Dilation after fundoplication: timing, frequency, indications, and outcome

Fundoplication for Pediatric Gastroesophageal Reflux Disease: Indications, Techniques, and Outcomes

Background This study aimed to evaluate the indications, techniques, and outcomes of fundoplication in pediatric patients with gastroesophageal reflux disease (GERD) at a tertiary hospital in Yemen. Methods A prospective cohort study was conducted at Al-Thawra Modern General Hospital, Sana'a, Yemen, between January 2015 and January 2022. The study included 45 pediatric patients under 18 years of age who underwent fundoplication for GERD. Data on demographic and clinical characteristics, surgical type, postoperative complications, and follow-up outcomes were collected and analyzed. Results The median age of the 45 pediatric patients was two years (range: two months to 10 years), with 25 males (56%) and 20 females (44%). The primary indications for fundoplication included GERD with hiatal hernia in 20 patients (44.4%), persistent symptoms despite medical management in 9 patients (20%), recurrent chest infections associated with neurological disorders in 7 patients (15.6%), esophageal stricture in 8 patients (17.8%), and both hiatal hernia and esophageal stricture in 1 patient (2.2%). Nissen fundoplication was performed in 36 patients (80%), and Thal fundoplication was performed in 9 patients (20%). Complete symptom resolution was achieved in 31 patients (68.89%). Dysphagia due to postoperative esophageal stricture was the most common complication, affecting 13 patients (29%). A structured dilatation protocol resulted in improvement after one session in four patients (30.8%), regular sessions in six patients (46.2%), and irregular sessions in three patients (23.1%). The mortality rate was two patients (5.56%), both of whom had cerebral palsy and died due to recurrent chest infections unrelated to GERD recurrence or esophageal stricture. Conclusions Fundoplication is a safe and effective surgical treatment for pediatric GERD, with a high success rate and manageable complications. A structured postoperative dilatation protocol is essential for managing esophageal strictures and improving outcomes. Early diagnosis and intervention, alongside adherence to postoperative protocols, are crucial for optimal results. Further research with larger sample sizes and long-term follow-up is recommended to confirm these findings and improve clinical practice.

Laparoscopic Nissen Versus Toupet Fundoplication for Short- and Long-Term Treatment of Gastroesophageal Reflux Disease: A Meta-Analysis and Systematic Review

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is the most common standard technique worldwidely for Gastroesophageal reflux disease (GERD). Another type of fundoplication, laparoscopic Toupet fundoplication (LTF), intends to reduce incidence of postoperative complications. A systematic review and meta-analysis are required on short- and long-term outcomes based on randomized controlled trials (RCTs) between LNF and LTF.

METHODS

We searched databases including PubMed, Cochrane, Embase, and Web of Knowledge for RCTs comparing LNF and LTF. Outcomes included postoperative reflux recurrence, postoperative heartburn, dysphagia and postoperative chest pain, inability to belch, gas bloating, satisfaction with intervention, postoperative esophagitis, postoperative DeMeester scores, operating time (min), in-hospital complications, postoperative use of proton pump inhibitors, reoperation rate, postoperative lower oesophageal sphincter (LOS) pressure (mmHg). We assessed data using risk ratios and weighted mean differences in meta-analyses.

RESULTS

Eight eligible RCTs comparing LNF (n = 605) and LTF (n = 607) were identified. There were no significant differences between the LNF and LTF in terms of postoperative reflux recurrence, postoperative heartburn, postoperative chest pain, satisfaction with intervention, reoperation rate in short and long term, in-hospital complications, esophagitis in short term, and gas bloating, postoperative DeMeester scores, postoperative use of proton pump inhibitors, reoperation rate in long term. LTF had lower LOS pressure (mmHg), fewer postoperative dysphagia and inability to belch in short and long term and gas bloating in short term compared to LNF.

CONCLUSION

LTF were equally effective at controlling reflux symptoms and improving the quality of life, but with lower rate of complications compared to LNF. We concluded that LTF surgical treatment was superior for over 16 years old patients with typical symptoms of GERD and without upper abdominal surgical history upon high-level evidence of evidence-based medicine.

