Laparoscopic treatment of gastro-oesophageal reflux disease

Robotic Approach to Paraesophageal Hernia Repair Results in Low Long-Term Recurrence Rate and Beneficial Patient-Centered Outcomes

BACKGROUND

Little is known regarding important long-term outcomes after robotic paraesophageal hernia (PEH) repairs, such as symptom relief and recurrence rates. The aim of this study was to evaluate the long-term clinical outcomes in a large series of patients undergoing robotic PEH repair.

STUDY DESIGN

This prospective, IRB-approved study analyzed adult patients who underwent robotic PEH repair, from 2010 to 2014, at a high-volume tertiary academic medical center. Detailed information on patient characteristics, perioperative factors, and long-term patient-reported outcomes for up to 5 years postoperatively were collected. Objective long-term outcomes included radiographic evidence of PEH recurrence at 1, 3, and 5 years postoperatively.

RESULTS

A total of 233 patients underwent robotic PEH repair during the study period-70% were primary, 30% were revisional. Seventy-eight percent of patients (181) had a type III PEH, 21% (49) had a type IV, and 1% (3) had a type II. At 5 years postoperatively, 62% of patients (145 of 233) were available for follow-up, with a radiographic recurrence rate of 9% (13 of 145). Additionally, there was a significant improvement in the GERD-HRQL score at 5 years postoperatively (preoperative: 25.6 ± 8.7, 5-year postoperative, 4.5 ± 1.7, p < 0.01, 95% CI 19.7 to 22.5).

CONCLUSIONS

This study represents one of the largest longitudinal robotic foregut surgical databases to date. Our results demonstrate that robotic PEH repair with an experienced surgical team is a safe and effective alternative to laparoscopic repair, with excellent long-term outcomes, including a very low recurrence rate.

Asymmetrical elevation of esophagogastric junction pressure suggests hiatal repair contributes to antireflux surgery dysphagia

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.

Randomized Trial of Division Versus Nondivision of Short Gastric Vessels During Nissen Fundoplication: 20-Year Outcomes

OBJECTIVE

To evaluate late outcomes from a randomized trial of division versus no division of short gastric vessels during laparoscopic Nissen fundoplication at up to 20 years follow-up.

BACKGROUND

Nissen fundoplication is an established procedure for the treatment of gastroesophageal reflux disease. Controversy about whether side effects such as dysphagia could be reduced by division of the short gastric vessels led to the establishment of a randomized trial in 1994. Early results showed equivalent reflux control and dysphagia, but more bloating after vessel division.

METHODS

A total of 102 patients underwent a laparoscopic Nissen fundoplication between May 1994 and October 1995, and were randomized to short gastric vessel division (50) versus nondivision (52). Follow-up was obtained yearly to 20 years using a standardized questionnaire administered by a blinded investigator. Clinical outcomes at 20 years or most recent follow-up were determined.

RESULTS

No significant differences for heartburn symptom and satisfaction scores or medication use were found between treatment groups. At 15 to 20 (mean 19.6) years follow-up, significant differences persisted for epigastric bloating: 26% versus 50% for nondivision versus division groups (P = 0.046). Heartburn symptom scores were low and not different for nondivision versus division groups (mean analog scores 1.4 vs 2.1/10, P = 0.152). Overall satisfaction after surgery was high in both groups (mean analog scores 8.1 vs 8.6/10, P = 0.989).

CONCLUSIONS

Although laparoscopic Nissen fundoplication has durable efficacy for heartburn symptom control at up to 20 years follow-up, division of short-gastric vessels failed to confer any reduction in side effects, and was associated with persistent epigastric bloat symptoms at late follow-up in this trial.

Long-term outcome of laparoscopic Nissen fundoplication in a regional hospital setting

BACKGROUND

Laparoscopic Nissen fundoplication is considered to be the standard approach for the surgical treatment of gastroesophageal reflux disease. Various trials have assessed the outcome of the operation performed in high-volume centers, but the existing evidence regarding peripheral, low-volume hospitals is scarce. The purpose of this study is to investigate the late outcome of laparoscopic Nissen fundoplication with regard to symptom control and postoperative quality of life in a community-hospital setting.

