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Anderson DJ, Kuchta K, Joseph S, Rwigema JC, Crafts T, Ishii S, Hedberg HM, Ujiki MB. Impact of Toupet fundoplication with bougie on post-operative dysphagia and quality of life. Surg Endosc 2024:10.1007/s00464-024-11038-9. [PMID: 39028347 DOI: 10.1007/s00464-024-11038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 06/30/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Numerous studies comment on quality of life outcomes comparing complete and partial fundoplication with or without a bougie. Society guidelines are moving toward recommending partial fundoplication over complete fundoplication due to improved side effect profile with similar outcomes. Retrospective studies and randomized trials have elucidated that use of a bougie during Nissen fundoplication does impact long-term dysphagia. To date there are no retrospective or prospective data that guide practice for partial fundoplications. OBJECTIVE The purpose of this project is to investigate the clinical implications of using a bougie for Toupet fundoplication with regard to short-term and long-term dysphagia and need for further therapeutic interventions. METHODS A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic, pre-operative quality of life outcomes data, perioperative, and post-operative quality of life outcomes data of 373 patients from 2011 to 2022 undergoing Toupet fundoplication without bougie or with a traditional Savary 56Fr or 58Fr bougie were reviewed. The two groups were compared using student's t-test to identify statically significant differences between the groups. RESULTS Between 2011 and 2022, 373 patients underwent Toupet fundoplication (276 with traditional bougie, 97 without). Median follow-up in the bougie group was 19 months, versus 9 months in the non bougie group. There was no difference between early (3 weeks) and late dysphagia scores (6 months). In the bougie group there were two mucosal perforations due to the bougie. There were no statistically significant differences in GERD-HRQL, gas bloat, and dysphagia scores between groups at one year. CONCLUSION There is no difference observed in early or late dysphagia scores, GERD-HRQL, gas bloat or need for dilation in patients undergoing Toupet fundoplication with or without a traditional bougie. It is reasonable to discontinue the use of a traditional bougie during Toupet fundoplication, especially due to risk of esophageal perforation.
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Affiliation(s)
- Derrius J Anderson
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA.
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Stephanie Joseph
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Jean-Christophe Rwigema
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Trevor Crafts
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Shun Ishii
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - H Mason Hedberg
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
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Miller JD, Kemple BP, Evans JK, Clayton SB. A Comparison of Functional Luminal Imaging Probe With High-resolution Manometry, Timed Barium Esophagram, and pH Impedance Testing to Evaluate Functional Luminal Imaging Probe's Diagnostic Capabilities. J Clin Gastroenterol 2024:00004836-990000000-00253. [PMID: 38227842 DOI: 10.1097/mcg.0000000000001966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE The aims of this study are to determine the functional luminal imaging probe's (FLIP) diagnostic utility by comparing FLIP measurements with results from other esophageal evaluation standards. BACKGROUND The FLIP is an esophageal evaluation technique performed at the time of endoscopy. Few studies have evaluated FLIP diagnostic capabilities compared with the established testing techniques, including high-resolution manometry (HRIM), time barium esophagram (TBE), and 24-hour impedance-pH monitoring. PATIENTS AND METHODS A retrospective review was performed for 413 preintervention patients who underwent FLIP testing during endoscopy. Data from HRIM, 24-hour pH monitoring, and TBE were compared. RESULTS Abnormal Distensibility Index (DI) was associated with abnormal integrated relaxation pressure (IRP; P = 0.003). Average DI was higher in patients with abnormal IRP (>15 mm Hg) when a hiatal hernia was present (P = 0.025). The total agreement between correlated diagnoses from FLIP and HRIM was 33.5%. DI was not associated with acid exposure time on pH monitoring. Agreement between FLIP and TBE was 49% with a sensitivity of 98.1% and a specificity of 36.5%. A 60 mL distension had a significantly lower detection rate than 40 mL and 50 mL for active peristalsis and was unaffected by pressure (P < 0.05). CONCLUSIONS FLIP as an adjunct to HRIM is supported by strong metric correlation. FLIP was not correlated to pH monitoring findings, suggesting FLIP is not useful in reflux assessment. The agreement between FLIP and TBE was lower than in previous studies. Hiatal hernia impacted the normality between DI and IRP, not between FLIP and TBE. We suggest analyzing peristaltic patterns on panometry at all fill volumes to optimize detection.
