The management of patients who have "failed" antireflux surgery

Characterization of gastric dysfunction after fundoplication using body surface gastric mapping

BACKGROUND

Adverse gastric symptoms persist in up to 20% of fundoplication operations completed for gastroesophageal reflux disease, causing significant morbidity and driving the need for revisional procedures. Noninvasive techniques to assess the mechanisms of persistent postoperative symptoms are lacking. This study aimed to investigate gastric myoelectrical abnormalities and symptoms in patients after fundoplication using a novel noninvasive body surface gastric mapping (BSGM) device.

METHODS

Patients with a previous fundoplication operation and ongoing significant gastroduodenal symptoms and matched controls were included. BSGM using Gastric Alimetry (Alimetry Ltd) was employed, consisting of a high-resolution 64-channel array, validated symptom-logging application, and wearable reader.

RESULTS

A total of 16 patients with significant chronic symptoms after fundoplication were recruited, with 16 matched controls. Overall, 6 of 16 patients (37.5%) showed significant spectral abnormalities defined by unstable gastric myoelectrical activity (n = 2), abnormally high gastric frequencies (n = 3), or high gastric amplitudes (n = 1). Patients with spectral abnormalities had higher Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index scores than those of patients without spectral abnormalities (3.2 [range, 2.8-3.6] vs 2.3 [range, 2.2-2.8], respectively; P = .024). Moreover, 7 of 16 patients (43.8%) had BSGM test results suggestive of gut-brain axis contributions and without myoelectrical dysfunction. Increasing Principal Gastric Frequency Deviation and decreasing Rhythm Index scores were associated with symptom severity (r > .40; P < .05).

CONCLUSION

A significant number of patients with persistent postfundoplication symptoms displayed abnormal gastric function on BSGM testing, which correlated with symptom severity. Our findings advance the pathophysiologic understanding of postfundoplication disorders, which may inform diagnosis and patient selection for medical therapy and revisional procedures.

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

Background

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

Patients and Methods

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

Results

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

Conclusion

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

ENDOSCOPIC EVALUATION OF POST-FUNDOPLICATION ANATOMY AND CORRELATION WITH SYMPTOMATOLOGY

Background:

Upper digestive endoscopy is important for the evaluation of patients submitted to fundoplication, especially to elucidate postoperative symptoms. However, endoscopic assessment of fundoplication anatomy and its complications is poorly standardized among endoscopists, which leads to inadequate agreement.

Aim:

To assess the frequency of postoperative abnormalities of fundoplication anatomy using a modified endoscopic classification and to correlate endoscopic findings with clinical symptoms.

Method:

This is a prospective observational study, conducted at a single center. Patients were submitted to a questionnaire for data collection. Endoscopic assessment of fundoplication was performed according to the classification in study, which considered four anatomical parameters including the gastroesophageal junction position in frontal view (above or at the level of the pressure zone); valve position at retroflex view (intra-abdominal or migrated); valve conformation (total, partial, disrupted or twisted) and paraesophageal hernia (present or absent).

Results:

One hundred patients submitted to fundoplication were evaluated, 51% male (mean age: 55.6 years). Forty-three percent reported postoperative symptoms. Endoscopic abnormalities of fundoplication anatomy were reported in 46% of patients. Gastroesophageal junction above the pressure zone (slipped fundoplication), and migrated fundoplication, were significantly correlated with the occurrence of postoperative symptoms. There was no correlation between symptoms and conformation of the fundoplication (total, partial or twisted).

Conclusion:

This modified endoscopic classification proposal of fundoplication anatomy is reproducible and seems to correlate with symptomatology. The most frequent abnormalities observed were slipped and migrated fundoplication, and both correlated with the presence of symptoms.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS AND INFERENCES

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

Evaluation of resection of the gastroesophageal junction and jejunal interposition (Merendino procedure) as a rescue procedure in patients with a failed redo antireflux procedure. A single-center experience

Background

Primary antireflux surgery has high success rates but 5 to 20% of patients undergoing antireflux operations can experience recurrent reflux and dysphagia, requiring reoperation. Different surgical approaches after failed fundoplication have been described in the literature. The aim of this study was to evaluate resection of the gastroesophageal junction with jejunal interposition (Merendino procedure) as a rescue procedure after failed fundoplication.

