Antireflux Surgery

Laparoscopic Fundoplication Using the Excluded Stomach as a Novel Management Option for Refractory Bile Reflux Following One Anastomosis Gastric Bypass (OAGB)

Background

One anastomosis gastric bypass (OAGB) is now a mainstream bariatric procedure. Refractory gastroesophageal reflux is a significant complication following OAGB, and conversion to Roux-en-Y has long been the treatment of choice for this issue. Strengthening the lower esophageal sphincter by Nissen fundoplication (NF) has been reported as an effective anti-reflux surgery. Here we report the short-term outcomes of a modified NF procedure using the excluded stomach (excluded stomach fundoplication—ESF) to treat refractory bile reflux in post-OAGB patients.

Methods

Thirteen post-OAGB patients underwent ESF for refractory bile reflux during the study, as detailed in the surgical technique. This paper reports the 12 patients whose follow-up data are available.

Results

Following ESF, the GERD-HRQL heartburn score improved from 22.7 ± 3.9 to 1.8 ± 3.5 (p < 0.05). The mean aggregate GERD-HRQL score improved from 27.9 ± 5.3 to 5.7 ± 5.9 (p < 0.05). The GERD-HRQL global satisfaction score showed that 100% of patients were satisfied with the improvement of symptoms. The mean VISICK score improved from 3.8 ± 0.39 to 1.2 ± 0.39 (p < 0.05). One patient was returned to the operating theatre to have the wrap loosened due to dysphagia. Eleven patients did not require PPIs after surgery.

Conclusions

ESF significantly improved the VISICK score and GERD-HRQL of post-OAGB patients with refractory bile reflux in the short term. The current study is being continued to increase the sample size and the follow-up period.

Esophageal strictures and diverticula

Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.

Radiologic and endoscopic characteristics of laparoscopic antireflux wrap: correlation with outcome

After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe's classification of the postoperative valve was used for the definition of a "normal" or "defective" wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A "normal" antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P < 0.001). "Defective" antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.

Transoral incisionless fundoplication offers high patient satisfaction and relief of therapy-resistant typical and atypical symptoms of GERD in community practice

This retrospective study evaluated clinical outcomes in 124 consecutive gastroesophageal reflux disease (GERD) patients who underwent transoral incisionless fundoplication (TIF) at 2 community hospitals. Out of 123 patients treated successfully, 110 gave consent (74% female, median age 60 [range 21-87] years, body mass index 27.5 [19.0-47.9]). At a median 7-month follow-up (range 5-17), typical and atypical symptom scores were normalized in 75% to 80% of patients, proton pump inhibitors (PPIs) were completely discontinued by 93%, and 83% were satisfied with their current health condition. Endoscopy in 53 patients revealed Hill grade I tight valves in 89% of the cases, reduced hiatal hernia in 33/34 (97%), and healed reflux esophagitis in 25/30 (83%). Based on global analysis, 72% of the patients were in remission, 20% improved symptomatically, and only 8% had ongoing GERD. These results supported the safety and efficacy of TIF as well as encouraged its application as an alternative treatment of GERD refractory to PPIs.