Anatomic fundoplication failure after laparoscopic antireflux surgery

Computed tomography roadmap for post-operative fundoplication imaging with a novel structured reporting checklist

INTRODUCTION

With increasing numbers and acceptability of laparoscopic anti-reflux surgery (LARS) procedures over long-term medical treatment in the past decade, it follows that the complications of fundoplication wrap are seen intermittently with recurrent symptoms of heartburn and dysphagia. Endoscopy and barium swallow are the initial investigations performed for suspected fundoplication wrap failures. However, with easy availability of multislice computed tomography (CT) and the multiplanar reconstructions along with reduction in familiarity with barium examinations, it would be prudent for the surgeons to familiarise themselves with various appearances of wrap failure. Currently, there is no accepted standard to report a fundoplication wrap failure. We did a thorough literature review on the use of CT scans for fundoplication wrap failure, created a multidisciplinary hernia team with prominent radiologists and surgeons and discussed the role of CT scans in the management of suspected wrap failure. After completing a pilot study with around 43 patients of wrap failure, we created a standard CT reporting format which helped us in the management of even the most complex cases. This standard reporting format can be used by trainees and surgeons worldwide. This would lead to uniformity in reporting, would help in decision-making and would also help create national and international primary wrap failure and redo fundoplication registry.

PATIENTS AND METHODS

A total of 43 patients of wrap failure of multislice CT evaluation were analysed for type of failure along with factors responsible for the maintenance of integrity of the wrap. A novel checklist with structured reporting was used for the description of the post-operative imaging findings.

RESULTS

The demographic characteristics, post-operative imaging and intraoperative findings were described. The different types of wrap failure - Hinder types and associated pathologies were analysed for relative frequency in wrap failures. The novel structured reporting included wrap integrity and failure complications in post-operative patients of LARS.

CONCLUSION

Fundoplication wrap failure is not an uncommon complication seen after LARS. A novel structured report with checklist will help the surgeons to evaluate the post-operative patient with recurrent symptoms. Multislice CT is the ideal modality for imaging suspected wrap failures after primary endoscopic evaluation. Multiplanar imaging with coronal and sagittal reconstructions is useful for understanding the integrity of the wrap and its ability to detect failure/migration.

Robotic versus laparoscopic revision to Toupet fundoplication for failed Nissen fundoplication: a single-center experience

Nissen fundoplication (NF) is a common surgical procedure to treat gastroesophageal reflux disease; however, a subset of patients may continue to experience symptoms or develop symptom recurrence despite a successful procedure. This study aims to compare laparoscopic and robotic approaches for treating failed NF and evaluate the outcomes after converting to Toupet fundoplication (TF). We conducted a retrospective analysis of patients who underwent robotic or laparoscopic revision to TF for failed NF between 2016 and 2023. The data collected included demographics, pre-operative workup, and peri- and post-operative outcomes. Symptom analysis and anti-reflux medication usage were collected using a patient questionnaire. Failed fundoplication was defined as the need for an additional operation due to unresolved GERD symptoms or the emergence of a new issue. Eighty-eight patients (56 laparoscopic, 32 robotic) were included. Mean operative time was 148.71 ± 53.64 min for the total cohort and was significantly longer in the robotic group (RG) 167.43 min vs 138.01 min in the Laparoscopic group (LG) (p value = 0.012). The LG had a length of hospital stay of 2.16 ± 1.69 days vs RG 2.21 ± 1.28 days (p value = 0.867). The LG had a higher number of early readmissions (5.4%, p value = 0.629) and both the LG and the RG had 1 patient that required an early reintervention. Symptoms of dysphagia and reflux decreased in both groups at last follow-up, but the reduction in PPI use was not significant. Surgical revision to TF for failed NF provides significant symptom improvement with low rates of complications and recurrences. Our study shows that both approaches are safe and feasible and have comparable surgical and symptom outcomes.

Endoscopic assessment of failed fundoplications differs between endoscopists

BACKGROUND

Despite excellent long-term outcomes, a small proportion of patients who undergo fundoplication with hiatal hernia repair (laparoscopic antireflux surgery [ARS]) for treatment of gastroesophageal reflux disease (GERD) may require reoperation. Esophagogastroduodenoscopy (EGD) assessment in patients presenting with symptom recurrence plays a critical role in surgical planning of redo-ARS by confirming failure of the fundoplication and revealing the pattern of failure. We aimed to compare the findings documented by external endoscopists (i.e., outside physicians) to those documented by internal endoscopists (i.e., operating foregut or thoracic surgeons) before redo-ARS.

METHODS

After IRB approval, we conducted a retrospective chart review of patients who underwent redo-ARS at a tertiary surgical center between November 2016 and March 2023. Patients with both external and internal EGD reports were included, and findings from the two reports were compared.

RESULTS

Of 197 patients who underwent redo-ARS, both preoperative EGD reports were available for 181 (136 [75.1%] women; median age, 61 years [IQR 53-69]; median BMI, 27.9 kg/m2 [IQR 24.9-31.3]). The median time between primary and redo-ARS was 89 months (IQR 38-153), and the median time between external and internal endoscopic evaluation was 5 months (IQR 2-12). Only 38.9% of external reports mentioned a prior fundoplication. Compared to the operating surgeons, external physicians reported a significantly lower proportion of Barrett's esophagus (52.4%, p < .001), slipped fundoplications (28.8%, p < .001), paraesophageal hernias (20.5%, p < .001), disrupted fundoplications (20%, p < .001), intrathoracic fundoplications (0%, p < .001), and twisted fundoplications (0%, p < .001).

CONCLUSIONS

External endoscopists' reports of failed fundoplications are often incomplete and lack relevant details. Discrepancies between nonsurgical endoscopists and experienced surgeons are likely explained by a lack of training and experience to discern and document fundoplication changes accurately. To reduce this gap, we strongly recommend the adoption of standard definitions describing post-fundoplication endoscopic changes and the inclusion of relevant training within educational programs.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

Is systematic formal crural repair mandatory at the time of magnetic sphincter augmentation implantation?