Methods

All patients who underwent a Merendino procedure at the Karolinska University Hospital between 2004 and 2012 after a failed antireflux fundoplication were identified. Data regarding previous surgical history, preoperative workup, postoperative complications, subsequent investigations and re-interventions were collected retrospectively. The follow-up also included questionnaires regarding quality of life, gastrointestinal function and the dumping syndrome.

Results

Twelve patients had a Merendino reconstruction. Ten patients had undergone at least two previous fundoplications, of which one patient had four such procedures. The main indication for surgery was epigastric and radiating back pain, with or without dysphagia. Postoperative complications occurred in 8/12 patients (67%). During a median follow-up of 35 months (range 20–61), four (25%) patients had an additional redo procedure with conversion to a Roux-en-Y esophagojejunostomy within 12 months, mainly due to obstructive symptoms that could not be managed conservatively or with endoscopic techniques. Questionnaires scores were generally poor in all dimensions.

Conclusions

In our experience, the Merendino procedure seems to be an unsuitable surgical option for patients who require an alternative surgical reconstruction due to a failed fundoplication. However, the small number of patients included in this study as well as the small number of participants who completed the postoperative workout limits this study.

Complications of Antireflux Surgery

Antireflux surgery anatomically restores the antireflux barrier and is a therapeutic option for proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease or PPI intolerance. Laparoscopic fundoplication is the standard antireflux surgery, though its popularity has declined due to concerns regarding wrap durability and adverse events. As the esophagogastric junction is an anatomically complex and dynamic area subject to mechanical stress, wraps are susceptible to disruption, herniation or slippage. Additionally, recreating an antireflux barrier to balance bidirectional bolus flow is challenging, and wraps may be too tight or too loose. Given these complexities it is not surprising that post-fundoplication symptoms and complications are common. Perioperative mortality rates range from 0.1 to 0.2% and prolonged structural complications occur in up to 30% of cases. Upper gastrointestinal endoscopy with a comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Management hinges on differentiating complications that can be managed with medical and lifestyle optimization versus those that require surgical revision. Reoperation is best reserved for severe structural abnormalities and troublesome symptoms despite medical and endoscopic therapy given its increased morbidity and mortality. Though further data are needed, magnetic sphincter augmentation may be a safer alternative to fundoplication.

Laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-Sleeve) for treatment of morbid obesity and gastroesophageal reflux

BACKGROUND

Gastroesophageal reflux (GERD) can be considered an obesity-related disease. Roux-en-Y gastric bypass is considered the gold standard for its therapeutic effects on acid reflux.

OBJECTIVES

The aim of this retrospective study is to assess the effectiveness of combined laparoscopic sleeve gastrectomy and Rossetti antireflux fundoplication for the treatment of morbidly obese patients with GERD.

SETTING

A private academic hospital in Italy.

METHODS

Forty obese patients with GERD underwent laparoscopic sleeve gastrectomy-Rossetti laparoscopic fundoplication from January 1 to October 31, 2015. A specific informed consent was obtained. Minimum follow-up was 12 months. No cases were lost to follow-up.

RESULTS

Mean body mass index was 44.4 ± 4.7 kg/m²; all patients had GERD. Mean operative time was 38 ± 6 minutes. The mortality rate was 0%. No intraoperative or medium- or long-term complications were reported. Excess weight loss percent at 1, 3, 6, 12 months was 25.6 ± 6.1, 41.9 ± 12.5, 56.7 ± 13.0, 61.7 ± 13.6, respectively. Excess body mass index loss percent at 1, 3, 6, 12 months was 29.3 ± 3.4, 47.2 ± 5.2, 64.0 ± 8.6, 73.3 ± 9.9, respectively. At the 12-month follow-up visit, 95% of the patients reported a good sense of repletion without episodes of vomiting, nausea, or dysphagia.