'Critical circle of fundoplication' - A key concept towards creating identical, replicable and consistent fundoplication wraps

Background

There is a significant learning curve associated with laparoscopic Nissen's fundoplication, during which, complications due to surgical errors are more likely to occur. Moreover, length of the wrap, its situation on the lower esophagus and the points of the fundus brought together to create the wrap are arbitrary and as per the surgeon's judgement and estimation. This leads to a lot of variation in the wraps created, not only from surgeon to surgeon, but also from case to case for each individual surgeon. We propose a new concept of 'Critical Circle of Fundoplication' and the new approach to construct the fundoplication based on this concept, by application of which, a mathematically precise fundoplication can be created which is consistent, accurate and optimum.

Patients and Methods

A total of 132 patients were operated based on the concept of 'Critical Circle of Fundoplication' between 2015 and 2020, of which 116 patients completed one year of follow-up and are included in the paper.

Results

The demographic characteristics, intraoperative findings and postoperative are described in detail. An additional average time of 10.5 minutes (range: 8-26 minutes) was required in the precise measurements and markings that were required by this approach.

Conclusion

By application of the concept of 'Critical Circle of Fundoplication', precise, consistent and optimum wraps can be created. By eliminating the errors of structural construction and placement of the wrap, overall results can be improved.

Current management of gastro-oesophageal reflux disease-treatment costs, safety profile, and effectiveness: a narrative review

Background

The purpose of this study was to review the current management of gastro-oesophageal reflux disease (GORD), including treatment costs, safety profile and effectiveness.

Methods

A literature review was performed of randomized-controlled trials, systematic reviews, Cochrane reports and National/Societal guidelines of the medical, endoscopic and surgical management of GORD. Proton pump inhibitor (PPI) prescribing patterns and expenditure were reviewed in different countries, including Australia, Canada, New Zealand, UK and USA.

Results

Proton pump inhibitors (PPIs) are primarily indicated for control of GORD, Helicobacter pylori eradication (combined with antibiotics), preventing NSAID-induced gastrointestinal bleeding and treating peptic ulcer disease. There is widespread overprescribing of PPIs in Western and Eastern nations in terms of indication and duration, with substantial expense for national health providers. Despite a favourable short-term safety profile, there are observational associations of adverse effects with long-term PPIs. These include nutrient malabsorption, enteric infections and cardiovascular events. The prevalence of PPI use makes their long-term safety profile clinically relevant. Cost-benefit, symptom control and quality-of-life outcomes favour laparoscopic fundoplication rather than chronic PPI treatment. Laparoscopic fundoplication in long-term management of PPI-responsive GORD is supported by SAGES, NICE and ACG, and PPI-refractory GORD by AGA and SAGES guidelines. The importance of establishing a definitive diagnosis prior to invasive management is emphasized, especially in PPI-refractory heartburn.

Conclusions

We examined evidence-based guidelines for PPI prescribing and deprescribing in primary care and hospital settings and the need for PPI stewardship and education of health professionals. This narrative review presents the advantages and disadvantages of surgical, endoscopic and medical management of GORD, which may assist in shared decision making and treatment choice in individual patients.This paper was presented (GS020) at the 88th RACS Annual Scientific Conference, 6-10 May, 2019.

Pneumatic dilation for the treatment of persistent post-laparoscopic fundoplication dysphagia: long-term efficacy and safety

BACKGROUND

Post-laparoscopic fundoplication (LF) dysphagia occurs in 5%-17% of patients and optimal management remains a topic of expert discussion. We assessed the efficacy and safety of pneumatic dilation (PD) in patients with persistent post-lLF dysphagia.

METHODS

Medical files of patients treated with PD for persistent post-fundoplication-associated dysphagia were reviewed. The primary outcome was long-term clinical success. Secondary endpoints were initial clinical success, dysphagia recurrence rate, and PD-related complication incidence.

RESULTS

Overall, 46 patients (74% women, 57.9±11.9 years) underwent 74 PD (mean: 1.6±0.8). A 30 mm, 35 mm, and 40 mm balloon was used in 45.9%, 43.2%, and 10.8%, respectively, of dilations. Among 45 patients with available follow-up, the overall long-term success rate of PD was 31/45 (68.9% [55.4-82.4]). Initial clinical success was 36/45 (80% [68.3-91.7]). Dysphagia recurred in 9 patients (25%; 95%CI 10.9-39.1) and 4 of these were effectively treated with a new dilation. Among 14 non-responders to PD, 11 underwent surgery. Four complications (2 perforations, 1 muscularis dilaceration, and 1 peri-procedural bleeding) occurred in 4 patients (incidence: 5.4% [95%CI; 0.3-10.6]) and were treated with partially covered self-expandable esophageal stents andhemostatic clips.

