Reoperative antireflux surgery

The impact of obesity on gastroesophageal reflux disease recurrence following re-operative anti-reflux surgery

INTRODUCTION

Obese patients represent a large proportion of patients experiencing recurrent reflux and re-operations after initial anti-reflux surgery. However, there is a limited data describing the impact of obesity on GERD recurrence following re-operative procedures.

METHODS

A review of patients who underwent re-operative anti-reflux surgery (Re-ARS) between 2012 and 2023. Peri-operative characteristics and post-operative Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores were compared across the three BMI categories: (BMI < 25 kg/m2, 25 ≤ BMI > 30 kg/m2, and BMI ≥ 30 kg/m2) over 12 IQR (9-14.9) months follow-up. Impedance planimetry measurements were included when it was utilized intraoperatively.

RESULTS

Of 718 patients who underwent robotic ARS, 84 patients (11.6%) underwent Re-ARS, of which 29.7% had a BMI < 25 kg/m2, 35.7% were ≤ 25 BMI < 30 kg/m2, and 34.5% had a BMI ≥ 30 kg/m2. The lower esophageal sphincter distensibility decreased similarly between groups with no differences in post-induction [3.2 ± 2 vs 4.5 ± 3.1 vs 3.9 ± 2.5 mm2/mmHg, p = 0.44] or post-fundoplication values [1 ± 0.6 vs 1.3 ± 0.7 vs 1.2 ± 0.6 mm2/mmHg, p = 0.46]. There was a significant improvement in GERD-HRQL scores postoperatively compared to preoperative levels across the three BMI classes (BMI < 25 kg/m2: pre 17 IQR (12-22), post 7.5 (1.5-15), p = 0.04 vs ≤ 25 BMI < 30 kg/m2: pre 26 IQR (10-34), post 8 IQR (0-17), p < 0.01 vs BMI ≥ 30 kg/m2: pre 44 IQR (26-51), post 5 IQR (3.5-14.5), p < 0.001) during 12 IQR (9-14.9) months follow-up. The rates of hiatal hernia recurrence on barium swallow [5.2 vs 15.7 vs 13.7%, p = 0.32] during 7 IQR (5.2-9.2) months follow-up, and endoscopy [13.3 vs 16.6 vs 7.1%, p = 0.74] during 11.8 (IQR 5.6-17.1) months follow-up period were also similar between groups.

CONCLUSION

GERD-HRQL scores in obese patients are expected to improve similarly compared to non-obese patients. Indicating that Re-ARS may be appropriate for patients across a range of BMIs.

Current Status of Anti-Reflux Surgery as a Treatment for GERD

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.

Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review

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.

Transoral incisionless fundoplication for recurrent symptoms after laparoscopic fundoplication

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.

A Technique of Preserving Preexisting Fundoplication When Converting to Roux-en-Y Gastric Bypass

BACKGROUND

The standard surgical treatment of gastro-esophageal reflux disease (GERD) consists of either 360° (Nissen, NFP) or 270° (Toupet, TFP) fundoplication. On some occasions, such as recurrent GERD and/or severe overweight, patients may benefit from conversion to Roux-en-Y gastric bypass (RYGB), which is however technically difficult. Most techniques of conversion involve unwrapping of the fundoplication. We developed a laparoscopic technique that includes preservation of the wrap, while constructing a standard small-pouch RYGB. We describe the surgical technique and report the short-term outcomes of our technique.

METHODS

Consecutive patients underwent conversion of NFP to RYGB by our fundoplication preserving technique as described in surgical technique. Perioperative outcomes were assessed by analysis of the electronic patient records; progression of GERD symptoms and patient satisfaction were evaluated by an on-line questionnaire.

RESULTS

Fourteen patients underwent the conversion. There were no peroperative complications and no conversions. Short-term complications were registered in 4 patients (Clavien-Dindo grade 1, n = 2; grade 2, n = 1 and grade 3a, n = 1). No long-term complications were reported. None of the participants reported significant GERD symptoms Patient satisfaction was good.

CONCLUSION

We developed a laparoscopic technique of NFP to RYGB conversion, with preservation of fundoplication integrity, which appears to add to the safety and efficacy of the procedure.

LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION

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.

Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation

BACKGROUND

Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons.

METHODS

Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated.

RESULTS

There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf's alpha <0.30), indicating low to no agreement between providers.