Laparoscopic placement of the LINX Magnetic Sphincter Augmentation (MSA) device has become an accepted alternative to fundoplication in appropriate patients. Initial studies of MSA targeted to patients with 'early' disease allowed for the most minimal dissection of the esophagus to place the device, without hiatal dissection or repair (NoHHR), in patients with no or minimal hernia findings at surgery. Subsequent studies have compared systematic formal hiatal dissection and repair (Formal HHR) with the original minimal dissection technique. Review of published literature on MSA includes discussion on treatment of hiatal hernia at the time of implantation, accompanying the review of the physiology of the crural diaphragm. Formal hiatal hernia repair at the time of MSA implantation results in better control of reflux with less dysphagia and risk of postoperative hernia than NoHHR, regardless of the presence or size of hiatal hernia. Systematic crural repair should accompany any MSA implantation regardless of the presence or size of hiatal hernia.

Analysis of Rates, Causes, and Risk Factors for 90-Day Readmission After Surgery for Large Hiatal Hernia: A Two-Center Study

Background: Hospital readmissions have become a more examined indicator of surgical care delivery and quality. There is scarcity of data in the literature on the rate, risk factors, and most common reasons of readmission following major hiatal hernia surgery. The primary endpoint was 90-day readmission after surgery for large hiatal hernia. Secondary endpoint was to examine which characteristics related with a higher risk of readmission. Methods: A retrospective review of two distinct institutional databases was performed for patients who had surgery for a large hiatal hernia between January 2012 and December 2019. Demographic, perioperative, and outpatient data were collected from the medical record. Results: A total of 71 patients met the inclusion criteria, most of them suffering from a type III hernia (66.2%). Mean operative time was 146 (±56.5) minutes and median length of stay (LOS) was 6 days (interquartile range = 3). The overall morbidity was 21.1% and the in-hospital mortality was 1.4%. The 30- and 90-day readmission rates were 7% and 8.5%, respectively. The mean time to readmission was 14.3 (±15.6) days. The reasons for 90-day hospital readmission were dysphagia (50%), pneumonia (16.7%), congestive heart failure (16.7%), and bowel obstruction (16.7%). Grade of esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days were significant risk factors for unplanned readmission within 90 days. Conclusion: We observed that about 6 out of 71 patients who had surgery readmitted within 90 days (8.5%). Readmissions were most often linked to esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days. These findings point to the necessity for focused treatments before, during, and after hospitalization to decrease morbidity and extra costs in this high-risk population.

Quantification of fluoroscopic fundoplication anatomy: inter- and intraobserver reliability

The etiology of postfundoplication dysphagia remains incompletely understood. Subtle changes of gastroesophageal junction (GEJ) anatomy may be contributory. Barium swallows have potential for standardization to evaluate postsurgical anatomical features. Using structured barium swallows, we aim to identify reproducible, objectively measured postfundoplication anatomical features that will permit future comparison between patients with/without dysphagia. At 6-12 months of postfundoplication, 31 patients underwent structured barium swallow with video-fluoroscopy recording: standing anteroposterior; standing oblique (×2); prone oblique (×2); and prone oblique with continuous free drinking. A primary observer recorded 11 variables of GEJ anatomy for each view, repeated 3 months later, forming two datasets to assess intraobserver consistency. Interobserver reliability was determined using a dataset each from the primary observer and two medical students (after training). Intraclass correlation coefficients (ICC) were based on two-way mixed-effects model (ICC agreement: 0.40-0.59 'fair'; 0.60-0.74 'good'; 0.75-1.00 'excellent'). Interobserver reliability was good-excellent for 47 of 66 measurements. Measures of maximal esophageal diameter cf. wrap opening diameter and posterior esophageal angle showed high interobserver reproducibility on all views (ICC range 0.84-0.91; 0.68-0.80, respectively). Interobserver agreement was good-excellent for 5/6 views when measuring anterior GEJ displacement and axis deviation (ICC range 0.56-0.79; 0.41-0.77, respectively). Measures of wrap length showed lower reproducibility. Prone oblique measurements showed highest reproducibility (good-excellent agreement in 19/22 measurements). Intraobserver consistency was excellent for 98% of measurements (ICC range 0.74-0.99). Objective measurements of postfundoplication GEJ anatomy using structured barium swallow are reproducible and may allow further interrogation of anatomical features contributing to postfundoplication dysphagia.

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

OBJECTIVE

The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF).

SUMMARY OF BACKGROUND DATA

Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair.

METHODS

A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%).

CONCLUSIONS

LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

Less is more: cruroplasty alone is sufficient for revisional hiatal hernia surgery

BACKGROUND

Recurrence of hiatal hernia after anti-reflux surgery is common, with past studies reporting recurrence rates of 10-15%. Most patients experience relief from GERD symptoms following initial repair; however, those suffering from recurrence can have symptoms severe enough to warrant another operation. Although the standard of care is to revise the fundoplication or convert to magnetic sphincter augmentation (MSA) in addition to redo cruroplasty, it stands to reason that with an intact fundoplication, a repeat cruroplasty is all that is necessary to alleviate the patients' symptoms. In other words, only fix that which is broken.

METHODS

A retrospective review of patients with symptomatic hiatal hernia recurrence who underwent reoperation between January 2011 and September 2018 was conducted. Patients who received revisional cruroplasty alone were compared with cruroplasty plus some other revision (fundoplication revision, or takedown and MSA placement). Demographics, operative details, and postoperative outcomes were collected.

RESULTS

There were 73 patients identified. Median time to recurrence after the first procedure was 3.7 (1.9-8.2) years. Thirty-two percent of the patients had GERD symptoms for more than 10 years. Twenty-six patients underwent cruroplasty only. Forty-seven patients underwent cruroplasty plus fundoplication revision. There were no significant differences in operative times (2.4 h cruroplasty alone, 2.8 h full revision, p = 0.75) or postoperative complications between the two groups. Patients had a mean follow-up time of 1.64 years. Of the 73 patients, 8 had subsequent hiatal hernia recurrence. The recurrence rate for patients with cruroplasty alone was 11%, and the recurrence rate for the full revision group was 12% (p = 1.00).

CONCLUSION

Leaving an intact fundoplication alone at the time of revisional surgery did not adversely affect surgical outcomes. This data suggests a role for hernia-only repair for recurrent hiatal hernias.

When should we use mesh in laparoscopic hiatal hernia repair? A systematic review

The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.

