Complications After Surgery for Gastroesophageal Reflux Disease

Patient-tailored algorithm for laparoscopic cruroplasty standardization: comparison with hiatal surface area and medium-term outcomes

BACKGROUND

Different methods have been described for laparoscopic hiatoplasty and hiatus hernia (HH) repair. All techniques are not standardized and the choice to reinforce or not the hiatus with a mesh is left to the operating surgeon's preference. Hiatal surface area (HSA) has been described as an attempt at standardization; in case the area is > 4 cm², a mesh is used to reinforce the repair.

OBJECTIVE

The aim of this study was to describe a new patient-tailored algorithm (PTA), compare its performance in predicting crura mesh buttressing to HSA, and analyze outcomes.

METHODS

Retrospective, single-center, descriptive study (September 2018-September 2021). Adult patients (≥ 18 years old) who underwent laparoscopic HH repair. Outcomes and quality of life measured with the disease-specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) were analyzed.

RESULTS

Fifty patients that underwent laparoscopic hiatoplasty and Toupet fundoplication were included. The median age was 61 years (range 32-83) and the median BMI was 26.7 (range 17-36). According to the PTA, 27 patients (54%) underwent simple suture repair while crural mesh buttressing with Phasix-ST® was used in 23 (46%). According to the HSA, the median hiatus area was 4.7 cm² while 26 patients had an HSA greater than 4 cm². The overall concordance rate between PTA and HSA was 94% (47/50). The median hospital stay was 1.9 days (range 1-8) and the 90-day complication rate was 4%. The median follow-up was 18.6 months (range 1-35). Hernia recurrence was diagnosed in 6%. Postoperative dysphagia occurred in one patient (2%). The GERD-HRQL (p < 0.001) and RSI (p = 0.001) were significantly improved.

CONCLUSIONS

The application of PTA for cruroplasty standardization in the setting of HH repair seems effective. While concordance with HSA is high, the PTA seems easier and promptly available in the operative theater with a potential increase in procedure standardization, reproducibility, and teaching.

Prospective Study of Lactose Intolerance as a Potential Cause of Gas Bloat Syndrome in Patients Treated Surgically for Gastroesophageal Reflux

Introduction. The high incidence of lactose intolerance leads us to consider that many of our patients could suffer from this alteration. Therefore, as its main sign (even when asymptomatic) is increased intestinal gas, patients recovering from a Nissen fundoplication have a significant probability of suffering from gas bloat syndrome. Materials and Methods. This prospective study was conducted from November 2012 to January 2017, we included all the patients who had been treated by the Nissen technique for gastroesophageal reflux disease with gas bloat syndrome detected during follow-up and tested positive for lactose intolerance. The study participants were then prescribed a lactose-poor diet to be followed for 3 months. The patients were asked to complete quality of life and symptomatology questionnaires before and after diet. The pre- and post-diet results were then compared. Results. The pre- and post-diet results showed statistically significant improvements in both questionnaires. Conclusion. Lactose intolerance may account for the symptoms presented by a significant number of patients with gas bloat syndrome following antireflux surgery; these patients could benefit from consuming a lactose-free diet, which we expect to alleviate or, in some cases, eliminate the above symptoms.

Surgical treatment of gastroesophageal reflux disease

Operative treatment of GERD has become more common since the introduction of LARS. Careful patient selection based on symptoms, response to medical therapy, and preoperative testing will optimize the chances for effective and durable postoperative control of symptoms. Complications of the LARS are rare and generally can be managed without reoperation. When reoperation is necessary for failed antireflux surgery, it should be performed by high-volume gastroesophageal surgeons.

Gastroesophageal reflux disease treatment: side effects and complications of fundoplication

Even skilled surgeons will have complications after antireflux surgery. Fortunately, the mortality is low (<1%) with laparoscopic surgery, immediate postoperative morbidity is uncommon (5%-20%), and conversion to an open operation is <2.5%. Common late postoperative complications include gas-bloat syndrome (up to 85%), dysphagia (10%-50%), diarrhea (18%-33%), and recurrent heartburn (10%-62%). Most of these complications improve during the 3-6 months after surgery. Dietary modifications, pharmacologic therapies, and esophageal dilation may be helpful. Failures after antireflux surgery usually occur within the first 2 years after the initial operation. They fall into 5 patterns: herniation of the fundoplication into the chest, slipped fundoplication, tight fundoplication, paraesophageal hernia, and malposition of the fundoplication. Reoperation rates range from 0%-15% and should be performed by experienced foregut surgeons.

Laparoscopic management of obstructive hepatoduodenal adhesions after open antireflux procedure

The case of a 3-year-old child who underwent open antireflux surgery for severe gastroesophageal reflux is presented. One month after the procedure, the child presented with abstinence from feeds, and vomiting after food intake. Esophagogastroscopy ruled out pathology in the area around the wrap. Upper gastrointestinal contrast studies demonstrated a kinking of the duodenal loop. Laparoscopy revealed severe adhesions between the duodenum and liver with kinking of the duodenum. The adhesions were taken down with careful dissection using hooked laparoscopic scissors. The symptoms subsided immediately after surgery and the further course and follow-up examinations were uneventful. The complication of mechanical ileus due to hepatoduodenal adhesions with severe kinking of the duodenum after antireflux surgery and with successful laparoscopic management has never been reported to date.

Esophageal involvement in scleroderma: gastroesophageal reflux, the common problem

OBJECTIVES

Systemic sclerosis (SSc) is a multisystem disease characterized by abnormalities of small blood vessels, and fibrosis of the skin and internal organs including gastrointestinal tract. This article reviews the esophageal involvement in SSc, emphasizing the gastroesophageal reflux, which is a common problem in SSc patients.

METHODS

We conducted a Medline search from 1966 to 2005. The keywords "systemic sclerosis," "esophageal involvement," "gastroesophageal reflux," "esophagitis," and "treatment" were used.

RESULTS

The gastrointestinal tract is frequently affected in diffuse and limited disease. Although any part of the gastrointestinal tract can be involved, esophageal disease occurs in nearly all patients with SSc. Common esophageal manifestations in SSc include motility abnormalities and gastroesophageal reflux (GER), Barrett's esophagus, adenocarcinoma, infectious esophagitis, and drug-induced esophagitis. Common complications of GER include esophagitis with erosions and bleeding and stricture formation. Extraesophageal manifestations of GER include mouth ulcers, chronic cough, hoarse voice, sore throat, pharyngitis, laryngospasm, asthma, and recurrent pneumonia. Diagnostic procedures used in the investigation of esophageal involvement include barium esophagram, esophageal manometry, 24-hour ambulatory pH, and endoscopy. Treatment of GER in SSc includes behavioral modification and medical therapy, mainly with proton pump inhibitors. Surgical intervention has a limited role in the management of GER in selected SSc patients.

CONCLUSIONS

Esophageal involvement is frequent in SSc patients. Gastroesophageal reflux may cause high morbidity. Careful examination of the patients reveals gastrointestinal abnormalities even in patients without symptoms. Appropriate treatment of esophageal involvement ameliorates symptoms and prevents complications.