Laparoscopic revision surgery for gastroesophageal reflux disease

Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review

BACKGROUND

The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review.

METHODS

We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery.

RESULTS

Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43-71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110-225) and the mean hospital stay was 3.2 days (range, 2-7). At a mean follow-up of 78 months (range, 18-192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien-Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage.

CONCLUSION

Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty.

Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution

BACKGROUND

Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr.

METHODS

A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis.

RESULTS

One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m², and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision.

CONCLUSION

Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

The role of hormones in symptoms and pathophysiology of reflux and esophageal motility disorders

PURPOSE

A few studies suggest that hormones play a role in the motility of the lower esophagus, but data is rare. In this prospective study we evaluated the correlation between hormones (TSH, fT3, fT4, calcitonin, gastrin, and VIP) and gastroesophageal reflux disease (GERD), esophageal motility disorders, and gastrointestinal symptoms.

METHODS

100 consecutive patients with reflux symptoms and dysphagia were hospitalized for diagnostic evaluation. Self-reporting questionnaires were handed out and patients routinely underwent serum analysis (TSH, fT3, fT4, calcitonin, gastrin, and VIP), 24-hour-pH-impendance monitoring, and high-resolution manometry.

RESULTS

Motility disorders were found in 38 out of 86 patients. There were no correlations between hormones, the DeMeester Score, and the lower esophageal sphincter pressure. A strong inverse relation between calcitonin and the Integrated Relaxation Pressure of the esophagogastric junction was found (r=-0.492; p<0.001). No correlations were found between hormone levels and the responses given in the questionnaires. Positive correlations, however, were found between VIP and gastrointestinal symptoms, as well as correlations between fT3 and dysphagia. Within the group with minor motility disorders, TSH and fT4 correlated with outcomes of the SCL-questionnaire. fT4 correlated with the typical symptoms, as well as the gastrointestinal symptoms (diarrhea, constipation, flatulence). TSH correlated with the typical symptoms. Moreover, a correlation between VIP and gas-bloat-symptoms was found within group II CONCLUSIONS: No correlation between TSH, fT3, fT4, gastrin, VIP, calcitonin, and GERD in the sense of acid reflux was found, although calcitonin seems to have an effect on the lower esophageal sphincter.

Efficacy of Combined Hiatal Hernia Repair and Transoral Incisionless Fundoplication for Giant Paraoesophageal Hernias: Technique and Early Results

INTRODUCTION

Data is limited on hybrid transoral incisionless fundoplication (TIF) and hiatal hernia repair in giant paraoesophageal hernia (GPEH). We aimed to assess the safety, patient satisfaction, and symptom resolution following a hybrid paraoesophageal hernia (PEH) repair and TIF in patients with GPEH.

PATIENTS AND METHODS

All single-session hybrid TIF combined with minimally invasive PEH repair performed between February 2020 and June 2021 were evaluated. Procedures were performed in the operating room under general anesthesia with robotic or laparoscopic PEH repair followed by TIF.

RESULTS

Twelve patients underwent combined surgical hiatal hernia repair and TIF. Primary presenting symptoms included heartburn (75.0%), dysphagia (41.7%), and chronic anemia from Cameron's ulcers (16.7%). The mean hernia defect size was 5.0 cm (range 3.0 to 6.0 cm). Hiatal hernia repairs were performed robotically in 7 patients and laparoscopically in 5 patients. The total mean operative time was 254 minutes (range: 180 to 390 min). One patient reported postoperative dysphagia requiring endoscopic dilation postdischarge with a resolution of symptoms. No gas-bloat symptoms were reported. All patients reported complete resolution of presenting symptoms at the time of follow-up. Postoperative mean follow-up for 4 patients at 6 months with upper endoscopy and pH testing showed an intact valve with no evidence of esophagitis or acid reflux.

CONCLUSIONS

In our experience, hybrid hiatal hernia repair and TIF is a safe and effective therapeutic option for patients with GPEH. This hybrid procedure allows for more expeditious completion of the repair and results in lower rates of postfundoplication dysphagia and gas-bloat. Furthermore, this approach requires a less extensive surgical dissection on the greater curvature of the stomach, thereby minimizing the risk of vagal nerve injury and bleeding from the short gastric vessels.

Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up

Background

Various technical modifications of Nissen fundoplication (NF) that aim to improve patients’ outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF.