Role of Wrap-Crural Fixation and Minimal Dissection in Prevention of Transmigration After Laparoscopic Nissen Fundoplication in Children

Background: Laparoscopic Nissen fundoplication is the gold standard antireflux procedure in pediatric age group. Intrathoracic migration of the fundic wrap is a common cause failure, leading to recurrence of gastroesophageal reflux disease (GERD) symptoms. Objectives: To investigate the impact of wrap-crural fixation and minimal esophageal dissection in prevention of wrap transmigration after laparoscopic Nissen fundoplication in children. Methods: Prospective randomized study of 46 pediatric patients with refractory GERD who underwent laparoscopic Nissen fundoplication divided into two equal groups. In Group A, wrap crural fixation was done, whereas in group B no fixation was done. Minimal esophageal dissection with preservation of the phrenoesophageal ligament was done in both groups. Approval of the Ethics Committee of our Faculty was obtained. Results: There was no difference between both groups regarding operative time, intraoperative complications, or length of hospital stay. Two patients in group B without wrap fixation suffered recurrence of GERD symptoms. On contrast study, they both showed intrathoracic wrap migration. One of them was reoperated. Whereas in group A, no recurrence of symptoms and no wrap transmigration were noticed in follow-up. Conclusion: In laparoscopic Nissen fundoplication, with minimal esophageal dissection and preservation of the phrenoesophageal ligament, there is no additional benefit from wrap-crural fixation in prevention of wrap transmigration.

The use of biosynthetic mesh in giant hiatal hernia repair: is there a rationale? A 3-year single-center experience

PURPOSE

Reinforced prosthetic crural repair is particularly indicated for giant hiatal hernias. The rationale is to reduce the recurrence rate in the long term. The aim of our study is to evaluate the outcomes of laparoscopic giant hiatal hernia repair using a biosynthetic mesh.

METHODS

We retrospectively analyzed 44 patients who underwent laparoscopic mesh-reinforced hiatal closure and fundoplication using a biosynthetic material. Inclusion criterion was large hiatal defects (> 5 cm). Follow-up was scheduled at 6, 12 and 36 months after surgery.

RESULTS

44 patients (29F) with a mean age of 62 years (range 14-85) and mean of BMI 24.5 kg/m² (range 21-29) underwent successful laparoscopic repair. Twenty-six (59.1%) patients had Nissen-Rossetti fundoplication, whereas 18 (40.9%) had Toupet fundoplication. Six-month questionnaire for the evaluation of symptoms was available for 43 patients (97.7%) and for 40 (90.9%) patients at 12 and 36 months. Mean preoperative symptoms score analysis was 1.68 ± 0.73. Mean scores at each follow-up time were significantly improved compared to baseline (p > 0.05). Barium swallow was available in 37 patients (84.1%) at 1 year after surgery. Radiologic recurrence was observed in two patients (4.5%). No patient had symptoms attributable to recurrence or required revisional surgery. There were no mesh-related complications at 3 years follow-up.

CONCLUSIONS

The use of biosynthetic mesh for crural reinforcement is associated with a low incidence of mesh-related complications and with a reasonably low recurrence rate (4.5%) at 36 months. However, additional data with longer follow-up are needed to determine long-term safety and efficacy.

Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion?

BACKGROUND

Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution.

METHODS

A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed.

RESULTS

180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m² (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m² and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001).

CONCLUSIONS

RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.

Does retching matter? Reviewing the evidence-Physiology and forces

Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure. Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking. Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown. Retching needs to be addressed if we are to reduce the incidence of wrap failure. Level of Evidence V.

A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication?

BACKGROUND

Nearly 20% of patients who undergo hiatal hernia (HH) repair and anti-reflux surgery (ARS) report recurrent HH at long-term follow-up and may be candidates for redo surgery. Current literature on redo-ARS has limitations due to small sample sizes or single center experiences. This type of redo surgery is challenging due to rare but severe complications. Furthermore, the optimal technique for redo-ARS remains debatable. The purpose of the current multicenter study was to review the outcomes of redo-fundoplication and to identify the best ARS repair technique for recurrent HH and gastroesophageal reflux disease (GERD).

METHODS

Data on 975 consecutive patients undergoing hiatal hernia and GERD repair were retrospectively collected in five European high-volume centers. Patient data included demographics, BMI, techniques of the first and redo surgeries (mesh/type of ARS), perioperative morbidity, perioperative complications, duration of hospitalization, time to recurrence, and follow-up. We analyzed the independent risk factors associated with recurrent symptoms and complications during the last ARS. Statistical analysis was performed using GraphPad Prism^® and R software^®.

RESULTS

Seventy-three (7.49%) patients underwent redo-ARS during the last decade; 71 (98%) of the surgeries were performed using a minimally invasive approach. Forty-two (57.5%) had conversion from Nissen to Toupet. In 17 (23.3%) patients, the initial Nissen fundoplication was conserved. The initial Toupet fundoplication was conserved in 9 (12.3%) patients, and 5 (6.9%) had conversion of Toupet to Nissen. Out of the 73 patients, 10 (13%) underwent more than one redo-ARS. At 8.5 (1-107) months of follow-up, patients who underwent reoperation with Toupet ARS were less symptomatic during the postoperative period compared to those who underwent Nissen fundoplication (p = 0.005, OR 0.038). Patients undergoing mesh repair during the redo-fundoplication (21%) were less symptomatic during the postoperative period (p = 0.020, OR 0.010). The overall rate of complications (Clavien-Dindo classification) after redo surgery was 11%. Multivariate analysis showed that the open approach (p = 0.036, OR 1.721), drain placement (p = 0.0388, OR 9.308), recurrence of dysphagia (p = 0.049, OR 8.411), and patient age (p = 0.0619, OR 1.111) were independent risk factors for complications during the last ARS.

CONCLUSIONS

Failure of ARS rarely occurs in the hands of experienced surgeons. Redo-ARS is feasible using a minimally invasive approach. According to our study, in terms of recurrence of symptoms, Toupet fundoplication is a superior ARS technique compared to Nissen for redo-fundoplication. Therefore, Toupet fundoplication should be considered in redo interventions for patients who initially underwent ARS with Nissen fundoplication. Furthermore, mesh repair in reoperations has a positive impact on reducing the recurrence of symptoms postoperatively.

Management of failure after surgery for gastro-esophageal reflux disease

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.