CONCLUSIONS

Pneumatic balloon dilation for post-fundoplication-associated symptoms is associated with a satisfactory long-term success rate and acceptable safety profile.

Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter?

BACKGROUND

Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia.

METHODS

A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected.

RESULTS

The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit.

CONCLUSION

One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.

Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia

BACKGROUND

Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia.

METHODS

We prospectively collected data on PF patients referred to Esophageal Clinic over 18 months. EGJO diagnosis was made by (a) endoscopist's description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8 mm²/mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20 mm, 30 mm, or 35 mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score.

RESULTS

Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3 cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20 mm balloon and 7 with ≥ 30 mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7-82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1-88.4%, p = 0.0001).

CONCLUSIONS AND INFERENCES

Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.

Reoperation after antireflux surgery: a population-based cohort study

Background

Antireflux surgery for gastro-oesophageal reflux disease (GORD) and/or hiatal hernia is effective. Between 10 and 20 per cent of patients undergo reoperation for recurrent symptoms. Most studies are undertaken in a single centre and possibly underestimate the rate of reoperation. The aim of this nationwide population-based cohort study was to investigate long-term reoperation rates after antireflux surgery.

Methods

This study included patients who underwent antireflux surgery between 2000 and 2017 in Denmark, and were registered in the Danish nationwide health registries. Reoperation rates were calculated for 1, 5, 10 and 15 years after the primary antireflux operation for GORD and/or hiatal hernia. Duration of hospital stay, 30- and 90-day mortality and morbidity, and use of endoscopic pneumatic dilatation were assessed.

Results

This study included a total of 4258 antireflux procedures performed in 3717 patients. Some 3252 patients had only primary antireflux surgery and 465 patients underwent reoperation. The 1-, 5-, 10- and 15-year rates of repeat antireflux surgery were 3·1, 9·3, 11·7 and 12·8 per cent respectively. Thirty- and 90-day mortality rates were similar for primary surgery (0·4 and 0·6 per cent respectively) and reoperations. The complication rate was higher for repeat antireflux surgery (7·0 and 8·3 per cent at 30 and 90 days respectively) than primary operation (3·4 and 4·8 per cent). A total of 391 patients (10·5 per cent of all patients) underwent endoscopic dilatation after primary antireflux surgery, of whom 95 (24·3 per cent) had repeat antireflux surgery.

Conclusion

In this population-based study in Denmark, the reoperation rate 15 years after antireflux surgery was 12·8 per cent. Reoperations were associated with more complications.

Clinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia

BACKGROUND & AIMS

Dysphagia is a consequence of antireflux surgery (ARS) for gastroesophageal reflux disease (GERD). We studied patient management and symptomatic outcomes.

METHODS

We performed a retrospective study of 157 consecutive adult patients with GERD (mean age, 65.1 ± 1.0 y; 72% female) who underwent ARS at a tertiary care center from 2003 through 2014. We characterized postfundoplication dysphagia using a self-reported Likert scale, which ranged from a low score of 0 (no dysphagia) to a high score of 4 (severe daily dysphagia); scores of 2 or more indicated clinically significant dysphagia. Postfundoplication dysphagia was categorized as early (≤6 wk after ARS) or late (>6 wk after ARS), and Kaplan-Meier analyses were used to assess the time to development of clinically significant dysphagia. We performed univariate and multivariate analyses to assess management response and identify factors associated with dysphagia. The primary aim was to determine the prevalence and clinical course of postfundoplication dysphagia in patients with GERD treated with ARS.

RESULTS

Of the 157 patients, 54.8% had early postfundoplication dysphagia (clinically significant in 20.4%); only 3.5% required endoscopic intervention. Over 2.1 ± 0.2 years of follow-up evaluation, 29 patients (18.5%) developed late postfundoplication dysphagia. Based on Kaplan-Meier analysis, the median time to clinically significant late postfundoplication dysphagia was 0.75 years (95% CI, 0.26-1.22). Of 13 patients (44.8%) who underwent endoscopic dilation, improvement was reported by 92.3%, with a mean decrease in dysphagia severity of 1.55 ± 0.3, based on the Likert scale. Prefundoplication dysphagia, early postfundoplication dysphagia, recurrent hiatal hernia, and lack of contraction reserve following multiple rapid swallows were univariate predictors of late postfundoplication dysphagia (P ≤ .04); lack of contraction reserve was associated independently with late postfundoplication dysphagia, based on multivariate logistic regression analysis (odds ratio, 3.73; 95% CI, 1.11-12.56).

