ENDOSCOPIC EVALUATION OF POST-FUNDOPLICATION ANATOMY AND CORRELATION WITH SYMPTOMATOLOGY

MAGNETIC SPHINCTER AUGMENTATION DEVICE FOR GASTROESOPHAGEAL REFLUX DISEASE: EFFECTIVE, BUT POSTOPERATIVE DYSPHAGIA AND RISK OF EROSION SHOULD NOT BE UNDERESTIMATED. A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Magnetic ring (MSA) implantation in the esophagus is an alternative surgical procedure to fundoplication for the treatment of gastroesophageal reflux disease.

AIMS

The aim of this study was to analyse the effectiveness and safety of magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD).

METHODS

A systematic literature review of articles on MSA was performed using the Medical Literature Analysis and Retrieval System Online (Medline) database between 2008 and 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 22 studies comprising 4,663 patients with MSA were analysed. Mean follow-up was 27.3 (7-108) months. The weighted pooled proportion of symptom improvement and patient satisfaction were 93% (95%CI 83-98%) and 85% (95%CI 78-90%), respectively. The mean DeMeester score (pre-MSA: 34.6 vs. post-MSA: 8.9, p=0.03) and GERD-HRQL score (pre-MSA: 25.8 vs. post-MSA: 4.4, p<0.0001) improved significantly after MSA. The proportion of patients taking proton pump inhibitor (PPIs) decreased from 92.8 to 12.4% (p<0.0001). The weighted pooled proportions of dysphagia, endoscopic dilatation and gas-related symptoms were 18, 13, and 3%, respectively. Esophageal erosion occurred in 1% of patients, but its risk significantly increased for every year of MSA use (odds ratio - OR 1.40, 95%CI 1.11-1.77, p=0.004). Device removal was needed in 4% of patients.

CONCLUSIONS

Although MSA is a very effective treatment modality for GERD, postoperative dysphagia is common and the risk of esophageal erosion increases over time. Further studies are needed to determine the long-term safety of MSA placement in patients with GERD.

Clinical Outcome and Recurrence of Open versus Laparoscopic Nissen Fundoplication in the Republic of Kazakhstan during 2010-2021

Background

Surgical treatment of recurrent gastroesophageal reflux disease (GERD) negatively affects patients' quality of life (QoL). Determination of risk factors is essential when considering a surgical approach. The present study aimed to evaluate short-term and long-term outcomes of primary laparoscopic Nissen fundoplication (LNF) and open Nissen fundoplication (ONF), as well as the risks of laparoscopic redo fundoplication.

Methods

A retrospective cohort observational study was conducted from 2010 to 2021 at the National Research Center of Surgery (Almaty, Kazakhstan). Depending on the type of primary GERD surgical correction, 475 patients were stratified into two groups, namely LNF (n=117) and ONF (n=358). The outcomes and associated complications of LNF and ONF surgeries were assessed. The odds ratio of recurrent GERD in terms of risk factors was analyzed as well as post-intervention QoL.

Results

Postoperative complications in ONF surgery were 2.7-fold higher than in LNF (P=0.0001). Moreover, intra-operative complications were higher with ONF surgery (7.7%) than with LNF (1.4%) (P=0.002). In cases with persistent clinical manifestations, the rate of redo fundoplication was the same after failed primary LNF and ONF. The risk factors associated with recurrent GERD, leading to redo fundoplication, were obesity (OR=2.16, P=0.473) and male sex (OR=3.0, P=0.272). One-year after LNF, 88.7% of the patients were satisfied with the outcome of the surgery.

Conclusion

Recurrent symptoms of GERD and the rate of redo fundoplication were associated with obesity and the male sex. Obesity was the main risk factor, necessitating stringent selection of patients for surgical management of the disease.

Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation

BACKGROUND

Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons.

METHODS

Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated.

RESULTS

There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf's alpha <0.30), indicating low to no agreement between providers.

CONCLUSION

In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.