Late esophageal wall injury after mesh repair for large esophageal hiatal hernia: a case report

Background

Plication of an esophageal hiatus during surgery for esophageal hiatal hernia is a common practice; however, a mesh may be used if the hiatus is markedly enlarged. Recently, various late complications occurring as a result of mesh-induced esophageal and/or gastric wall injuries have been reported.

Case presentation

A 71-year-old woman presented at a neighborhood clinic in November 2010 with chief complaints of respiratory distress on exertion and heartburn. She was diagnosed as having a large esophageal hiatal hernia and was treated at our hospital using a laparoscopic Toupet fundoplication with mesh repair of the esophageal hiatus. Two years and 1 month after the operation, the patient complained of a bowel obstruction. An upper gastrointestinal endoscopy revealed that part of the mesh had extruded into the esophageal lumen, resulting in ulceration and stricture of the esophageal wall. Endoscopic balloon dilatation failed to improve the esophageal stricture. In July 2012, the patient underwent a lower esophagectomy with proximal gastrectomy and was discharged on the 25th hospital day.

Conclusions

We experienced a rare case requiring surgical treatment for a mesh-induced esophageal wall injury after surgery for a giant esophageal hiatal hernia. The selection of a soft, durable mash and its firm securement at a position distant from the gastrointestinal wall may be important to avoid late esophageal wall injury.

Predictive factors for short gastric vessels division during laparoscopic total fundoplication

OBJECTIVE

to determine clinical variables that can predict the need for division of the short gastric vessels (SGV), based on the gastric fundus tension, assessing postoperative outcomes in patients submitted or not to section of these vessels.

METHODS

we analyzed data from 399 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease (GERD). The section of the SGV was performed according to the surgeon evaluation, based on the fundus tension. Patients were divided into two groups: not requiring SGV section (group A) or requiring SGV section (group B).

RESULTS

the section was not necessary in 364 (91%) patients (Group A) and required in 35 (9%) patients (Group B). Group B had proportionally more male patients and higher average height. The endoscopic parameters were worse for Group B, with larger hiatal hernias, greater hernias proportion with more than four centimeters, more intense esophagitis, higher proportion of Barrett's esophagus and long Barrett's esophagus. Male gender and grade IV-V esophagitis were considered independent predictors in the multivariate analysis. Transient dysphagia and GERD symptoms were more common in Group B.

CONCLUSION

the division of the short gastric vessels is not required routinely, but male gender and grade IV-V esophagitis are independent predictors of the need for section of these vessels.

Temporal patterns of hiatus hernia recurrence and hiatal failure: quality of life and recurrence after revision surgery

Antireflux and paraesophageal hernia repair surgery is increasingly performed and there is an increased requirement for revision hiatus hernia surgery. There are no reports on the changes in types of failures and/or the variations in location of crural defects over time following primary surgery and limited reports on the outcomes of revision surgery. The aim of this study is to report the changes in types of hernia recurrence and location of crural defects following primary surgery, to test our hypothesis of the temporal events leading to hiatal recurrence and aid prevention. Quality of life scores following revision surgery are also reported, in one of the largest and longest follow-up series in revision hiatus surgery. Review of a single-surgeon database of all revision hiatal surgery between 1992 and 2015. The type of recurrence and the location of crural defect were noted intraoperatively. Recurrence was diagnosed on gastroscopy and/or contrast study. Quality of life outcomes were measured using Visick, dysphagia, atypical reflux symptoms, satisfaction scores, and Gastrointestinal Quality of Life Index (GIQLI). Two-hundred eighty four patients (126 male, 158 female), median age 60.8(48.2-69.1), underwent revision hiatal surgery. Median follow-up following primary surgery was 122.8(75.3-180.3) and 91.6(40.5-152.5) months after revision surgery. The most common type of hernia recurrence in the early period after primary surgery was 'telescope'(42.9%), but overall, fundoplication apparatus transhiatal migration was consistently the predominant type of recurrence at 1-3 years (54.3%), 3-5 years (42.5%), 5-10 years (45.1%), and >10 years (44.1%). The location of crural defects changed over duration following primary surgery as anteroposterior defects was most common in the early period (45.5% in <1 year) but decreased over time (30.3% at 1-3 years) while anterior defects increased in the long term with 35.9%, 40%, and 42.2% at 3-5 years, 5-10 years, and >10 years, respectively. Revision surgery intraoperative morbidity was 19.7%, mainly gastric (9.5%) and esophageal (2.1%) perforation. There was a 75% follow-up rate and recurrence following revision surgery was 15.4%(44/284) in unscreened population and 21%(44/212) in screened population. There was no difference in recurrence rate based on size of hiatus hernia at primary surgery, or at revision surgery. There were significant improvements in the Visick score (3.3 vs. 2.4), the modified Dakkak score (23.2 vs. 15.4), the atypical reflux symptom score (23.7 vs. 15.4), and satisfaction scores (0.9 vs. 2.2), but no difference in the various domains (symptom, physical, social, and medical) of the GIQLI scores following revision surgery. Revision hiatal surgery has higher intraoperative morbidity but may achieve adequate long-term satisfaction and quality of life. The most common type of early recurrence following primary surgery is telescoping, and overall is wrap herniation. Anterior crural defects may be strong contributor to late hiatus hernia recurrence. Symptom-specific components of GIQLI, but not the overall GIQLI score, may be required to detect improvements in QOL.

Tri-comparison of Laparoscopic Nissen, Hill, and Nissen-Hill Hybrid Repairs for Uncomplicated Gastroesophageal Reflux Disease

BACKGROUND

A randomized controlled trial (RCT) showed that laparoscopic Nissen fundoplication (LNF) and Hill (LHR) repairs are equivalent in treating uncomplicated GERD. We combined both repairs to create a laparoscopic Nissen-Hill Hybrid repair (HYB). The purpose of this study is to compare clinical and objective outcomes of a matched group of HYB to the two cohorts of the RCT.

METHODS

A retrospective analysis of prospectively collected data from the RCT and a prospectively collected data base was performed. Data were collected preoperatively, postoperatively short-term (ST) at 6 weeks and mid-term (MT) at 6-12 months. Evaluation was standardized according to the RCT and included three quality of life metrics (QOLRAD, GERD-HRQL, Dysphagia), endoscopy, manometry, pH testing, and barium swallow.