CONCLUSIONS

Early and late postfundoplication dysphagia can be successfully managed conservatively or with endoscopic dilation, respectively. Lack of contraction reserve on multiple rapid swallows is associated independently with late postfundoplication dysphagia.

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.

The effect of pneumatic dilation in management of postfundoplication dysphagia

BACKGROUND

Fundoplication surgery is a commonly performed procedure for gastro-esophageal reflux disease or hiatal hernia repair. Up to 10% of patients develop persistent postoperative dysphagia after surgery. Data on the effectiveness of pneumatic dilation for treatment are limited. The aim of this study was to evaluate clinical outcomes and identify clinical factors associated with successful response to pneumatic dilation among patients with persistent postfundoplication dysphagia (PPFD).

METHODS

We retrospectively evaluated patients who had undergone pneumatic dilation for PPFD between 1999 and 2016. Patients with dysphagia or achalasia prior to fundoplication were excluded. Demographic information, surgical history, severity of dysphagia, and clinical outcomes were collected. Data pertaining to esophagram, manometry, endoscopy, and pneumatic dilation were also collected.

RESULTS

We identified 38 patients (82% female, 95% Caucasian, and median age 59 years) with PPFD who completed pneumatic dilation. The median postfundoplication dysphagia score was 2. Eleven patients had abnormal peristalsis on manometry. Seventeen patients reported response (seven complete) with an average decrease of 1 in their dysphagia score. Fifteen patients underwent reoperation due to PPFD. Hiatal hernia repair was the only factor that predicts a higher response rate to pneumatic dilation. Only one patient in our study developed complication (pneumoperitoneum) from pneumatic dilation.

CONCLUSION & INFERENCES

We found that pneumatic dilation to be a safe treatment option for PPFD with moderate efficacy. Patients who developed PPFD after a hiatal hernia repair may gain the greatest benefit after pneumatic dilation. We were not able to identify additional clinical, radiological, endoscopic, or manometric parameters that were predictive of response.

Post-Nissen Dysphagia and Bloating Syndrome: Outcomes After Conversion to Toupet Fundoplication

INTRODUCTION

Protracted dysphagia and bloating are potential troublesome side effects following Nissen fundoplication. The aim of this study was to evaluate the effects of conversion from Nissen to Toupet on dysphagia and bloating.

METHODS

The study used a retrospective chart review of all patients who had undergone conversion from Nissen to Toupet between 2001 and 2014. Endpoints were to determine the effect of conversion on dysphagia, bloating, and reflux control.

RESULTS

Twenty-five patients underwent conversion at a median of 3.7 years (1.4-10.5) after initial fundoplication. Indications were dysphagia in 19 (76%) and bloating syndrome in 6 (24%) patients. The median operative time was 104 min (86-146). There were no serious complications or mortality. Median follow-up was 27 months (0.8-130). Dysphagia was relieved in 16 (84%) and bloating in all 6 patients. Two patients developed reflux requiring a redo-Nissen. Two patients had persistent dysphagia and required endoscopic dilation. The GERD-HRQL post-conversion showed a median score of 5 (3-13).

CONCLUSIONS

Conversion relieved dysphagia in 84% and bloating in 100%. Significant recurrence of GERD was rare. Given the absence of serious complications, conversion should be considered in patients with severe bloating or dysphagia.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

Evaluation and management of patients with symptoms after anti-reflux surgery

Over the past two decades, there has been an increase in the number of anti-reflux operations being performed. This is mostly due to the use of laparoscopic techniques, the increasing prevalence of gastroesophageal reflux disease (GERD) in the population, and the increasing unwillingness of patients to take acid suppressive medications for life. Laparoscopic fundoplication is now widely available in both academic and community hospitals, has a limited length of stay and postoperative recovery time, and is associated with excellent outcomes in carefully selected patients. Although the operation has low mortality and postoperative morbidity, it is associated with late postoperative complications, such as gas bloat syndrome, dysphagia, diarrhea, and recurrent GERD symptoms. This review summarizes the diagnostic evaluation and appropriate management of such postoperative complications. If a reoperation is needed, it should be performed by experienced foregut surgeons.