CONCLUSIONS

Rossetti laparoscopic fundoplication is well tolerated, feasible, and safe in obese patients with GERD, with good postoperative weight results. Following this evidence, 2 monocentric prospective and randomized studies will start to analyze and confirm the reported data.

Development of acute pancreatitis after Nissen fundoplication

Acute pancreatitis subsequent to Nissen fundoplication for gastroesophageal reflux disease (GERD) is an extremely rare adverse event. We describe a pediatric case of acute pancreatitis resulting from superior mesenteric artery syndrome (SMAS) and gas bloat after fundoplication. Gas bloat is one of the known postoperative complications after Nissen fundoplication. Poor nutrition status, which is often associated with severe pediatric GERD, is a risk factor for SMAS. In this case, development of gas bloat and SMAS led to the formation of a closed loop and increased intraluminal pressure of the duodenum and pancreatic duct. Many pediatric patients who need anti-reflux surgery face the risk of developing this entity. Preventive measures, such as treatment with prokinetics and frequent small-volume meals, should be considered until improvement of nutritional status after fundoplication.

Gastric necrosis: A late complication of nissen fundoplication

Gastric necrosis is a rare condition because of the rich blood supply and the extensive submucosal vascular network of the stomach. "Gas-bloat" syndrome is a well known Nissen fundoplication postoperative complication. It may cause severe gastric dilatation, but very rarely an ischemic compromise of the organ. Other factors, such as gastric outlet obstruction, may concur to cause an intraluminal pressure enough to blockade venous return and ultimately arterial blood supply and oxygen deliver, leading to ischaemia. We report a case of a 63-year-old women, who presented a total gastric necrosis following laparoscopic Nissen fundoplication and a pyloric phytobezoar which was the trigger event. No preexisting gastric motility disorders were present by the time of surgery, as demonstrated in the preoperative barium swallow, thus a poor mastication (patient needed no dentures) of a high fiber meal (cabbage) may have been predisposing factors for the development of a bezoar in an otherwise healthy women at the onset of old age. A total gastrectomy with esophagojejunostomy was performed and patient was discharged home after a 7-d hospital stay with no immediate complications. We also discuss some technical aspects of the procedure that might be important to reduce the incidence of this complication.

Modern medical and surgical management of difficult-to-treat GORD

Approximately 30-40% of patients taking proton pump inhibitors (PPIs) for presumed gastro-oesophageal reflux (GOR) symptoms do not achieve adequate symptom control, especially when no oesophageal mucosal breaks are present at endoscopy and when extra-oesophageal symptoms are concerned. After failure of optimization of medical therapy, a careful work up is mandatory that aims at determining whether symptoms are related to GOR or not. Most patients with refractory symptoms do not have GOR-related symptoms. Some may have symptoms related to weakly acidic reflux and/or oesophageal hypersensitivity. Baclofen is currently the only antireflux compound available as add-on therapy to PPIs, but its poor tolerability limits its use in clinical practice. There is room for pain modulators in patients with hypersensitive oesophagus and functional heartburn. Antireflux surgery is a suitable option in patients responding to medical therapy who want to avoid taking medication or if persisting symptoms can be clearly attributed to poorly controlled GOR.

Borderline indications and selection of gastroesophageal reflux disease patients: 'Is surgery better than medical therapy'?