CONCLUSION

In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis

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.

Redo-laparoscopy in the management of complications after laparoscopic colorectal surgery: a systematic review and meta-analysis of surgical outcomes

BACKGROUND

The laparoscopic approach for colorectal surgery has gradually become widely accepted for the treatment of both benign and malignant diseases thanks to its several advantages over the open approach. However, it is associated with the same potential postoperative complications. Some recent studies have analyzed the potential role of laparoscopy in early diagnosis and management of complications following laparoscopic colorectal surgery. The aim of this systematic review was to investigate the outcomes of redo-laparoscopy (RL) for the management of early postoperative complications following laparoscopic colorectal surgery, focusing on length of stay, morbidity and mortality.

METHODS

A systematic review of the literature was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines through MEDLINE (PubMed), Embase and Google Scholar from January 1990 to December 2019. The main outcomes examined were conversion rate, length of hospital stay, postoperative morbidity and mortality rates. A meta-analysis of all eligible studies was then conducted and forest plots were generated.

RESULTS

A total of 19 studies involving 1394 patients who required reoperation after laparoscopic colorectal resection were included. In 539 (38.2%) of these patients, a laparoscopic approach was adopted. The most common indication for returning to the operating theater was anastomotic leakage (64.4% of all redo-surgeries, 67.7% of RL) and the most common type of intervention performed in RL was diverting stoma with or without anastomotic repair/redo (47.1%). Nine studies were included in the pooled analysis. The mean length of stay was significantly shorter in the RL group than in the redo-open one (WMD = - 0.90; 95% CI - 1.04 to - 0.76; Z =  - 12,6; p < 0.001). A significantly lower risk of mortality was observed in the RL cohort (OR =  - 0.91; 95% CI - 1.58 to - 0.23; Z = - 2.62; p = 0.009).

CONCLUSIONS

Laparoscopy is a valid and effective approach for the treatment of complications following laparoscopic primary colorectal surgery thanks to it is well-established advantages over the open approach, which remain noticeable even in redo-surgeries.

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.

FAILURE AFTER FUNDOPLICATION: RE-FUNDOPLICATION? IS THERE A ROOM FOR GASTRECTOMY? IN WHICH CLINICAL SCENARIES?

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.

Salvage Options for Fundoplication Failure

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.

Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis

BACKGROUND

Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP.

METHODS

Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded.

RESULTS

During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m² and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging.

CONCLUSION

POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.

[Redo laparoscopic surgery for recurrent gastroesophageal reflux disease and hiatal hernia]

AIM

To assess mechanisms of recurrent gastroesophageal reflux disease and the ability to perform adequate surgical correction after previous surgery.

MATERIAL AND METHODS

The authors from various surgical centers have operated 2678 patients with gastroesophageal reflux disease and hiatal hernia for the period 1993-2018. 127 (4.74%) patients underwent redo surgery for recurrent disease, 46 of them were previously operated in other clinics.

RESULTS

Median follow-up after redo surgery was 63 months (12-139). Satisfactory functional result was achieved in 76.4% of patients.

Impact of vagus nerve integrity testing on surgical management in patients with previous operations with potential risk of vagal injury

BACKGROUND

Thoracic and foregut operations can cause vagal nerve injury resulting in delayed gastric emptying or gastroparesis. However, the cause of gastroparesis in these patients is not always from a vagal injury. We hypothesize that vagal nerve integrity (VNI) testing may better define who has vagal nerve dysfunction. This information may change subsequent operations. The aim of this study was to evaluate the impact of VNI testing in patients with prior thoracic or gastric surgery.

METHODS

From January 2014 to December 2017, patients who had previous operations with the potential risk of vagal injury and had VNI testing were reviewed. Excluded patients were those with no plan for a second operation or the second operation was only for gastroparesis. The main outcome was the percentage of operations altered due to the results of VNI testing.

RESULTS

Twelve patients (eight females) were included. Ages ranged from 37 to 77 years. VNI results were compatible with vagal injury in eight patients (67%). VNI test results altered subsequent operative plans in 41.7% (5/12). Pyloroplasty was done in addition to fundoplication in two patients. Plans for hiatal hernia repair with or without redo-fundoplication in three patients were changed by an additional pyloroplasty in one patient and partial gastrectomy with Roux-en-Y reconstruction in two patients. All patients who had secondary surgery had resolution of symptoms and improvement in objective testing.