A Case of Postfundoplication Dysphagia without Symptomatic Improvement after Endoscopic Dilatation

Laparoscopic fundoplication is a treatment option for gastroesophageal reflux disease refractory to medical treatment. When deciding whether or not to undergo surgery, patients with refractory gastroesophageal reflux disease and esophageal motility disorder need to fully understand the operative procedure, postoperative complications, and residual symptoms such as dysphagia, globus sensation, and recurrence of reflux. Herein, we report a case of a patient diagnosed with gastroesophageal reflux disease and aperistalsis who underwent Nissen (total, 360°) fundoplication after lack of response to medical treatment and subsequently underwent pneumatic dilatation due to unrelieved postoperative dysphagia and globus sensation.

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.

Outcome following management of dysphagia after laparoscopic anti-reflux surgery

BACKGROUND

Some patients develop troublesome dysphagia after laparoscopic antireflux surgery, and a proportion require further intervention. The management of this problem was evaluated.

METHODS

Patients who underwent intervention for dysphagia after laparoscopic fundoplication were identified from a database. Outcomes were prospectively determined from a standardized questionnaire that evaluated symptoms scores for dysphagia for solids and liquids, as well as patient satisfaction with the overall outcome. Outcomes 1 year after reintervention, and at the most recent follow-up were evaluated.

RESULTS

From 1994 to 2009, 121 (6.6%) of 1,821 patients who underwent laparoscopic fundoplication for gastroesophageal reflux also underwent endoscopic or surgical reintervention for dysphagia. Of these 121 patients, 56 underwent endoscopic dilatation, and 24 were satisfied with the outcome of dilatation; 18 progressed to surgery, and dysphagia persisted in 14 of them. Overall, 83 patients underwent revisional surgery, and 47 (62.7%) were satisfied with the outcome. Compared to patients who did not undergo any intervention for dysphagia, patients who underwent reintervention had lower satisfaction scores and higher dysphagia scores.

CONCLUSIONS

Approximately two thirds of patients with troublesome post-fundoplication dysphagia have a satisfactory outcome following either endoscopic dilatation or revisional surgery. However, approximately one third continue to be troubled by symptoms, despite further intervention.

Postoperative problems 2011: fundoplication and obesity surgery

Although the surgical treatment of both GERD and obesity is very successful, these procedures have a significant impact on the physiology and function of the proximal GI tract. With the increasing prevalence of both GERD and obesity, more and more patients present at the motility outpatient clinic with symptoms related to surgical interventions for these medical problems. In this review, we describe the main complications following antireflux surgery: dysphagia, gas bloat syndrome, recurrent (persistent) GERD symptoms, and dyspeptic symptoms. The most common motility-related complications of obesity surgery are dumping syndrome and esophageal dysmotility.

Trends and perioperative outcomes of inpatient antireflux surgery in the United States, 1993-2006

Antireflux surgery is an effective treatment for gastroesophageal reflux disease, but postoperation complications and durability may be problematic. The objective of the study was to determine whether inpatient antireflux surgery continued to decline in the United States due to concerns about its long-term effectiveness and the popularity of gastric bypass surgery and to assess recent changes in its perioperative outcomes. Using the Nationwide Inpatient Sample, we identified adult patients undergoing inpatient antireflux surgery during 1993-2006 and compared the trends of inpatient antireflux surgery with inpatient gastric bypass surgery. Perioperative complications included laceration, splenectomy, transfusion, esophageal dilation, total parenteral nutrition, and infection. Inpatient antireflux surgery increased from 9173 in 1993 to 32 980 in 2000 (+260%) but then decreased to 19 668 in 2006 (-40%). Compared with 2000, patients undergoing inpatient antireflux surgery in 2006 were older (49.9 ± 32.4 vs. 54.6 ± 33.6 years) and had a longer length of stay (3.1 ± 10.0 vs. 3.7 ± 13.4 days), more complications (4.7% vs. 6.1%), and higher mortality (0.26% vs. 0.54%) (all P < 0.05). Compared with inpatient gastric bypass surgery, length of stay was longer and mortality was higher for inpatient antireflux surgery in 2006, but neither was significant controlling for age. In 2006, perioperative outcomes of inpatient antireflux surgery were better in high-volume hospitals (all P < 0.01). Inpatient antireflux surgery continued to decline in the United States from 2000 to 2006, concomitant with a dramatic increase in inpatient gastric bypass surgery. Older patient age and worsening perioperative outcomes for inpatient antireflux surgery suggest increased medical complexity and possibly a larger share of reoperations over time. Designating centers of excellence for antireflux surgery based on local expertise may improve outcomes.