Modern medical therapies for gastroesophageal reflux disease (GERD) are totally dedicated to the control of the acid component of the refluxate. In chronic erosive GERD, antireflux surgery has proven to be very efficacious and superior to traditional medical therapies, such as H2 blockers. The introduction of proton pump inhibitors (PPIs), however, substantially improved medical therapy. Still, treatment failures are inevitable regardless of which of these two effective therapies is chosen. Some recent reports have presented conflicting results from trials comparing antireflux surgery and PPIs. This may be due to differences in trial designs as well as in the structure and content of the therapeutic strategies that are compared. The study with the longest clinical follow-up by far is the SOPRAN study comparing open antireflux surgery and omeprazole. The protocol provides for a follow-up period of more than a decade and the clinical outcomes have recently been published. There has always been concern about the long-term effectiveness of reflux prevention whether by surgery or PPI therapy. It is likely that a marker for an emerging risk for recurrence of GERD is abnormal acid reflux as assessed by ambulatory 24-hour pH-metry. The LOTUS trial compared maintenance therapy provided by esomeprazole (dose-adjusted when required) with standardized laparoscopic antireflux surgery in patients with good response to acid suppressive therapy. An operation is suitable when symptoms are poorly controlled despite medication, especially for patients who suffer large-volume regurgitation and those who wake at night coughing and choking and who regurgitate acidic fluid or food into their throat and airways. Regurgitation into the throat upon stooping or exercising can limit a patient's ability to work, play sports or even do simple housework. A few patients cannot tolerate medical treatment. If surgery is to be a good option, it must be ensured that the right surgeon performs a standardized operation for the right indications on the right patient and provides good preoperative counseling and testing along with postoperative support. When a patient is refractory to medical treatment, the diagnosis of GERD should be reconsidered before surgery is advised; extradigestive manifestations should be accounted for with care.

CONCLUSIONS

Laparoscopic fundoplication (LF) substantially improves GERD symptoms, although in some individuals symptoms return and acid-suppressive medication use increases. Limited data suggest that LF is less effective at reducing symptoms in partial responders to medical therapy than in complete responders. This may affect cost arguments for using fundoplication surgery rather than acid-suppressive medications, as data are based largely on complete responders.

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.

Gastroesophageal reflux disease treatment: side effects and complications of fundoplication

Even skilled surgeons will have complications after antireflux surgery. Fortunately, the mortality is low (<1%) with laparoscopic surgery, immediate postoperative morbidity is uncommon (5%-20%), and conversion to an open operation is <2.5%. Common late postoperative complications include gas-bloat syndrome (up to 85%), dysphagia (10%-50%), diarrhea (18%-33%), and recurrent heartburn (10%-62%). Most of these complications improve during the 3-6 months after surgery. Dietary modifications, pharmacologic therapies, and esophageal dilation may be helpful. Failures after antireflux surgery usually occur within the first 2 years after the initial operation. They fall into 5 patterns: herniation of the fundoplication into the chest, slipped fundoplication, tight fundoplication, paraesophageal hernia, and malposition of the fundoplication. Reoperation rates range from 0%-15% and should be performed by experienced foregut surgeons.

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.

Re-operation for failed gastro-esophageal fundoplication. What results to expect?

The aim of this study is to evaluate short and medium term results of re-operation for failed fundoplication in a retrospective monocentric cohort of 47 patients.

PATIENTS AND METHODS

Between 1995 and 2011, 595 patients underwent a laparoscopic primary fundoplication (PFP) for gastroesophageal reflux disease (GERD). During the same period, 47 patients required a re-operative fundoplication (RFP). In 11 patients, the original wrap had herniated into the thorax. All these revisions consisted of a complete takedown of the original wrap before constructing a tension-free wrap using a standardized technique. Patients with a follow-up of at least 2 years were matched to patients who had been operated only once to assess satisfaction and quality of life.

RESULTS

Short term: All patients were operated by laparoscopy with no conversion. There was no mortality. Two postoperative complications necessitating re-operation were observed (morbidity 4.3%): one complete aphagia and one gastric perforation. Long term: 29 re-operated patients with a follow-up of at least 2 years (mean: 4,5 years) (Group RFP) were compared to a matched group of 29 patients operated only once (Group PFP). These groups were comparable in age, sex ratio, BMI and follow-up. In both groups, all patients were operated by laparoscopy without conversion. Morbidity was 3.5% in the RFP group, none in the PFP group. There was no mortality in either group. The length of stay and operative time were significantly higher in the RFP group (4.6 vs. 2.6 days, p<0.05). Two RFP patients (5%) required re-operation at three and seven months vs. none in the PFP group. The long-term satisfaction was comparable in the two groups (78% vs. 85%, p=NS). Quality of life assessed by the GIQLI was significantly better in the PFP group (104 vs. 84, p<0.05).