RESULTS

There were 51 HYB, 46 LNF, and 56 LHR patients. Age, BMI, follow-up, and gender were comparable. QOLRAD, HRQL, PPI use, DeMeester scores, and pH% time <4 significantly improved in all groups and were equivalent. Anatomic recurrence was seen in five LNF, four LHR, and two HYB patients. Reoperations were performed in three LHR, two LNF, and zero HYB patients.

CONCLUSION

Tri-comparison shows that HYB is a promising alternative to LHR and LNF. Side effects were not increased and there were fewer reoperations for failure.

Short- and Long-Term, 11-22 Years, Results after Laparoscopic Nissen Fundoplication in Obese versus Nonobese Patients

BACKGROUND

Some studies suggest that obesity is associated with a poor outcome after Laparoscopic Nissen Fundoplication (LNF), whereas others have not replicated these findings. The effect of body mass index (BMI) on the short- and long-term results of LNF is investigated.

METHODS

Inclusion criteria were only patients who undergone a LNF with at least 11-year follow-up data available, patients with preoperative weight and height data available for calculation of BMI (Kg/m²), and patients with a BMI up to a maximum of 34.9.

RESULTS

201 patients met the inclusion criteria: 43 (21.4%) had a normal BMI, 89 (44.2%) were overweight, and 69 (34.4%) were obese. The operation was significantly longer in obese patients; the use of drains and graft was less in the normal BMI group (p < 0.0001). The hospital stay, conversion (6,4%), and intraoperative and early postoperative complications were not influenced by BMI.

CONCLUSIONS

BMI does not influence short-term outcomes following LNF, but long-term control of reflux in obese patients is worse than in normal weight subjects.

YouTube as a Potential Training Resource for Laparoscopic Fundoplication

OBJECTIVE

To analyze the surgical proficiency and educational quality of YouTube videos demonstrating laparoscopic fundoplication (LF).

DESIGN

In this cross-sectional study, a search was performed on YouTube for videos demonstrating the LF procedure. The surgical and educational proficiency was evaluated using the objective component rating scale, the educational quality rating score, and total video quality score. Statistical significance was determined by analysis of variance, receiver operating characteristic curve, and odds ratio analysis.

RESULTS

A total of 71 videos were included in the study; 28 (39.4%) videos were evaluated as good, 23 (32.4%) were moderate, and 20 (28.2%) were poor. Good-rated videos were significantly longer (good, 22.0 ± 5.2min; moderate, 7.8 ± 0.9min; poor, 8.5 ± 1.0min; p = 0.007) and video duration was predictive of good quality (AUC, 0.672 ± 0.067; 95% CI: 0.541-0.802; p = 0.015). For good quality, the cut-off video duration was 7:42 minute. This cut-off value had a sensitivity of 67.9%, a specificity of 60.5%, and an odds ratio of 3.23 (95% CI: 1.19-8.79; p = 0.022) in predicting good quality. Videos uploaded from industrial sources and with a higher views/days online ratio had a higher objective component rating scale and total video quality score. In contrast, the likes/dislikes ratio was not predictive of video quality.

CONCLUSIONS

Many videos showing the LF procedure have been uploaded to YouTube with varying degrees of quality. A process for filtering LF videos with high surgical and educational quality is feasible by evaluating the video duration, uploading source, and the views/days online ratio. However, alternative videos platforms aimed at professionals should also be considered for educational purposes.

Laparoscopic Antireflux Surgery: Importance of Patient's Selection and Preoperative Workup

BACKGROUND

Laparoscopic antireflux surgery (LARS) is an excellent option for patients with symptoms refractory to medical treatment, for patients who have complications secondary to the use of proton pump inhibitors, and for those who do not want to take medications for a long period of time.

HYPOTHESIS

We hypothesized that (1) LARS has excellent outcomes if a complete preoperative workup and proper patient selection are performed and (2) recurrent symptoms often are not due to failure of the fundoplication to control the pathologic reflux.

PATIENTS AND METHODS

Every patient referred for antireflux surgery underwent a detailed symptomatic evaluation, barium swallow, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM), and pH monitoring. A fundoplication was performed in all of them. Data were analyzed to determine outcomes across 8 years.

RESULTS

From 2008 to 2016, 176 patients with gastroesophageal reflux disease (GERD) underwent LARS. One hundred and thirty-four patients (76.1%) had a total fundoplication, 31 (17.6%) had an anterior partial fundoplication, and 11 (6.3%) had a posterior partial fundoplication. Thirty-nine patients (22.2%) referred persistent or recurrent symptoms after the procedure and underwent EGD, HRM, and pH monitoring. Abnormal reflux was documented in 5 patients (2.8%). Among these failures, 3 patients had a body mass index (BMI) ≥30 and 2 had ≥35.

CONCLUSIONS

The results of this study showed that (1) laparoscopic fundoplication is an effective procedure for GERD; (2) patient's BMI can affect the outcome of a fundoplication; and (3) pH monitoring is important to establish if recurrent symptoms are secondary to failure of the operation.

Impact of obesity treatment on gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a frequently encountered disorder. Obesity is an important risk factor for GERD, and there are several pathophysiologic mechanisms linking the two conditions. For obese patients with GERD, much of the treatment effort is focused on weight loss and its consistent benefit to symptoms, while there is a relative lack of evidence regarding outcomes after novel or even standard medical therapy is offered to this population. Physicians are hesitant to recommend operative anti-reflux therapy to obese patients due to the potentially higher risks and decreased efficacy, and these patients instead are often considered for bariatric surgery. Bariatric surgical approaches are broadening, and each technique has emerging evidence regarding its effect on both the risk and outcome of GERD. Furthermore, combined anti-reflux and bariatric options are now being offered to obese patients with GERD. However, currently Roux-en-Y gastric bypass remains the most effective surgical treatment option in this population, due to its consistent benefits in both weight loss and GERD itself. This article aims to review the impact of both conservative and aggressive approaches of obesity treatment on GERD.

Outcome for Asymptomatic Recurrence Following Laparoscopic Repair of Very Large Hiatus Hernia

BACKGROUND

Radiological follow-up following repair of large hiatus hernias have identified recurrence rates of 20-30%, although most are small and asymptomatic. Whether patients will eventually develop clinical problems is uncertain. This study evaluated the outcome for individuals identified with an asymptomatic hiatus hernia following previous repair vs. asymptomatic controls.