The Stretta procedure versus proton pump inhibitors and laparoscopic Nissen fundoplication in the management of gastroesophageal reflux disease: a cost-effectiveness analysis

BACKGROUND

The Stretta procedure is an endoscopic therapy for gastroesophageal reflux disease.

OBJECTIVE

To evaluate the cost-effectiveness of the Stretta procedure and that of competing strategies in the long-term management of gastroesophageal reflux disease.

METHODS

A Markov model was designed to estimate costs and health outcomes in Canadian patients with gastroesophageal reflux disease over five years, from a Ministry of Health perspective. Strategies included the use of daily proton pump inhibitors (PPIs), laparoscopic Nissen fundoplication (LNF) and the Stretta procedure. Probabilities and utilities were derived from the literature. Costs are expressed in 2006 Canadian dollars. Units of effectiveness were symptom-free months (SFMs) and quality-adjusted life years (QALYs), using a five-year time horizon.

RESULTS

In the analysis that used SFMs, the strategy using PPIs exhibited the lowest costs ($40 per SFM) and the greatest number of SFMs, thus dominating both the LNF and Stretta systems. But the cost-effectiveness analysis using QALYs as the measure of effectiveness showed that PPIs presented the lowest cost-effectiveness ratio, while both the LNF and Stretta strategies were associated with very high incremental costs (approximately $353,000 and $393,000, respectively) to achieve an additional QALY. However, the PPI strategy did not dominate the two other strategies, which were associated with better effectiveness.

CONCLUSIONS

If SFMs are used as the measure of effectiveness, PPIs dominate the Stretta and LNF strategies. However, if QALYs are used, the PPIs still present the lowest cost and LNF gives the best effectiveness. Regardless of the units of effectiveness or utility used in the present cost analysis, an approach of prescribing PPIs appears to be the preferred strategy.

Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux disease

Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.

Long-term results (6-10 years) of laparoscopic fundoplication

Most papers report excellent results of laparoscopic fundoplication but with relatively short follow-up. Only few studies have a follow-up longer than 5 years. We prospectively collected data of 399 consecutive patients with gastroesophageal reflux disease (GERD) or large paraesophageal/mixed hiatal hernia who underwent laparoscopic fundoplication between January 1992 and June 2005. Preoperative workup included symptoms questionnaire, videoesophagogram, upper endoscopy, manometry, and pH-metry. Postoperative clinical/functional studies were performed at 1, 6, 12 months, and thereafter every other year. Patients were divided into four groups: GERD with nonerosive esophagitis, erosive esophagitis, Barrett's esophagus, and large paraesophageal/mixed hiatal hernia. Surgical failures were considered as follows: (1) recurrence of GERD symptoms or abnormal 24-h pH monitoring; (2) recurrence of endoscopic esophagitis; (3) recurrence of hiatal hernia/slipped fundoplication on endoscopy/barium swallow; (4) postoperative onset of dysphagia; (5) postoperative onset of gas bloating. One hundred and forty-five patients (87 M:58 F) were operated between January 1992 and June 1999: 80 nonerosive esophagitis, 29 erosive esophagitis, 17 Barrett's esophagus, and 19 large paraesophageal/mixed hiatal hernias. At a median follow-up of 97 months, the success rate was 74% for surgery only and 86% for primary surgery and 'complementary' treatments (21 patients: 13 redo surgery and eight endoscopic dilations). Dysphagia and recurrence of reflux were the most frequent causes of failure for nonerosive esophagitis patients; recurrence of hernia was prevalent among patients with large paraesophageal/mixed hiatal hernia. Gas bloating (causing failure) was reported by nonerosive esophagitis patients only. At last follow-up, 115 patients were off 'proton-pump inhibitors'; 30 were still on medications (eight for causes unrelated to GERD). Conclusion confirms that laparoscopic fundoplication provides effective, long-term treatment of gastroesophageal reflux disease. Hernia recurrence and dysphagia are its weak points.