CONCLUSION

Re-do fundoplication is a safe procedure and is feasible by laparoscopy. In the long-term, patient satisfaction is comparable to primary intervention with, however, a slightly poorer quality of life.

Endoscopic assessment of failed fundoplication: a case for standardization

BACKGROUND

Preoperative endoscopic assessment of the failed fundoplication is instrumental in diagnosis and surgical management. Endoscopy is a routine and essential part of the workup for a failed fundoplication, but no clear guidelines exist for reporting endoscopic findings. This study aimed to compare endoscopic findings reported by community physicians (gastroenterologists and surgeons) with the findings of the authors (esophageal center) for patients who underwent reoperative intervention after a previous antireflux procedure.

METHODS

Retrospective review of a prospectively maintained database was performed to identify patients who underwent reoperation after a failed antireflux operation between 1 December 2003 and 30 June 2010. Endoscopic findings as reported by the outside physician and by the esophageal center endoscopist were reviewed and compared.

RESULTS

During the study period, 229 patients underwent reoperation. Of these patients, 20 did not have endoscopy performed by an outside physician and were excluded from the study, leaving 208 patients. The endoscopic reports of the esophageal center physician included 97 cases of hiatal hernia (64 type 1 and 33 types 2 and 3), 52 slipped fundoplications, 61 disrupted fundoplications, 30 intrathoracic fundoplications, 25 twisted fundoplications, 14 two-compartment stomachs, and 27 cases of Barrett's esophagus. Outside physicians identified 68% of the hiatal hernias and 61% of the paraesophageal hernias reported by the authors. Only 32% of the outside reports mentioned a previous fundoplication. Furthermore, only 17% of the slipped fundoplications and 30% of the disrupted fundoplications were so described. Outside physicians identified 19 of the 27 patients with Barrett's esophagus.

CONCLUSION

Fundoplication changes described by the general endoscopist are inadequate. With an increasing population of patients who have undergone prior antireflux surgery, incorporation of fundoplication assessment in an endoscopic curriculum may be helpful.

Surgical reintervention after failed antireflux surgery: a systematic review of the literature

BACKGROUND

Outcome and morbidity of redo antireflux surgery are suggested to be less satisfactory than those of primary surgery. Studies reporting on redo surgery, however, are usually much smaller than those of primary surgery. The aim of this study was to summarize the currently available literature on redo antireflux surgery.

MATERIAL AND METHODS

A structured literature search was performed in the electronic databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

RESULTS

A total of 81 studies met the inclusion criteria. The study design was prospective in 29, retrospective in 15, and not reported in 37 studies. In these studies, 4,584 reoperations in 4,509 patients are reported. Recurrent reflux and dysphagia were the most frequent indications; intraoperative complications occurred in 21.4% and postoperative complications in 15.6%, with an overall mortality rate of 0.9%. The conversion rate in laparoscopic surgery was 8.7%. Mean(+/-SEM) duration of surgery was 177.4 +/- 10.3 min and mean hospital stay was 5.5 +/- 0.5 days. Symptomatic outcome was successful in 81.1% and was equal in the laparoscopic and conventional approach. Objective outcome was obtained in 24 studies (29.6%) and success was reported in 78.3%, with a slightly higher success rate in case of laparoscopy than with open surgery (85.8% vs. 78.0%).

CONCLUSION

This systematic review on redo antireflux surgery has confirmed that morbidity and mortality after redo surgery is higher than after primary surgery and symptomatic and objective outcome are less satisfactory. Data on objective results were scarce and consistency with regard to reporting outcome is necessary.

Surgical management of gastroesophageal reflux disease

Managing gastroesophageal reflux disease (GERD) is difficult because it is a chronic relapsing disease. Surgical management of GERD is indicated only after medical management has failed. In patients who have the most advanced forms of GERD, surgical therapy is good for treating symptoms and healing esophagitis, but far from a gold standard. Freedom from symptoms, side effects, medical therapy, or reoperation cannot be guaranteed. Care must be taken when prescribing surgery for GERD, and it is best that an experienced surgeon at a specialty center participate in the patient's lifelong care.