METHODS

376 patients underwent laparoscopic Nissen fundoplication in our hospital during the period of 1997-2012. Patients were asked to subjectively; assess the pre- and postoperative severity of their symptoms and quality of life. Follow-up was conducted by means of a mailed questionnaire.

RESULTS

Respondents had a median follow-up of 8.8 years (range: 1.4-17). 60.8% (101/166) patients reported complete control of heartburn. Ten patients (6%) had undergone revisional surgery. 31 respondents (18.6%) reported a new-onset dysphagia postoperatively. 85% (138/166) of the respondents would have; the operation again, if necessary. 73.6% (120/166) reported a lasting improvement of their overall quality of life.

CONCLUSION

Laparoscopic Nissen fundoplication is a safe method with significant long-term efficacy in terms of symptom control and quality of life, even when; performed in a low-volume, community-hospital setting.

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.

Ressecões hepáticas por videolaparoscopia

INTRODUÇÃO: As ressecções hepáticas representam umas das últimas fronteiras vencidas pela cirurgia videolaparoscópica. Apesar da complexidade do procedimento, da demanda de grande incorporação de tecnologia e necessidade de experiência em cirurgia hepática e laparoscópica, a indicação do método tem crescido de forma expressiva nos últimos anos. OBJETIVO: Realizar análise crítica do método, baseada nos trabalhos existentes na literatura, ressaltando o estado atual de suas indicações, exequibilidade, segurança, resultados e aspectos técnicos primordiais. MÉTODO: Foram identificados e analisados os trabalhos pertinentes nas bases de dados LILACS e PUBMED até dezembro de 2009, utilizando-se os descritores "liver resection", "laparoscopic" e "liver surgery". Não foram encontrados trabalhos prospectivos e randomizados sobre o tema, sendo os dados disponíveis provenientes de série de casos, estudos caso-controle e alguns estudos multicêntricos e metanálises. CONCLUSÃO: A hepatectomia por videolaparoscopia é hoje operação segura e factível, mesmo para as ressecções hepáticas maiores, com baixo índice de morbimortalidade. O método pode ser utilizado para lesões malignas sem prejuízo dos princípios oncológicos e com vantagens nos pacientes com cirrose ou disfunção hepática. A melhor indicação recai sobre as lesões benignas, em especial o adenoma hepatocelular. Em mãos experientes e casos selecionados, como as lesões benignas localizadas nos segmentos anterolaterais hepáticos, principalmente no segmento lateral esquerdo, a ressecção videolaparoscópica pode ser considerada hoje como tratamento padrão.

The short esophagus: intraoperative assessment of esophageal length

OBJECTIVE

To define the frequency and predictors of short esophagus in a case series of patients undergoing antireflux surgery.

METHOD

An observational prospective study from September 10, 2004, to October 31, 2006, was performed at 8 centers. The distance between the esophagogastric junction as identified by intraoperative esophagoscopy and the apex of the diaphragmatic hiatus was measured intraoperatively before and after esophageal mediastinal dissection; a distance of 1.5 cm was arbitrarily determined to categorize cases as long (>1.5 cm) or short (<or=1.5 cm).

RESULTS

One hundred eighty patients were enrolled; the mean age of patients was 49.3 +/- 15.3 years. At the first measurement (after isolation of the esophagogastric junction), the median distance between the esophagogastric junction and the apex of the hiatus was equal to or shorter than 1.5 cm in 68 (37.7%) patients; at the second measurement (after full mediastinal isolation), the measurement of the distance was still shorter than 1.5 cm in 34 (18.8%) patients and between 1.5 and 2.5 cm in 24 (13.4%) patients. The median length of the mediastinal esophageal dissection was 6 cm (range 1-12 cm). An esophageal lengthening procedure was performed in 26 (14.4%) patients. The duration of symptoms (P = .047), the General Health domain of the SF-36 questionnaire (P = .001), and an x-ray barium swallow (P = .000) are predictive factors for a "true" short esophagus.

