Recent advances in the surgical treatment of achalasia and gastroesophageal reflux disease

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.

Over 250 Laparoendoscopic Single Site (LESS) Fundoplications: Lessons Learned

Laparoendoscopic single site (LESS) surgery is a more recent advance in the progression of minimally invasive surgery. This study was undertaken to assess lessons learned after our first 250 LESS fundoplications for gastroesophageal reflux disease (GERD). All patients undergoing LESS fundoplications were prospectively followed from 2008 to 2014. Patients scored the frequency/severity of their symptoms before/after LESS fundoplication using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients also scored satisfaction with their incision using a Likert scale (1 = revolting to 10 = beautiful). A total of 300 patients undergoing LESS fundoplication for GERD were not different by age or gender. Surgeons undertook 190 Nissen fundoplications and 110 Toupet fundoplications; 28 of which were “redo” fundoplications. Preoperative symptoms were notable, especially heartburn (frequency = 8, severity = 7). Symptoms were ameliorated postoperatively (e.g., heartburn: frequency = 0, severity = 0, P < 0.01). Postoperatively, patients scored satisfaction of their incisions with a median score of 10. Eighty-three per cent of patients were at least satisfied with their overall experience; 92 per cent would undergo the operation again knowing what they know now. Patients report significant symptom relief, high satisfaction, and excellent cosmesis after LESS fundoplication. LESS fundoplication safely ameliorates symptoms of GERD with pronounced satisfaction, in part, because of the cosmetic outcome (i.e., lack of scaring), and its application is encouraged.

Transoral Incisionless Fundoplication: Is it as Safe and Efficacious as a Nissen or Toupet Fundoplication?

Transoral incisionless fundoplication (TIF) was U.S. Food and Drug Administration-approved in 2007 to treat gastroesophageal reflux disease (GERD), but comparative data are lacking. This study was undertaken to compare outcomes for patients with GERD undergoing TIF versus laparoscopic Nissen or Toupet fundoplications. We undertook a case-controlled study of three cohorts of 20 patients undergoing TIF or laparoscopic Nissen or Toupet fundoplications from 2010 to 2013 controlling for age, body mass index, and preoperative DeMeester scores. All patients were pro-spectively followed. Median data are reported. Patients undergoing TIF had significantly shorter operative times (in minutes: 71 vs 119 and 85, respectively, P < 0.001) and length of stay (in days: 1, 2, and 1, respectively, P < 0.001). No matter the approach, patients reported dramatic and similar reduction in symptom frequency and severity (e.g., heartburn 8 to 0, P < 0.05). At follow-up, 83 per cent of patients after TIF, 80 per cent after Nissen, or 92 per cent after Toupet fundoplications had symptoms less than once per month ( P = 0.12). TIF leads to dramatic symptom resolution, similar when compared with Nissen or Toupet fundoplications. TIF promotes shorter operative times and lengths of stay. Patient satisfaction and effective palliation of symptoms show that TIF is safe and efficacious in comparison to Nissen and Toupet fundoplications and support its continued application and evaluation.

The learning curve of laparoendoscopic single-Site (LESS) fundoplication: definable, short, and safe

The learning curve for laparoendoscopic single-site (LESS) surgery was found to be definable, short, and safe.

Background and Objectives:

This study of laparoendoscopic single-site (LESS) fundoplication for gastroesophageal reflux disease was undertaken to determine the “learning curve” for implementing LESS fundoplication.

Methods:

One hundred patients, 38% men, with a median age of 61 years and median body mass index of 26 kg/m², underwent LESS fundoplications. The operative times, placement of additional trocars, conversions to “open” operations, and complications were compared among patient quartiles to establish a learning curve. Median data are reported.

Results:

The median operative times and complications did not differ among 25-patient cohorts. Additional trocars were placed in 27% of patients, 67% of whom were in the first 25-patient cohort. Patients undergoing LESS fundoplication had a dramatic relief in the frequency and severity of all symptoms of reflux across all cohorts equally (P < .05), particularly for heartburn and regurgitation, without causing dysphagia.