Efficacy of laparoscopic mesh-augmented hiatoplasty in GERD and symptomatic hiatal hernia. Study using combined impedance-pH monitoring

BACKGROUND

Laparoscopic fundoplication is the standard antireflux procedure. However, side effects such as gas bloating indicate that the procedure is not unproblematic. Laparoscopic mesh-augmented hiatoplasty (LMAH) might be an alternative operation aimed at restoring the intra-abdominal part of the esophagus and reducing the size of the diaphragmatic hiatus.

AIM

The aim of this study was to prospectively evaluate gastroesophageal reflux disease symptoms and gastroesophageal reflux before and after LMAH using 24 h impedance-pH monitoring (MII-pH).

MATERIALS AND METHODS

Twenty patients underwent MII-pH monitoring pre- and 3 months post-LMAH. Symptoms were assessed using the Gastrointestinal Symptom Rating Scale questionnaire.

RESULTS

LMAH reduced the mean (SD) reflux syndrome score [pre-op 4.5 (1.7) vs post-op 1.4 (0.9); p<0.001], median (25th-75th percentile) distal %time pH<4 [4.9 (3.4-10.3) vs 1.0 (0.3-2.5) %; p=0.001) and total number of liquid reflux episodes [27.5 (17.5-38.3) vs 18 (7.3-29.3); p<0.05] without changing the number of gas reflux episodes [12 (6-34.3) vs 13.5 (6-20); p=0.346). All patients reported no limitation of their ability to belch.

CONCLUSION

LMAH significantly reduces reflux symptoms and esophageal acid exposure without interfering with the ability to vent gas from the stomach documented by an unchanged number of gas reflux episodes before and after LMAH.

Laparoscopic mesh-augmented hiatoplasty as a treatment of gastroesophageal reflux disease and hiatal hernias-preliminary clinical and functional results of a prospective case series

BACKGROUND

Because fundoplication-related side effects are frequent, we evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as a potential treatment option for gastroesophageal reflux disease and/or symptomatic hiatal herania. LMAH aims to prevent reflux solely by mesh-reinforced narrowing of the hiatus and lengthening of the intra-abdominal esophagus.

METHODS

Twenty-two consecutive patients with LMAH were evaluated prospectively using a modified Gastrointestinal Symptom Rating Scale questionnaire, pH measurement, manometry, and endoscopy. Follow-up was scheduled at 3 and 12 months after surgery.

RESULTS

Total reflux decreased from 16.3% before surgery to 3.5% 3 months after surgery (P = .001). The reflux score decreased from 3.8 before surgery to 2.1 1 year after surgery (P = .001). The respective values of the indigestion score were 3.4 and 2.0 (P < .001). After surgery, all patients were able to belch. Vomiting was impossible only for 2 patients, and 90% of patients assessed their results as good to excellent.

CONCLUSIONS

LMAH seems to be feasible, safe, and has no significant side effects.

Drinking capacity and severity of dyspeptic symptoms during a water load test after Nissen fundoplication

Up to 30% of subjects undergoing Nissen fundoplication develop dyspeptic symptoms. Previous studies using the water load test have shown that functional dyspepsia patients have a diminished drinking capacity due to increased visceral sensitivity. Here we investigate drinking capacity and severity of symptoms in 9 patients with dyspeptic symptoms after fundoplication, 9 patients without symptoms after surgery, 18 functional dyspepsia patients, and 18 controls. The water load test was performed by having subjects drinking room-temperature tap water at a predetermined rate of 15 ml/min. The presence and severity of symptoms during the test were evaluated every 5 min using a Likert scale. We found that patients with dyspeptic symptoms after fundoplication had a significantly lower drinking capacity and higher symptoms scores than controls (P<0.05) but values similar to those of functional dyspepsia patients (P>0.05). In contrast, drinking capacity in patients without symptoms after surgery was similar to that in controls (P>0.05). These findings suggest that, as in functional dyspepsia, severe dyspeptic symptoms after Nissen fundoplication are associated with an impaired drinking capacity, reflecting visceral hypersensitivity or impaired gastric accommodation or both.

