23, hiatal stenosis in 24, hiatal mesh complication in 8, and wrap dehiscence in 10. Operative approaches generally followed an institutional algorithm and consisted of hiatal hernia repair with: re-do fundoplication in 55%, takedown of fundoplication alone in 24%, Roux-en-Y gastrojejunostomy in 14%, and GE junction resection in 7%. Laparoscopic approach was successful in 81%. RESULTS Mean duration of operations was 217 min and median length of stay was 3 days. The complication rate was 13%, with 7% undergoing unplanned early re-operation. Patients were followed for mean 11 months, and recurrent hiatal hernia was detected in 13%. Late re-operation was performed in 6% for recurrent hiatal hernia. Recurrent reflux symptomatology resolved in 93%. Dysphagia resolved in 84%. There were no significant differences in outcomes with regard to number of prior operations, operative approach, BMI, or age. CONCLUSIONS There is no single best approach to remediation in the multi-fundoplication failure patient. Re-do fundoplication is appropriate in over half of patients. Reoperation for multi-fundoplication failure can be performed via minimally invasive approach with excellent remediation of symptoms, low morbidity, and low recurrence rates.
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Affiliation(s)
- Michael Antiporda
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Chloe Jackson
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Mathew Thomas
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Enrique F Elli
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Steven P Bowers
- Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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50
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Analatos A, Lindblad M, Rouvelas I, Elbe P, Lundell L, Nilsson M, Tsekrekos A, Tsai JA. Evaluation of resection of the gastroesophageal junction and jejunal interposition (Merendino procedure) as a rescue procedure in patients with a failed redo antireflux procedure. A single-center experience. BMC Surg 2018; 18:70. [PMID: 30165834 PMCID: PMC6117955 DOI: 10.1186/s12893-018-0401-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 08/22/2018] [Indexed: 01/02/2023] Open
Abstract
Background Primary antireflux surgery has high success rates but 5 to 20% of patients undergoing antireflux operations can experience recurrent reflux and dysphagia, requiring reoperation. Different surgical approaches after failed fundoplication have been described in the literature. The aim of this study was to evaluate resection of the gastroesophageal junction with jejunal interposition (Merendino procedure) as a rescue procedure after failed fundoplication. Methods All patients who underwent a Merendino procedure at the Karolinska University Hospital between 2004 and 2012 after a failed antireflux fundoplication were identified. Data regarding previous surgical history, preoperative workup, postoperative complications, subsequent investigations and re-interventions were collected retrospectively. The follow-up also included questionnaires regarding quality of life, gastrointestinal function and the dumping syndrome. Results Twelve patients had a Merendino reconstruction. Ten patients had undergone at least two previous fundoplications, of which one patient had four such procedures. The main indication for surgery was epigastric and radiating back pain, with or without dysphagia. Postoperative complications occurred in 8/12 patients (67%). During a median follow-up of 35 months (range 20–61), four (25%) patients had an additional redo procedure with conversion to a Roux-en-Y esophagojejunostomy within 12 months, mainly due to obstructive symptoms that could not be managed conservatively or with endoscopic techniques. Questionnaires scores were generally poor in all dimensions. Conclusions In our experience, the Merendino procedure seems to be an unsuitable surgical option for patients who require an alternative surgical reconstruction due to a failed fundoplication. However, the small number of patients included in this study as well as the small number of participants who completed the postoperative workout limits this study.
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Affiliation(s)
- Apostolos Analatos
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden. .,Department of Surgery, Nyköping Hospital, Nyköping, Sweden. .,Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.
| | - Mats Lindblad
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Ioannis Rouvelas
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Peter Elbe
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Lars Lundell
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Magnus Nilsson
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Andrianos Tsekrekos
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
| | - Jon A Tsai
- Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockhom, Sweden
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