METHODS

One hundred fifteen asymptomatic patients who had previously undergone sutured repair of a large hiatus hernia and then underwent barium meal X-ray 6-60 months after surgery within a clinical trial were identified and divided into two cohorts: with (n = 41) vs. without (n = 74) an asymptomatic hernia. Heartburn, dysphagia, and satisfaction with surgery were assessed prospectively using a standardized questionnaire applying analogue scales. Consumption of antisecretory medication and revision surgery were also determined. To determine the natural history of asymptomatic recurrent hiatus hernia, outcomes for the two groups were compared at 1 and 5 years and at most recent (late) follow-up.

RESULTS

Outcomes were available at 1 year for 98.2% and 5 years or the latest follow-up (range 6-237 months) for 100%. Heartburn and dysphagia scores were low and satisfaction scores high in both groups at all follow-up points, but heartburn scores and medication use were higher in the recurrent hernia group. At late follow-up, 94.6% of the recurrent hernia group vs. 98.5% without a hernia regarded their original decision for surgery to be correct. Two patients in recurrent hernia group underwent revision surgery.

CONCLUSIONS

Patients with an initially asymptomatic recurrent hiatus hernia are more likely to report heartburn and use antisecretory medication at later follow-up than controls. However, overall clinical outcomes remain good, with high satisfaction and low surgical revision rates. Additional interventions to reduce the risk of recurrence might not be warranted.

Laparoscopic Repair of Paraesophageal Hernias with a Falciform Ligament Buttress

BACKGROUND

Buttressing the crura in paraesophageal hernia (PEH) repairs with synthetic mesh may be associated with erosions and dysphagia, while biologic buttresses are expensive and do not decrease long-term recurrence rates. This study documents outcomes following laparoscopic PEH repairs using the falciform ligament as a buttress.

METHODS

This is a prospective study of laparoscopic PEH repairs with a falciform ligament buttress. Preoperatively and at 6 months follow-up, medications, radiologic studies and symptom scores were recorded. Patients included had a hiatal defect greater than 5 cm, while recurrent PEH or prior gastric surgery patients were excluded.

RESULTS

Thirty-four patients were included with a mean age of 61 years, and 33 patients completed postoperative evaluation with a mean follow-up of 7.1 months. The mean symptom severity decreased from 11.24 ± 1.71 to 3.24 ± 0.84, mean symptom frequency decreased from 11.62 ± 1.70 to 3.45 ± 0.85, and mean total symptom score decreased from 22.85 ± 3.40 to 6.69 ± 1.69 (p < 0.0001). Three patients had recurrences on the upper gastrointestinal (UGI) series. Only one required reoperation.

CONCLUSIONS

Laparoscopic PEH repair with a falciform ligament buttress is a viable option. Ongoing follow-up will demonstrate the utility of this approach to decrease morbidity and recurrence rates for paraesophageal hernia repairs.

Reoperative antireflux surgery

Patient satisfaction with primary antireflux surgery is high, but a small percentage of patients experience recurrent reflux and dysphagia, requiring reoperation. The major anatomic causes of failed fundoplication are slipped fundoplication, failure to identify a short esophagus, and problems with the wrap. Minimally invasive surgery has become more common for these procedures. Options for surgery include redo fundoplication with hiatal hernia repair if needed, conversion to Roux-en-Y anatomy, or, as a last resort, esophagectomy. Conversion to Roux-en-Y anatomy has a high rate of success, making this approach an important option in the properly selected patient.

Preoperative factors predicting clinical outcome following laparoscopic fundoplication

BACKGROUND

Antireflux surgery is effective for the treatment of gastroesophageal reflux, but not all patients benefit equally from it. The challenge is to identify the patients who will ultimately benefit from antireflux surgery. The aim of this study was to identify preoperative factors that predict clinical outcome after antireflux surgery, with special interest in the influence of socioeconomic factors.

METHODS

Preoperative clinical and socioeconomic data from 1,650 patients who were to undergo laparoscopic fundoplication were collected prospectively. Clinical outcome measures (persistent heartburn, dysphagia, satisfaction) were assessed at short-term (1 year) and longer-term (≥ 3 years) follow-up.

RESULTS

At early follow-up, male gender (relative risk [RR] 1.091, p < 0.001) and the presence of a hiatus hernia (RR 1.065, p = 0.002) were independently associated with less heartburn. Male gender was also associated with higher overall satisfaction (RR 1.046, p = 0.034). An association was found between postoperative dysphagia and age (RR 0.988, p = 0.007) and the absence of a hiatus hernia (RR 0.767, p = 0.001). At longer-term follow-up, only male gender (RR 1.125, p < 0.001) was an independent prognostic factor for heartburn control. Male gender (RR 0.761, p = 0.001), the presence of a hiatus hernia (RR 0.823, p = 0.014), and cerebrovascular comorbidities (RR 1.306, p = 0.019) were independent prognosticators for dysphagia at longer-term follow-up. A hiatus hernia was the only factor associated with better overall satisfaction. Socioeconomic factors did not influence any clinical outcomes at short- and longer-term follow-up.

CONCLUSION

Male gender and hiatus hernia are associated with a better clinical outcome following laparoscopic fundoplication, whereas socioeconomic status does not influence outcome.

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.

Surgical treatment of GERD: where have we been and where are we going?

Surgical management of gastroesophageal reflux disease has evolved from relatively invasive procedures requiring open laparotomy or thoracotomy to minimally invasive laparoscopic techniques. Although side effects may still occur, with careful patient selection and good technique, the overall symptomatic control leads to satisfaction rates in the 90% range. Unfortunately, the next evolution to endoluminal techniques has not been as successful. Reliable devices are still awaited that consistently produce long-term symptomatic relief with correction of pathologic reflux. However, newer laparoscopically placed devices hold promise in achieving equivalent symptomatic relief with fewer side effects. Clinical trials are still forthcoming.

Radiologic and endoscopic characteristics of laparoscopic antireflux wrap: correlation with outcome

After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe's classification of the postoperative valve was used for the definition of a "normal" or "defective" wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A "normal" antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P < 0.001). "Defective" antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.