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Affiliation(s)
| | - Brendan P Kemple
- Wake Forest University School of Medicine
- Department of Medicine, Medical College of Georgia
| | - Joni K Evans
- Biostatistics and Data Science, Wake Forest University School of Medicine
| | - Steven B Clayton
- Department of Medicine, Section on Gastroenterology, Wake Forest University School of Medicine
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Amundson JR, Kuchta K, VanDruff VN, Wu H, Campbell M, Hedberg HM, Ujiki MB. Experience with Impedance Planimetry for Surgical Foregut Disease in 1,097 Cases. J Am Coll Surg 2023; 237:35-48. [PMID: 36896984 DOI: 10.1097/xcs.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND The geometry and compliance of gastrointestinal sphincters may be assessed by impedance planimetry using a functional lumen imaging probe (FLIP). We describe our institutional foregut surgeon experience using FLIP in 1,097 cases, highlighting instances where FLIP changed operative decision making. STUDY DESIGN A retrospective review of an IRB-approved prospective quality database was performed. This included operative and endoscopic suite foregut procedures using FLIP between February 2013 and May 2022. RESULTS During the study period, FLIP was used a total of 1,097 times in 919 unique patients by 2 foregut surgeons. Intraoperative FLIP was used during 573 antireflux procedures and 272 endoscopic myotomies. FLIP was also used during 252 endoscopic suite procedures. For those undergoing preoperative workup of GERD, starting in 2021, esophageal panometry was performed in addition to standard FLIP measurements at the lower esophageal sphincter. In 77 cases, intraoperative FLIP changed operative decision making. During antireflux procedures, changes included adding or removing crural sutures, adjusting a fundoplication tightness, choice of full vs partial wrap, and magnetic sphincter augmentation sizing. For endoscopic procedures, changes included aborting peroral endoscopic myotomy or Zenker's peroral endoscopic myotomy, performing a myotomy when preoperative diagnosis was unclear, or performing additional myotomy. CONCLUSIONS FLIP is a useful tool for assessing the upper esophageal sphincter, lower esophageal sphincter, pylorus, and secondary esophageal peristalsis that can be used in a wide variety of clinical situations within a foregut surgeon's practice. It can also function as an adjunct in intraoperative decision making.
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Affiliation(s)
- Julia R Amundson
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Kristine Kuchta
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Vanessa N VanDruff
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Hoover Wu
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Michelle Campbell
- From the Department of Surgery, University of Chicago, Chicago, IL (Amundson, VanDruff, Wu, Campbell)
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - H Mason Hedberg
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
| | - Michael B Ujiki
- the Department of Surgery, NorthShore University Health System, Evanston, IL (Amundson, Kuchta, VanDruff, Wu, Campbell, Hedburg, Ujiki)
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Amundson JR, Zukancic H, Kuchta K, Zimmermann CJ, VanDruff VN, Joseph S, Che S, Ishii S, Hedberg HM, Ujiki MB. Acid exposure time better predicts outcomes following anti-reflux surgery than DeMeester score. Surg Endosc 2023:10.1007/s00464-023-10164-0. [PMID: 37311888 DOI: 10.1007/s00464-023-10164-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/25/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Criteria to diagnose gastroesophageal reflux disease (GERD) vary. The American Gastroenterology Association (AGA) 2022 Expert Review on GERD focuses on acid exposure time (AET) rather than DeMeester score from ambulatory pH testing (BRAVO). We aim to review outcomes following anti-reflux surgery (ARS) at our institution, grouped by differing criteria for the diagnosis of GERD. METHODS A retrospective review of a prospective gastroesophageal quality database was performed for all patients undergoing evaluation for ARS with preoperative BRAVO ≥ 48 h. Group comparisons were made using two-tailed Wilcoxon rank-sum and Fisher's exact tests and two-tailed statistical significance of p < 0.05. RESULTS Between 2010 and 2022, 253 patients underwent an evaluation for ARS with BRAVO testing. Most patients (86.9%) met our institution's historical criteria: LA C/D esophagitis, Barrett's, or DeMeester ≥ 14.72 on 1+ days. Fewer patients (67.2%) met new AGA criteria: LA B/C/D esophagitis, Barrett's, or AET ≥ 6% on 2+ days. Sixty-one patients (24%) met historical criteria only, with significantly lower BMI, ASA, less hiatal hernias, and less DeMeester and AET-positive days, a less severe GERD phenotype. There were no differences between groups in perioperative outcomes or % symptom resolution. Objective GERD outcomes (need for dilation, esophagitis, and postop BRAVO) were equivalent between groups. Patient-reported quality of life scores, including GERD-HRQL, RSI, and Dysphagia Score did not differ between groups from preop through 1 year postop. Those who met our historical criteria only reported significantly worse RSI scores (p = 0.03) and worse GERD-HRQL scores at 2 years postop, though not statistically significant (p = 0.07). CONCLUSION Updated AGA GERD guidelines exclude a portion of patients who historically would have been diagnosed with and surgically treated for GERD. This cohort appears to have a less severe GERD phenotype but equivalent outcomes up to 1 year, with more atypical GERD symptoms at 2 years postop. AET may better define who should be offered ARS than DeMeester score.
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Affiliation(s)
- Julia R Amundson
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA.
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
| | - Haris Zukancic
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Christopher J Zimmermann
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Vanessa N VanDruff
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Stephanie Joseph
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Simon Che
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Shun Ishii
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - H Mason Hedberg
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
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Froiio C, Tareq A, Riggio V, Siboni S, Bonavina L. Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review. Eur Surg 2023. [DOI: 10.1007/s10353-022-00789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Summary
Background
The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force.
Methods
An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence.
Results
Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia.
Conclusion
A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.
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