CONCLUSION

The addition of VNI testing in patients with a previous potential risk of vagal nerve injury may help the surgeon select the appropriate secondary operation.

Long-term reported outcomes of transoral incisionless fundoplication: an 8-year cohort study

BACKGROUND

Transoral incisionless fundoplication (TIF) offers an endoscopic approach to the treatment of gastroesophageal reflux disease (GERD). Controlled trials have demonstrated the short-term efficacy of this procedure, but long-term follow-up studies are lacking. The objective of this study was to evaluate the long-term impact of TIF on disease-specific quality of life and antisecretory medication use.

METHODS

We performed retrospective cohort study of all patients undergoing TIF between 2007 and 2014 in a large academic medical center. Reflux symptoms and quality of life were assessed using the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) questionnaire at baseline, short-term, and long-term follow-up.

RESULTS

Fifty-seven patients with a median age of 46 (37-59) years and an average BMI of 28.8 ± 4.9 kg/m² underwent TIF during the study period. Sixty percent of the patients were female, and all were taking a PPI at least daily. At a median follow-up interval of 97 months, twelve patients had undergone subsequent laparoscopic antireflux surgery (LARS). Of those who had not, 23 had complete long-term follow-up data for analysis and were included in the study. Seventy-three percent reported daily acid-reducing medication use, and the median GERD-HRQL score was 10 (6-14) compared to 24 (15-28) at baseline (p < 0.01). Seventy-eight percent of these patients expressed satisfaction or neutral feelings about their GERD management. There were no significant differences in the baseline characteristics of patients who underwent LARS during the study period and those who did not.

CONCLUSIONS

This study demonstrates that TIF can produce durable improvements in disease-specific quality of life in some patients with symptomatic GERD. The majority of patients resumed daily PPI therapy during the study period, but with significantly improved GERD-HRQL scores compared to baseline and increased satisfaction with their medical condition.

Complications of Antireflux Surgery

Antireflux surgery anatomically restores the antireflux barrier and is a therapeutic option for proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease or PPI intolerance. Laparoscopic fundoplication is the standard antireflux surgery, though its popularity has declined due to concerns regarding wrap durability and adverse events. As the esophagogastric junction is an anatomically complex and dynamic area subject to mechanical stress, wraps are susceptible to disruption, herniation or slippage. Additionally, recreating an antireflux barrier to balance bidirectional bolus flow is challenging, and wraps may be too tight or too loose. Given these complexities it is not surprising that post-fundoplication symptoms and complications are common. Perioperative mortality rates range from 0.1 to 0.2% and prolonged structural complications occur in up to 30% of cases. Upper gastrointestinal endoscopy with a comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Management hinges on differentiating complications that can be managed with medical and lifestyle optimization versus those that require surgical revision. Reoperation is best reserved for severe structural abnormalities and troublesome symptoms despite medical and endoscopic therapy given its increased morbidity and mortality. Though further data are needed, magnetic sphincter augmentation may be a safer alternative to fundoplication.

Roux-en-Y gastric bypass as a salvage procedure in complicated patients with failed fundoplication(s)

BACKGROUND

In symptomatic patients after failed fundoplication, reoperation is considered. In complex or obese patients, Roux-en Y gastric bypass (RYGB) may be the best operation. We sought to characterize the outcomes of patients with failed fundoplication to undergo salvage RYGB, and to compare these outcomes to patients undergoing reoperative fundoplication.

METHODS

A prospectively maintained database was queried for procedures performed at a single institution from 2011 to 2017. GERD health-related quality of life (HRQL) surveys were administered at defined intervals.