Technical considerations in laparoscopic fundoplication. How I do it

Gastroesophageal reflux disease (GERD) is a common disease and can be successfully treated by laparoscopic fundoplication. This article describes the technique of laparoscopic surgery for GERD with a focus on operative pitfalls.

The extended learning curve for laparoscopic fundoplication: a cohort analysis of 400 consecutive cases

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years. The patients were grouped consecutively into cohorts of 50 patients. The operating time, the length of postoperative hospital stay, the conversion rate to open operation, the postoperative dilatation rate, and the reoperation rate were analyzed. Results showed that the mean length of operative time decreased from 143 min in the first 50 patients to 86 min in the last 50 patients. The mean postoperative length of hospital stay decreased from 3.7 days initially to 1.2 days latterly. There was a 14% conversion to open operation rate in the first cohort compared with a 2% rate in the last cohort. Fourteen percent of patients required reoperation in the first cohort and 6% in the last cohort. Sixteen percent required postoperative dilatation in the first cohort. None of the last 150 patients required dilatation. In conclusion, laparoscopic fundoplication is a safe and effective operation for patients with gastroesophageal reflux disease. New techniques and better instrumentation were introduced in the early era of LNF. The learning curve, however, continues well beyond the first 20 patients.

Dysphagia after laparoscopic Nissen fundoplication

OBJECTIVE

To investigate the frequency and severity of dysphagia during the first 8 weeks after laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. So far, there have been no studies reporting data on day-to-day occurrence of dysphagia after laparoscopic fundoplication in a consecutive series of patients. This may explain why the frequency of dysphagia varies greatly in the literature (4-100%).

MATERIAL AND METHODS

Forty consecutive patients, undergoing elective laparoscopic Nissen fundoplication, completed a standard dysphagia registration diary each day during the first 8 weeks after surgery. Patients who preoperatively had suffered from dysphagia were excluded. Thus, none of the patients had dysphagia in the 2-month period before surgery. Ten patients undergoing elective cholecystectomy served as controls. Data were quantified, and a score value of 4 or more was considered bothersome.

RESULTS

Thirty-seven patients (93%) experienced some degree of dysphagia during the observation period. Sixteen patients (44%) had at least one day with annoying dysphagia. The dysphagia started 1-2 days after surgery, was most prominent during the first few weeks, and subsided in nearly all cases after 5-6 weeks. Two patients with persistent dysphagia were treated once with balloon dilatation. None of the patients in the control group had dysphagia.

CONCLUSIONS

Nearly all patients experience some degree of dysphagia after laparoscopic Nissen fundoplication, and in nearly half of the patients it is considered annoying. However, even severe dysphagia usually disappears within 5-6 weeks. These results suggest a conservative attitude for the first 1-2 months after surgery. The data may also serve as a background for preoperative information to the patients.

Endoscopic endoluminal radiofrequency ablation of Barrett's esophagus in patients with fundoplications

BACKGROUND

Endoscopic endoluminal radiofrequency ablation using the Barrx device is a new technique to treat Barrett's esophagus. This procedure has been used in patients who have not had antireflux surgery. This report is presents an early experience of the effects of endoluminal ablation on the reflux symptoms and completeness of ablation in post-fundoplication patients.

METHODS

Seven patients who have had either a laparoscopic or open Nissen fundoplication and Barrett's esophagus underwent endoscopic endoluminal ablation of the Barrett's metaplasia using the Barrx device (Barrx Medical, Sunnyvale, CA). Preprocedure, none of the patients had significant symptoms related to gastroesophageal reflux disease. One to two weeks after the ablation, patients were questioned as to the presence of symptoms. Preprocedure and postprocedure, they completed the GERD-HRQL symptom severity questionnaire (best possible score, 0; worst possible score, 50). Patients had follow-up endoscopy to assess completeness of ablation 3 months after the original treatment.

RESULTS

All patients completed the ablation without complications. No patients reported recurrence of their GERD symptoms. The median preprocedure total GERD-HRQL score was 2, compared to a median postprocedure score of 1. One patient had residual Barrett's metaplasia at 3 months follow-up, requiring re-ablation.