Recurrent heartburn after laparoscopic fundoplication is not always recurrent reflux

INTRODUCTION

A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Many of these patients have been empirically recommenced on proton pump inhibitors.

OBJECTIVE

The aim of this study was to determine whether patients with symptoms that suggest recurrent reflux had objective evidence of reflux, and to determine predictors of recurrent reflux.

METHODS

We identified all patients from an existing database who had undergone pH monitoring for "recurrent heartburn" after fundoplication. These patients were then cross-referenced to another database, which recorded the outcomes for patients who had undergone a laparoscopic fundoplication. Patients complaining of dysphagia or other problems without heartburn were excluded from analysis.

RESULTS

Seventy-six patients were identified who met the inclusion criteria. Fifty-six (74%) of these had a normal 24-h pH study. Thirty-five patients (63%) with a normal pH study were on medication for heartburn at the time of referral. Three factors were found to be associated with an abnormal 24-h pH study: a partial fundoplication (P = 0.039), onset of symptoms 6 months or more after surgery (P < 0.001), and a good symptom response when antireflux medication was recommenced (P = 0.015).

CONCLUSIONS

Not all patients complaining of recurrent heartburn after fundoplication have evidence of abnormal reflux. Objective evidence of abnormal esophageal acid exposure should be confirmed before recommencing antireflux medication.

Gastroesophageal reflux disease: integrating the barium esophagram before and after antireflux surgery

Gastroesophageal reflux disease (GERD) is a common medical problem in the United States. As a result, laparoscopic antireflux surgery is a common surgical procedure. At the authors' institution, the barium esophagram before and after antireflux surgery is a critical examination in patients with GERD. This article summarizes the authors' examination protocol and describes how the findings are integrated in the care of these patients.

Altered esophageal sensory-motor function in patients with persistent symptoms after Nissen fundoplication

BACKGROUND

The pathophysiology of persistent gastroesophageal reflux disease (GERD) symptoms after antireflux surgery is unclear. We assessed esophageal sensorimotor function in patients with GERD before and after Nissen fundoplication (NF).

METHODS

Sensory and biomechanical properties were evaluated before surgery using impedance planimetry in 17 GERD patients and 16 healthy volunteers. All patients underwent standard laparoscopic NF. Eight GERD patients with persistent symptoms after surgery underwent repeat evaluations at least 12 months after surgery.

RESULTS

At baseline, GERD patients had lower thresholds for first perception (P < .001), discomfort (P < .001), and pain (P < .001) compared with controls. The esophagus was more reactive (P = .001) and less distensible (P = .04) in patients than controls. After NF, in patients with persistent symptoms, the sensory thresholds were unchanged (P > .05) but esophageal wall reactivity decreased (P = .001), and distensibility improved (P = .025).

CONCLUSIONS

NF improves esophageal biomechanical dysfunction but not the underlying hypersensitivity. Visceral hypersensitivity of the esophagus may explain persistent symptoms after NF.

Surgical approach to gastroesophageal reflux disease: what the radiologist needs to know

Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.

Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement

BACKGROUND

The recurrence rate after laparoscopic repair of hiatal hernias with paraesophageal involvement (LRHP) is reported to be high. Mesh reinforcement has been proposed with the objective of solving this problem. This study aimed to compare the outcome of LRHP before and after the introduction of mesh reinforcement.

METHODS

Between 1992 and 2003, 56 consecutive patients received LRHP including posterior crurorrhaphy and additional fundoplication. Of these 56 patients, 17 underwent a mesh-reinforced hiatoplasty. Perioperative outcome was assessed retrospectively, and follow-up assessment was performed according to protocol including a barium contrast swallow.