Methods

283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed.

Results

Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively.

Conclusion

Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF.

Screening Esophagogastroduodenoscopy Before Laparoscopic Sleeve Gastrectomy: Results in 819 Patients

Aim: The routine use of esophagogastroduodenoscopy (EGD) during the preoperative evaluation of surgical weight loss candidates is controversial. The aim of this study is to evaluate the findings of preoperative EGD in patients who are scheduled for a primary laparoscopic sleeve gastrectomy (LSG). The probable effect of these findings on the medical and surgical strategy that was followed is assessed. Methods: Findings of EGD obtained from consecutive LSG candidates and all data were prospectively recorded and retrieved from the database. Results: A total of 819 patients underwent EGD successfully. Mean age and body mass index were 38 ± 11.3 and 43.17 ± 7.2 kg/m², respectively. Fifty-eight percent were female. EGD of 263 (32.1%) patients was normal and 687 (84%) patients were asymptomatic. At least one abnormal finding was detected in 65% of the asymptomatic patients. Abnormal findings that did not change the surgical strategy were found in 550 patients (67.2%). Findings such as gastritis or duodenitis that changed the medical management before surgery were found in 309 patients (38.2%). Helicobacter pylori was positive in 218 (26.6%) patients but eradication treatment was not applied in the preoperative period. No pathology was detected that would create absolute contraindication or change the type of surgery in any patient. Only technical modifications were required in 13% due to hiatal hernia. The timing of the planned surgery has changed in only 6 patients (0.74%) (early stage neuroendocrine tumor, leiomyoma, severe ulcer). Conclusions: Routine EGD performed before LSG did not change the planned bariatric option in any patient, but led to 13% rate of technical modifications due to the presence of hiatal hernia. At least one abnormal finding was detected in 65% of asymptomatic patients. Due to endoscopic findings, the rate of patients who started medical acid-suppression treatment in the preoperative period was 38%.

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repairin regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m2at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.

[Redo surgery after laparoscopic fundoplication]

OBJECTIVE

To analyze the results of redo surgeries after previous laparoscopic fundoplication.

MATERIAL AND METHODS

A retrospective analysis included 37 repeated anti-reflux surgeries. Control group consisted of 38 patients after the first anti-reflux surgery performed on the same clinical base. The causes of unsatisfactory results of the first operations were studied. Intraoperative data, immediate and long-term results of surgical treatment were compared in both groups. Quality of life in both groups was studied before surgery and in long-term period using GIQLI questionnaire.

RESULTS

The most common cause of recurrent reflux was a hernia recurrence combined with slipping or destruction of the fundoplication cuff. Dysphagia was usually a result of compression of the esophagus by tightly sutured diaphragmatic crura and recurrent paraesophageal hernia. The main group was characterized by significantly greater surgery time, hospital-stay, incidence of intraoperative and postoperative complications. However, a more significant improvement of quality of life (∆GIQLI) was observed in the main group due to the low QOL index before redo surgery.

CONCLUSION

Redo surgeries are effective and safe procedures. These operations significantly improve QOL in long-term period despite certain technical difficulties. Repeated surgeries for dysphagia accounted for 2%, for recurrent reflux - 6%. Persistent postoperative dysphagia is usually associated with diaphragm repair rather fundoplication cuff. Reflux recurrence is often caused by cuff slippage and recurrent hernia.

Endoscopic Evaluation of Post-Fundoplication Anatomy

PURPOSE OF REVIEW

We aim to review the endoscopic evaluation of post-fundoplication anatomy and its role in assessment of fundoplication outcomes and in pre-operative planning for reoperation in failed procedures.

RECENT FINDINGS

There is no universally accepted system for evaluating post-fundoplication anatomy endoscopically. However, multiple reports described the usefulness of post-operative endoscopy as a quality control measure and in the evaluation of complex cases such as repeat procedures and paraesophageal hernias (PEH). Endoscopic evaluation of post-fundoplication anatomy has an important role in assessing the outcomes of operative repair and pre-operative planning for failed fundoplications. Attempts have been made to characterize the appearance of the newly formed gastroesophageal valve after successful repairs and to standardize endoscopic reporting and classification of anatomic descriptions of failed fundoplications. However, there is no consensus. More studies are needed to evaluate the applicability and reproducibility of proposed endoscopic evaluation systems in order for such tools to become widely accepted.