CONCLUSIONS

This preliminary report of a small number of patients demonstrates that endoscopic endoluminal ablation of Barrett's metaplasia using the Barrx device is safe and effective in patients who have already undergone antireflux surgery. There appears to be no disruption in the fundoplication or recurrence of GERD-related symptoms. Nevertheless, longer-term follow-up with more patients is needed.

Complications and antireflux medication use after antireflux surgery

BACKGROUND & AIMS

Although antireflux surgery is increasingly common, few studies have assessed the associated complications and health care use after surgery. The aim of this study was to estimate postoperative complications and continued use of antireflux medications and to identify predictors of complications.

METHODS

Through a review of the Department of Veterans Affairs administrative databases, all patients undergoing antireflux surgery from October 1, 1990, through January 29, 2001, were identified. Of 3367 patients identified, 222 were excluded as a result of a diagnosis of esophageal cancer, achalasia, or because there was no diagnosis related to gastroesophageal reflux disease. Medication use was determined for 2406 patients who had a minimum of 1 year of follow-up, including 1 or more outpatient visits at least 6 months after surgery and during the time when national pharmacy records were available.

RESULTS

Dysphagia was recorded in 19.4%, dilation was performed in 6.4%, and a repeat antireflux surgery was performed in 2.3%. The surgical mortality rate was .8%. Prescriptions were dispensed repeatedly for H2 receptor antagonists in 23.8%, proton pump inhibitors in 34.3%, and promotility agents in 9.2% of patients. Overall, 49.8% of patients received at least 3 prescriptions for one of these medications.

CONCLUSIONS

A moderate proportion of patients undergoing antireflux surgeries experienced complications and approximately 50% of patients received multiple prescriptions for antireflux medications at a median of 5 years of follow-up evaluation. Therefore, before surgery is performed, patients considering surgery should be counseled fully about the risk for complications and the likelihood of continued antireflux medication use.

Personal view: Why is my GI clinic filled with surgical mishaps? Post-operative syndromes as an externality problem

The aim of the present analysis was to review why gastroenterology clinics appear filled with patients suffering from postsurgical syndromes. The long-term sequelae of gastrointestinal surgery can be modelled as a negative production externality of surgical operations. When seeking to maximize their profits, surgeons are primarily concerned with the price and cost of surgery alone. They tend to ignore parts of the ensuing long-term costs they impose through postsurgical syndromes on other medical specialties. The complication-related rise in the cost of gastroenterology practice reflects parts of the societal costs of surgery that are not included on the surgical balance sheet. To the surgeon, surgery appears cheaper than to the rest of the medical community, because cost shifting from surgery to other medical specialties leads to a favourable surgical outcome with more surgical operations performed than medically needed or economically feasible. The amount of surgical sequelae could drop, if surgeons were forced to care for all their own postsurgical syndromes or if surgery entered a joint enterprise with gastroenterology caring for the same patient pool.

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.

Gastrointestinal complications of fundoplication

In children with medically refractory gastroesophageal reflux disease (GERD), fundoplication is effective and safe. However, in a subset of patients, gastrointestinal dysfunction occurs postoperatively. Symptoms include chest pain, persistent dysphagia in 5%, gas bloat in 2% to 4%, diarrhea in up to 20%, and dumping syndrome in up to 30%. Symptoms are often nonspecific, arising from recurrent or persistent GERD, anatomic complications such as disrupted or herniated wrap, functional disturbances such as rapid gastric emptying or altered gastric accommodation, or alternative diagnoses such as cyclic vomiting syndrome or food allergy. Detailed investigation, including various combinations of pHmetry, videofluoroscopy, endoscopy, motility studies, and dumping provocation testing, may be required to clarify pathophysiology and guide management.

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.

The management of patients who have "failed" antireflux surgery

Gastroenterologists may be called upon to manage patients who have had antireflux surgery that failed. The available literature on this topic comprises predominantly reports on retrospective, observational studies written by surgeons who often have focused on how technical deficiencies in performing the operation led to the failure. Such reports are of limited value to the gastroenterologist seeking guidance on patient management. Furthermore, comparisons among the reports are confounded by the lack of a standardized definition for failed antireflux surgery. This report critically reviews the available literature, and suggests a practical approach to the management of patients who have symptoms that were not completely relieved, that reappeared later, or that were caused by antireflux surgery.

Outcome of laparoscopic antireflux surgery in patients with nonerosive reflux disease

As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa.