Building a Comprehensive Rural Anti-Reflux Center

BACKGROUND

Gastroesophageal disease (GERD) is a highly prevalent gastrointestinal disease. In rural areas, general surgeons perform esophagogastroduodenoscopy (EGD) despite its low diagnostic yield. When EGD findings are equivocal, GERD patients are usually referred to tertiary hospitals for further workup. We envisaged establishing a comprehensive anti-reflux program with diagnostic and therapeutic capabilities in a rural setting.

STUDY DESIGN

This is an IRB approved retrospective chart review of patients who presented with GERD symptoms to a rural anti-reflux clinic between August 2015 and February 2021. Standardized workup included upper gastrointestinal study and EGD with concomitant wireless pH placement. High resolution impedance manometry and gastric emptying scans were selectively utilized initially, then were performed routinely. We used endoFLIP impedance planimetry system starting in February 2019.

RESULTS

A total of 830 patients were evaluated. There were 537 (64.6%) females and 293 (35.4%) males. The average age was 57.7 ± 15.2 years. The average BMI was 30.8 ± 6.7 kg/m². Approximately one-third of these patients were referred by the primary care provider (PCP) within our health system and a comparable percentage from external PCPs. Self referral was noted in 15.4% and 19.2% were referred by different specialties such as pulmonary (10.7%), surgical for large hiatal hernia (5.8%), inpatient and emergency room (2%), and gastroenterology (0.7%).

CONCLUSION

Rural surgeons with appropriate endoscopic and laparoscopic training can establish a comprehensive anti-reflux program with diagnostic and therapeutic capabilities. It meets the high community need and can expand to be a regional center. The revenues generated are critical for the financial survival of rural hospitals.

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.

METHODS

Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m²) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

RESULTS

The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.

CONCLUSION

Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

The Outcomes of Performing Partial Fundoplication Based on Endoflip Versus Manometric Findings

BACKGROUND

The surgical management of gastroesophageal reflux disease (GERD) involves extensive diagnostic studies and sophisticated surgical techniques. The workup should be comprehensive and purposeful. High resolution impedance manometry (HRIM) provides valuable information regarding peristalsis and lower esophageal sphincter relaxation. The disadvantages of HRIM such as intolerance or inability to pass the catheter led to its selective use or even omission especially in laparoscopic hiatal hernia repair with partial fundoplication. This pragmatic approach risks missing motility disorders in patients with secondary reflux symptoms related to achalasia or scleroderma. Endolumenal functional lumen imaging probe (endoFLIP) can fill this void as it evaluates the dynamics of the esophagogastric junction under sedation. This study aims to compare the outcomes of preoperative use of HRIM vs endoFLIP for laparoscopic repair of hiatal hernia with partial fundoplication.

METHODS

This is a retrospective cohort study for consecutive patients who underwent antireflux surgery with partial fundoplication between July 2018 and February 2021. Preoperative and postoperative outcomes were compared between two cohorts of patients: those with preoperative HRIM and those with preoperative endoFLIP.

RESULTS

A total of 72 patients were evaluated, 41 had preoperative HRIM and 31 had endoFLIP. There was no statistically significant difference in their age, sex, BMI, duration of GERD symptoms, or proton pump inhibitors use. The endoscopic findings of esophagitis, hiatal hernia, and Hill's grade were comparable. There was no difference in the American Society of Anesthesiology classification or the choice of antireflux surgery. The improvement of postoperative GERD scores and dysphagia subscore was similar between the two groups.

CONCLUSION

Performing partial fundoplication based on endoFLIP evaluation of the dynamics of the esophagogastric junction is safe and does not increase postoperative dysphagia compared to preoperative manometric use. Randomized prospective studies are needed to confirm the findings of this study.