CONCLUSIONS

True short esophagus is present in about 20% of patients undergoing routine antireflux surgery. Radiology, severity, and duration of symptoms are predictors of true foreshortening.

Esophageal manometry and clinical outcome after laparoscopic Nissen fundoplication

INTRODUCTION

The outcome after laparoscopic Nissen fundoplication can be assessed by either clinical symptoms or objective tests. Outcomes from objective tests are often held in higher regard than clinical data when determining the merits, or otherwise, of various antireflux surgery procedures. In this study, we sought to determine whether there is a relationship between postoperative symptoms and parameters measured by esophageal manometry to determine whether early postoperative esophageal manometry is a useful investigation for the routine assessment of post fundoplication outcome.

METHODS

One hundred and forty-three patients who had undergone a laparoscopic Nissen fundoplication, clinical follow-up at 3 months and 5 years after surgery, and esophageal manometry at 3 months after fundoplication as part of routine follow-up in 1 of 5 clinical trials were studied. Nineteen of these patients also underwent manometry 5 years after fundoplication. Postoperative symptoms were prospectively determined by applying a standardized questionnaire, which assessed dysphagia, heartburn, bloat symptoms, and overall satisfaction using analog scales. Patients were classified into different groups according to the analog scores for clinical symptoms. Correlations between clinical and postoperative manometry outcomes were sought.

RESULTS

No significant associations were found between parameters measured by esophageal manometry (lower esophageal sphincter resting and residual relaxation pressures, peristaltic amplitude and normal peristaltic propagation) and clinical parameters (dysphagia, heartburn, bloating, and overall satisfaction) for all time points -- 3 months postoperative manometry vs symptoms at 3 months and 5 years, 5 years postoperative manometry vs symptoms at 5 years, except for a weak (r = -0.17, p = 0.042) correlation between the percentage of successfully propagated swallows at 3 months and dysphagia for solids at 5 years.

CONCLUSION

Postoperative esophageal manometry parameters at 3 months and 5 years after surgery were not associated with any clinically important differences in the postoperative symptoms of heartburn, dysphagia, bloat or with overall satisfaction with the surgical outcome. The routine use of esophageal manometry to assess the outcome after Nissen fundoplication does not predict clinical outcome.

The many manifestations of gastroesophageal reflux disease: presentation, evaluation, and treatment

Gastroesophageal reflux disease (GERD) is a common problem that is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world, with important risk factors being obesity and the eradication of Helicobacter pylori. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory esophageal pH testing is the most sensitive test for GERD, whereas endoscopy is the most specific test. Medical treatment with proton pump inhibitors (PPIs) has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic anti-reflux surgery and PPIs have similar efficacy in the few available long-term trials. This article reviews the presentation, evaluation, and treatment of GERD.

Gastrooesophageal reflux disease

Gastrooesophageal reflux disease, GERD, is a common problem which is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world with important risk factors being obesity and the eradication of Helicobacter pylori. Increasing research points to transient LES relaxation and spatial separation of the diaphragm and LES (hiatal hernia in chest) being the critical mechanisms of acid reflux. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory oesophageal pH testing is the most sensitive test for GERD, while endoscopy is the most specific test. Medical treatment with PPIs has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic antireflux surgery and PPIs have similar efficacy in the few available long-term trials. Currently, endoscopic treatments for GERD should not be a clinical alternative outside of research trials. New drug therapies should be directed at modulating transient LES relaxation.

An anterior or posterior approach to partial fundoplication? Long-term results of a randomized trial

BACKGROUND

Partial fundoplications have been popularized by their lower risk of mechanical side effects. The question then emerges whether a similar partial wrap should be done posterior or anterior to the distal esophagus? We therefore conducted a study to compare the long-term outcome of laparoscopic partial fundoplications constructed either as anterior (AF) or posterior (PF) repairs.