Long-term maintenance effect of radiofrequency energy delivery for refractory GERD: a decade later

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) often seek alternative therapy for inadequate symptom control, with over 40% not responding to medical treatment. We evaluated the long-term safety, efficacy, and durability of response to radiofrequency treatment of the lower esophageal sphincter (Stretta).

METHODS

Using an intent-to-treat analysis, we prospectively assessed 217 patients with medically refractory GERD before and after Stretta. There was no concurrent control group in the study. Primary outcome measure was normalization of GERD-health-related quality of life (GERD-HRQL) in 70% or greater of patients at 10 years. Secondary outcomes were 50% reduction or elimination of proton pump inhibitors (PPIs) and 60% or greater improvement in satisfaction at 10 years. Successful treatment was defined as achievement of secondary outcomes in a minimum of 50% of patients. Complications and effect on existing comorbidities were evaluated. The results of a 10-year study are reported.

RESULTS

The primary outcome was achieved in 72% of patients (95% confidence interval 65-79). For secondary outcomes, a 50% or greater reduction in PPI use occurred in 64% of patients, (41% eliminating PPIs entirely), and a 60% or greater increase in satisfaction occurred in 54% of patients. Both secondary endpoints were achieved. The most common side effect was short-term chest pain (50%). Pre-existing Barrett's metaplasia regressed in 85% of biopsied patients. No cases of esophageal cancer occurred.

CONCLUSIONS

In this single-group evaluation of 217 patients before and after Stretta, GERD-HRQL scores, satisfaction, and PPI use significantly improved and results were immediate and durable at 10 years.

Hiatal hernia repair with biologic mesh reinforcement reduces recurrence rate in small hiatal hernias

The utility of mesh reinforcement for small hiatal hernia found especially during antireflux surgery is unknown. Initial reports for the use of biological mesh for crural reinforcement during repair for defects greater than 5 cm have been shown to decrease recurrence rates. This study compares patients with small hiatal hernias who underwent onlay biologic mesh buttress repair versus those with suture cruroplasty alone. This is a single-institution retrospective review of all patients undergoing repair of hiatal hernia measuring 1-5 cm between 2002 and 2009. The patients were evaluated based on surgical repair: one group undergoing crural reinforcement with onlay biologic mesh and other group with suture cruroplasty only. Seventy patients with hiatal hernia measuring 1-5 cm were identified. Thirty-eight patients had hernia repair with biologic mesh, and 32 patients had repair with suture cruroplasty only. Recurrence rate at 1 year was 16% (5/32) in patients who had suture cruroplasty only and 0% (0/38) in the group with crural reinforcement with absorbable mesh (statistically significant, P = 0.017). Suture cruroplasty alone appears to be inadequate for hiatal hernias measuring 1-5 cm with significant recurrence rate and failure of antireflux surgery. Crural reinforcement with absorbable mesh may reduce hiatal hernia recurrence rate in small hiatal hernias.

[The Mexican consensus on gastroesophageal reflux disease. Part II]

OBJECTIVE

To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002.

METHODS

Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher.

RESULTS

Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%.

CONCLUSION

Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.

A randomized trial on endoscopic full-thickness gastroplication versus laparoscopic antireflux surgery in GERD patients without hiatal hernias

BACKGROUND AND GOALS

Endoscopic full-thickness gastroplication by the Plicator instrument has proven to be a safe and effective method to improve symptoms of gastroesophageal reflux disease. This is the first comparative objective data study for endoscopic versus laparoscopic antireflux procedures.

STUDY

In this single-center controlled open trial in 70 adult patients with documented gastroesophageal reflux disease without hiatal hernias, objective and subjective outcome parameters were evaluated prospectively and compared. Patients were randomly assigned to either endoscopic full-thickness gastroplication or laparoscopic antireflux surgery. Patients in the Plicator group received between 1 and 3 transmural-pledgeted sutures to the gastric cardia. Patients in the laparoscopic anti-reflux surgery (LARS) group underwent Nissen or Toupet fundoplication. Esophageal manometry, 24-hour impedance pH monitoring, Gastrointestinal Quality-of-Life Index, and symptom questionnaires were evaluated at baseline and at the 3-month follow-up for significant (P<0.05) changes and differences.

RESULTS

Lower esophageal sphincter pressures were increased in the LARS group and unchanged in the Plicator group. Total reflux numbers, acid, nonacid, proximal, upright, and recumbent reflux events were reduced in both groups, significantly more in the LARS group. Reductions in reflux-related esophageal acid scores were significant only in the LARS group. Similar improvements of Gastrointestinal Quality-of-Life Index were found in both groups. General and gas-related symptom scores were comparably reduced. Greater Reductions in reflux-specific symptom scores were found after LARS. Bowel dysfunction symptom scores were lower after LARS.

CONCLUSIONS

Improvements in the general subjective outcome parameters were similar after endoscopic full-thickness gastroplication compared with LARS despite a stronger reflux control provided by LARS. More effective relief of reflux-related symptoms favors LARS, and differences in side effect symptoms favor endoscopic full-thickness gastroplication.

Causes of dissatisfaction after laparoscopic fundoplication: the impact of new symptoms, recurrent symptoms, and the patient experience

BACKGROUND

Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication.

METHODS

All patients undergoing laparoscopic fundoplication in the authors' series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from "very satisfying" to "very unsatisfying." Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported.

RESULTS

Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication.

CONCLUSIONS

Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time.

Incidence and predisponent factors for the migration of the fundoplication by Nissen-Rossetti technique in the surgical treatment of GERD

BACKGROUND

Gastroesophageal reflux is the gastrointestinal tract disease most frequently find nowadays. The Nissen-Rossetti fundoplication is widely used for the surgical treatment, and intrathoracic migration of the valve is the most frequent complication.

AIM

To assess the incidence of the fundoplication and its risk factors.

METHODS

Were analyzed retrospectively medical records of 207 patients undergoing laparoscopic fundoplication by the Nissen-Rossetti technique for the treatment of reflux disease. The variables analyzed were: sex, age, esophagitis grade, size of the herniation, enlargement of the cardia and esophageal shortening. For quantitative variables, was considered the Student's t test. For the nominal, was considered the chi-square or Fisher's exact test. P values ​​<0.05 were considered statistically significant.