RESULTS

The follow-up period averaged 52 +/- 31 months (range, 9-117 months). The recurrence rate for hiatal hernia without mesh reinforcement was 19% (7/36). No recurrence (0/16) was observed in patients with mesh reinforcement. The intraoperative complication rate was 9%, and the perioperative morbidity rate was 14%. There were neither mesh-related complications nor operation-related deaths.

CONCLUSIONS

Although challenging, LRPH is a successful procedure. The high recurrence rate reported in the literature can be reduced by additional mesh reinforcement.

Laparoscopic Nissen fundoplication decreases gastroesophageal junction distensibility in patients with gastroesophageal reflux disease

Laparoscopic Nissen fundoplication (LNF) is the surgical treatment of choice for gastroesophageal reflux disease (GERD). Post-LNF complications, such as gas bloat syndrome, inability to belch and vomit, and dysphagia, remain too common and prevent LNF from being more highly recommended. It remains controversial as to whether preoperative assessment can predict the development of post-LNF complications. Some authors have shown a correlation between pre-LNF manometry characteristics and post-LNF dysphagia, and others have not. We hypothesize that many post-LNF complications are caused by a decrease in the distensibility of the GEJ and that standard manometry is at best an indirect measure of this. The aim of this study is to directly measure the effect of LNF on gastroesophageal junction (GEJ) distensibility (GEJD). The lower esophageal sphincter (LES) of 15 patients undergoing LNF was characterized using standard manometry. The GEJD before and after a standardized LNF was measured using a specialized catheter, containing an infinitely compliant bag, placed within the LES. GEJD was measured, as dV/dP over volumes 5 to 25 mL distended at a rate of 20 mL/min. Mean dP +/- standard error of the mean for each volume was calculated, and distensibility curves were generated and compared. Measurements were also taken after abolishing LES tone by mid-esophageal balloon distension. Patient symptoms were recorded before and after surgery. Statistical analysis was performed by two-way repeated-measures analysis of variance, paired t test, and the Tukey test. Laparoscopic Nissen fundoplication led to a statistically significant increase in Delta pressure over each volume tested and therefore a significant decrease in the distensibility of the GEJ. Abolition of LES tone had no statistical effect on GEJD after fundoplication. There were no complications, and none of the patients developed the symptom of dysphagia postoperatively. These are the first direct measurements to show that LNF significantly reduces the distensibility of the GEJ. We hypothesize that the magnitude of this reduction may be the vital variable in the development of post-LNF complications and specifically post-LNF dysphagia. The intraoperative measurement of LES distensibility may provide a means for avoiding this feared and other post-LNF complications in the future.

Enteryx implant for gastroesophageal reflux disease

Although pharmacologic therapy is safe and effective for gastroesophageal reflux disease (GERD), patients requiring chronic drug treatment often seek alternatives. Surgical alternatives to chronic drug treatment are associated with increased morbidity and long-term failure rates in more than 50% of surgically treated patients. Newer endoluminal therapies using modifications of standard endoscopy techniques are under evaluation as alternatives to chronic drug treatment or surgical intervention for GERD. Appropriate patient selection is KEY. Patients considered for any endoluminal therapy should have well documented GERD and demonstrated appropriate and successful response to medical therapy with a proton pump inhibitor (PPI). The Enteryx implant is an injectable biocompatible polymer approved by the US Food and Drug Administration for the management of GERD symptoms. Clinical trial data indicate that the Enteryx procedure is a safe and effective GERD treatment that manages symptoms of GERD and addresses the underlying anatomic and functional aspects of the disorder. Multicenter clinical trials have shown that the Enteryx procedure safely and effectively eliminates or significantly reduces PPI use in approximately 84% of patients at 1 year and 72% of patients at two years. The risk-benefit profile of this procedure and alternative treatment options should be carefully evaluated for each patient considered a candidate for Enteryx and all endoluminal therapies. Randomized-controlled studies comparing the Enteryx procedure to placebo and cost-effective analyses comparing treatment options will further define the use of the Enteryx implant in patients with GERD.