Conclusion:

LESS fundoplication ameliorates symptoms of gastroesophageal reflux disease without apparent scarring. Notably, few operations required additional trocars after the first 25-patient cohort. Patient selection became more inclusive (eg, more “redo” fundoplications) with increasing experience, whereas operative times and complications remained relatively unchanged. The learning curve of LESS fundoplication is definable, short, and safe. We believe that patients will seek LESS fundoplication because of the efficacy and superior cosmetic outcomes; surgeons will need to meet this demand.

Late results after laparoscopic fundoplication denote durable symptomatic relief of gastroesophageal reflux disease

BACKGROUND

Late outcomes after laparoscopic Nissen fundoplication are only now becoming available. This study was undertaken to document late outcomes after laparoscopic Nissen fundoplication.

METHODS

Five hundred ten patients underwent laparoscopic Nissen fundoplication >10 years ago and were prospectively followed. Preoperatively and postoperatively, patients scored the frequency and severity of symptoms (from 0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before and after fundoplication were compared. Median symptom scores are presented.

RESULTS

Early after fundoplication, significant improvements were noted in the frequency and severity of symptoms (e.g., for heartburn, from 8 to 0 and from 8 to 0, respectively, P < .001 for each). Late after fundoplication, significant improvements were maintained in the palliation of symptoms (e.g., frequency and severity for heartburn, 2, 1; respectively). At latest follow-up, 89% of patients were pleased with their symptom resolution.

CONCLUSIONS

With long-term follow-up, laparoscopic Nissen fundoplication durably and significantly palliates symptoms of gastroesophageal reflux disease. This trial promotes the application of laparoscopic Nissen fundoplication.

Solitary Rectal Ulcer Syndrome: Exploring Possible Management Options

Solitary rectal ulcer syndrome (SRUS) is a rare condition with various causes that results in ischemic injury. The aim of this study was to assess the clinical findings, diagnosis, and outcomes of treatment in patients with SRUS. Between 1992 and 2006, a retrospective review was undertaken for all patients diagnosed with SRUS. Fifty-eight patients were diagnosed with SRUS. Among patients with paradoxic rectal spasm (PRS), lesions disappeared in 1 of 3 given applied biofeedback treatment, and in 2 of 4 injected with Botulinum toxin (BotoxTM). Twenty-three patients underwent appropriate surgical treatment. Overall, postoperative improvement was seen in 18 patients (78.2%). In conclusion, every patient with SRUS must be assessed for causative disease. Treatment should include conservative approaches such as Botox injection; in patients with pelvic floor disorders, surgical treatment should be considered.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease.

METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis.

RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients’ satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.

CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Expression of inducible nitric oxide synthase and heme oxygenase-1 in the esophageal mucosa of patients with reflux esophagitis

AIM: To detect the expression of inducible nitric oxide synthase (iNOS) and heme oxygenase-1 (HO-1) in human esophageal mucosa of patients with reflux esophagitis (RE), and to find out the role of gas messenger molecules such as nitric oxide (NO) and carbon monoxide (CO) in the pathogenesis of RE.

METHODS: The distributions of iNOS and HO-1 proteins in esophageal tissues 77 RE patients and 20 normal controls were detected by immunohistochemistry (SP method), and the relationship between iNOS and HO-1 expression was analyzed.

RESULTS: iNOS and HO-1 were expressed mainly in esophageal mucosal epithelia. The expression levels of iNOS and HO-1 in RE patients were significantly higher than those in the normal controls (0.2473 ± 0.0548 vs 0.1616 ± 0.0169; 0.2334 ± 0.0511 vs 0.1776 ± 0.0164; both P < 0.01). Moreover the expression of HO-1 was positively correlated with iNOS expression in esophageal mucosa of RE patients (r = 0. 513, P = 0.000). There was no marked difference between iNOS and NO expression in the normal controls (r = -0.073, P = 0.758).

CONCLUSION: HO-1 and iNOS are abnormally expressed in esophageal mucosa of RE patients, suggesting that NO and CO may play important roles in the pathogenesis of gastrointestinal motility disorders such as RE.