PATIENTS AND METHODS

Ninety-five patients were enrolled in a randomized clinical trial. After a mean follow up of 65 months, 43 AF and 45 PF patients remained in the study. The levels of reflux control and postfundoplication complaints were assessed by use of validated instruments.

RESULTS

A posterior fundoplication was found to provide significantly better control of reflux related symptoms (heartburn p < 0.0001, acid regurgitation p < 0.0001). This was also reflected in a significantly lower number of reoperations and need for antisecretory drug therapy. The earlier postoperative difference in postfundoplication symptoms had disappeared.

CONCLUSIONS

A laparoscopic posterior partial fundoplication offers a high and durable level of disease control with few side effects. The current anterior type of repair cannot be recommended due to insufficient reflux control.

Leptin and ghrelin expression in adipose tissues and serum levels in gastric banding patients

BACKGROUND

To determine how leptin and ghrelin are expressed in the adipose tissues of obese adults undergoing gastric banding (LAGB), and to correlate tissue expression with serum concentrations and parameters of the metabolic syndrome.

MATERIALS AND METHODS

A cross-sectional analysis of 92 patients: 61 obese patients with a body mass index (BMI) 49.2 +/- 1 kg m(-2) received LAGB, 20 patients underwent band exchange (BMI, 36.6 +/- 1.4 kg m(-2)) and 11 adult patients (BMI, 24.3 +/- 0.6 kg m(-2)) with fundoplication served as controls. Clinical data such as BMI and blood pressure were evaluated along with subcutaneous and visceral adipose tissue gene expression and fasting levels of leptin and ghrelin. Tissue transcripts were measured using real-time PCR, serum protein concentrations radio-immunologically.

RESULTS

Leptin gene expression was highest in the primary LAGB group and more pronounced in subcutaneous fat in both sexes (P < 0.0001). Serum leptin concentrations were highest in the LAGB group (P < 0.001), whereby women exhibited higher serum levels than men. Leptin concentrations correlated positively to expression in subcutaneous fat (P < 0.0001), and leptin expression was also correlated to BMI and systolic blood pressure. We detected ghrelin gene expression in both types of fat. The ghrelin mRNA amounts in adipose tissues were similar in both sexes and comparable within groups; serum concentrations were lower in patients with primary LAGB than in controls (P < 0.05).

CONCLUSIONS

Human adipose tissue expression of leptin is weight-course dependent and ghrelin is constitutional. Serum levels of leptin, but not of ghrelin, are indicative of an adaptive pattern of local gene expression in obese subjects undergoing weight reduction.

Management of esophageal symptoms following fundoplication

Laparoscopic antireflux surgery has emerged as a widely used and effective management option for the properly selected patient with gastroesophageal reflux disease. Poor symptomatic outcomes occur even in the best of hands, the most common being recurrent or persistent heartburn (or atypical symptoms) and dysphagia. When heartburn predominates, the initial management step is an anatomical and physiologic evaluation to determine whether acid reflux is controlled and if the postoperative neoanatomy is appropriate. If anatomical evaluation indicates surgical failure (eg, slipped or loose fundoplication, recurrent hiatal hernia), earlier re- operation may be warranted. Objective evidence of ongoing acid reflux or a reflux-symptom association despite anatomical integrity indicates reintroduction of antireflux medical therapy. Evidence favoring physiologic and anatomical success should direct treatment toward functional heartburn, including the use of tricyclic antidepressants. Dysphagia in the immediate postoperative setting mandates reassurance, as conservative measures alone often suffice while postoperative changes resolve. With persistent dysphagia, anatomical and physiologic evaluation is again indicated in the search for a mechanical-, motility-, or reflux-related symptom basis. Dilation techniques can prevent the need for re-operation, but persistent dysphagia associated with distorted postoperative anatomy will likely require surgical intervention. Regardless of the indication, re-operation carries substantial morbidity and reduced success rates compared with the initial procedure. These procedures mandate careful patient selection and referral to a center with thorough surgical experience.