RESULTS

Thirty-six patients underwent salvage RYGB and 84 patients underwent reoperative fundoplication. The RYGB cohort had a higher BMI (35.5 ± 6.8 vs. 28.7 ± 5.3, p < 0.01), more gastroparesis (52.8% vs. 9.5%, p < 0.01), more esophagitis (42.9% vs. 20.2%, p = 0.01), and more prior fundoplications (1.9 vs. 1.2, p < 0.01). The incidence of gastroparesis and esophagitis was directly related to the number of failed fundoplications (p < 0.05). Operative times were longer with RYGB (332.7 ± 131.5 vs. 200.0 ± 67.6 min, p < 0.01) as was length of stay (4.3 ± 3.4 vs. 2.8 ± 1.5 days, p = 0.02), incidence of Clavien-Dindo complications ≥ Grade 3 (19.4% vs. 4.8%, p = 0.01), 30-day reoperation (11.1% vs. 1.2%, p = 0.01), and 30-day readmission (32.4% vs. 11.9%, p < 0.01). In five patients with three or more prior fundoplication attempts, an esophagojejunostomy was necessary. If these patients are excluded, there was no difference for RYGB with gastrojejunostomy compared to reoperative fundoplication for complications, reoperations, or readmissions. GERD-HRQL scores were similar prior to surgery in both cohorts and improved significantly and to a similar degree on long-term follow-up.

CONCLUSIONS

In a complex cohort of patients with high rates of obesity and numerous failed previous fundoplication attempts, conversion to RYGB results in good symptomatic outcomes. Patients with three or more previous fundoplication attempts are more likely to require esophagojejunostomy. Complication rates in this subset of patients appear to be quite high.

Roux-en-Y Gastric Bypass Following Nissen Fundoplication: Higher Risk Same Reward

BACKGROUND

Roux-en-Y gastric bypass (RYGB) effectively treats obesity and gastroesophageal reflux disease (GERD). As more surgeons recommend RYGB to treat GERD in patients with obesity, there are concerns about this approach in patients with previous non-bariatric foregut surgery. This study aims to evaluate the effect of previous non-bariatric foregut surgery on subsequent RYGB.

METHODS

Retrospective review of 2089 patients undergoing RYGB between January 1985 and June 2015 was conducted to identify all patients with previous non-bariatric foregut surgery. Perioperative and postoperative data was collected by retrospective chart review.

RESULTS

A total of 11 patients with prior non-bariatric foregut surgery underwent RYGB with median time between operations of 95.6 months. Of note, 7/11 (63.6%) had previous Nissen fundoplication. Conversion to open operation was required in 3/7 (42.9%) with previous Nissen compared to 1/4 (25%) in those without previous Nissen. The average length of stay (LOS) was 3.9 ± 0.9 days, significantly longer than our institutional average for RYGB of 3.2 ± 3.2 days (p = 0.02). Mean percentage of excess body mass index loss (%EBMIL) was 64.7 ± 23.5 at 4-year median follow-up, comparable to our institution's previously reported data. No mortalities were attributed to RYGB and the overall complication rate was 18.2%, compared to our institutional complication rate for RYGB of 8.5% (p = 0.253).

CONCLUSION

Despite increased technical difficulty and increase perioperative morbidity, patients undergoing RYGB with previous non-bariatric foregut surgery had long-term symptom resolution and robust weight loss. This indicates that in the right hands, RYGB after non-bariatric foregut surgery may be performed safely and effectively.

Laparoscopic revision surgery for gastroesophageal reflux disease

Laparoscopic antireflux surgery is a frequently performed procedure for the treatment of gastroesophageal reflux in surgical clinics. Reflux can recur in between 3% and 30% of patients on whom antireflux surgery has been performed, and so revision surgery can be required due to recurrent symptoms or dysphagia in approximately 3% to 6% of the patients. The objective of this study is to evaluate the mechanism of recurrences after antireflux surgery and to share our results after revision surgery in recurrent cases.From 2001 to 2014, revision surgery was performed on 43 patients (31 men, 12 women) between the ages of 24 and 70 years. The technical details of the first operation, recurrence symptoms, endoscopy, and manometry findings were evaluated. The findings of revision surgery, surgical techniques, morbidity rates, length of hospitalization, and follow-up period were also recorded and evaluated.The first operation was Nissen fundoplication in 34 patients and Toupet fundoplication in 9 patients. Mesh hiatoplasty was performed for enforcement in 18 (41.9%) of these patients. The period between the first operation and the revision surgery ranged from 4 days to 60 months. The most common finding was slipped fundoplication and presence of hiatal hernia during revision surgery. Revision fundoplication and hernia repair with mesh reinforcement were used in 33 patients. The other techniques were Collis gastroplasty, revision fundoplication, and hernia repair without mesh. The range of follow-up period was from 2 to 134 months. Recurrence occurred in 3 patients after revision surgery (6.9%). Although revision surgery is difficult and it has higher morbidity, it can be performed effectively and safely in experienced centers.