RESULTS

Of the total, 135 were women (65.22%) and 72 men (34.78%) with mean age of 47.43 years. The size of the hernia varied between 2 and 6 cm. Two hundred patients had esophagitis (96.62%) and 113 (56.50%) grade I, 75 grade II (37.50%) and 12 grade III or IV (6%). Enlargement of the cardia and Barrett's esophagus were seen in 153 (73.91%) and 13 (6.28%) cases, respectively. One patient had esophageal shortening. Among women, 33 (24.4%) showed migration and among men, only six (8.3%) (p = 0.005). The average age of patients with and without migration was 54.03 and 45.89 years, respectively (p = 0.001).

CONCLUSION

The incidence of the fundoplication migration was 18.8%. The gender (female) and higher age influence the probability of migration. The degree of esophagitis, size of hernia and enlargement of the cardia were not risk factors for intrathoracic migration of the fundoplication.

Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications

BACKGROUND

The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce.

METHODS

This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294).

RESULTS

Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF.

CONCLUSIONS

Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair

BACKGROUND

Hiatal repair failure is the nemesis of laparoscopic paraesophageal hernia repair as well as the major cause of failure of primary fundoplication and reoperation on the hiatus. Biologic prosthetics offer the promise of reinforcing the repair without risks associated with permanent prosthetics.

DESIGN

Retrospective evaluation of safety and relative efficacy of laparoscopic hiatal hernia repair using an allograft (acellular dermal matrix) onlay. Patients with symptomatic failures underwent endoscopic or radiographic assessment of hiatal status.

RESULTS

Greater than 6-month follow-up was available for 252 of 450 consecutive patients undergoing laparoscopic allograft-reinforced hiatal hernia repair between January 2007 and March 2011. No erosions, strictures, or persisting dysphagia were encountered. Adhesions were minimal in cases where reoperation was required. Failure of the hiatal repair at median 18 months (6-51 months) was significantly (p < 0.005) different between groups: group A (primary fundoplication with axial hernia ≤ 2 cm), 3.7 %; group B (primary fundoplication with axial hernia 2-5 cm), 7.1 %; group G (giant/paraesophageal), 8.8 %; group R (reoperative), 23.4 %. Additionally, mean time to failure was significantly shorter in group R (247 days) compared with the other groups (462-489 days).

CONCLUSIONS

Use of allograft reinforcement to the hiatus is safe at 18 months median follow-up. Reoperations had a significantly higher failure rate and shorter time to failure than the other groups despite allograft, suggesting that primary repairs require utmost attention and that additional techniques may be needed in reoperations. Patients with hiatal hernias >2 cm axially had a recurrence rate equal to that of patients undergoing paraesophageal hiatal hernia repair, and should be treated similarly.

Predictability of hiatal hernia/defect size: is there a correlation between pre- and intraoperative findings?

PURPOSE

Closure of the esophageal hiatus is an important step during laparoscopic antireflux surgery and hiatal hernia surgery. The aim of this study was to investigate the correlation between the preoperatively determined hiatal hernia size and the intraoperative size of the esophageal hiatus.

METHODS

One hundred patients with documented chronic gastroesophageal reflux disease underwent laparoscopic fundoplication. All patients had been subjected to barium studies before surgery, specifically to measure the presence and size of hiatal hernia. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). HSA size >5 cm(2) was defined as large hiatal defect. Patients were grouped according to radiologic criteria: no visible hernia (n = 42), hernia size between 2 and 5 cm (n = 52), and >5 cm (n = 6). A retrospective correlation analysis between hiatal hernia size and intraoperative HSA size was undertaken.

RESULTS

The mean radiologically predicted size of hiatal hernias was 1.81 cm (range 0-6.20 cm), while the interoperative measurement was 3.86 cm(2) (range 1.51-12.38 cm(2)). No correlation (p < 0.05) was found between HSA and hiatal hernia size for all patients, and in the single radiologic groups, 11.9 % (5/42) of the patients who had no hernia on preoperative X-ray study had a large hiatal defect, and 66.6 % (4/6) patients with giant hiatal hernia had a HSA size <5 cm(2).

CONCLUSIONS

The study clearly demonstrates that a surgeon cannot rely on preoperative findings from the barium swallow examination, because the sensitivity of a preoperative swallow is very poor.

Multislice computed tomography for the study of complications of gastric fundoplication

The traditional approach to the imaging evaluation of patients after gastric fundoplication is an upper gastrointestinal series obtained by fluoroscopy. In this article, we describe a new technique using multislice computed tomography that we think can be useful to evaluate patients with suspected complications or late failure after gastric fundoplication.

Rectus abdominus fascial sheath usage for crural reinforcement during surgical management of GERD: preliminary report of a prospective randomized clinical trial

PURPOSE

Many materials are currently being used to reinforce the crural repair. Perforation, intensive fibrosis, and price are limiting the usage of these materials. Our purpose was to seek an alternative, cheap, always available, and inert material to use for cruroplasty reinforcement.

METHODS

Twenty-four patients participated and were randomly divided into 2 groups (graft+laparoscopic Nissen fundoplication and laparoscopic Nissen fundoplication alone) with 12 patients in each group. Total operation time, postoperative dysphagia rate, dysphagia improvement time, postoperative pain, recurrence, and incisional hernia rate were compared.

RESULTS

There was no difference in terms of study parameters between both groups except for the mean operation time.

CONCLUSIONS

Autograft hiatoplasty seems to be a good alternative for crural reinforcement. It provides safe reinforcement, has the same dysphagia rates as meshless hiatoplasty, and avoids potential complications of redo surgery by minimizing extensive fibrosis. Furthermore, the rectus abdominus sheath is always available and inexpensive.

Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia

OBJECTIVES

Laparoscopic repair of a giant paraesophageal hiatal hernia remains a challenging procedure. Several techniques have been developed in efforts to achieve tension-free reconstruction of the esophageal hiatus. In this report, we describe a technique whereby the falciform ligament is used as an autologous onlay flap to achieve tension-free closure of the crural defect of a giant paraesophageal hernia (GPEH).

DISCUSSION

Use of the falciform ligament as a vascularized autologous onlay flap is a safe and effective procedure to obtain closure of the crural defect of a GPEH. The falciform ligament should be adequately mobilized from the anterior abdominal wall to prevent lateral tension on the flap, but care must be taken to avoid devascularization. Interrupted vertical mattress sutures are used to fix the falciform ligament to the left and right hiatal crurae.