Laparoscopic Nissen fundoplication in the treatment of Barrett's esophagus - 10 years of experience

The learning curve for transoral incisionless fundoplication

Background and study aims  Transoral incisionless fundoplication (TIF) is a safe and effective minimally invasive endoscopic technique for treating gastroesophageal reflux disease (GERD). The learning curve for this technique has not been reported. We studied the learning curve for TIF when performed by a gastroenterologist by identifying the threshold number of procedures needed to achieve consistent technical success or proficiency (consistent creation of TIF valve ≥ 270 degrees in circumference, ≥ 2 cm long) and efficiency after didactic, hands-on and case observation experience. Patients and methods  We analyzed prospectively collected data from patients who had TIF performed by a single therapeutic endoscopist within 17 months after basic training. We determined thresholds for procedural learning using cumulative sum of means (CUSUM) analysis to detect changes in achievement rates over time. We used breakpoint analysis to calculate procedure metrics related to proficiency and efficiency. Results  A total of 69 patients had 72 TIFs. The most common indications were refractory GERD (44.7 %) and proton pump inhbitor intolerance (23.6 %). Proficiency was achieved at the 18 ^th to 20 ^th procedure. The maximum efficiency for performing a plication was achieved after the 26 ^th procedure, when mean time per plication decreased to 2.7 from 5.1 minutes (P < 0.0001). TIF procedures time varied until the 44 ^th procedure, after which it decreased significantly from 53.7 minutes to 39.4 minutes (P < 0.0001). Conclusions  TIF can be safely, successfully, and efficiently performed in the endoscopy suite by a therapeutic endoscopist. The TIF learning curve is steep but proficiency can be achieved after a basic training experience and 18 to 20 independently performed procedures.

Dynamics of quality of life improvement after floppy Nissen fundoplication for gastroesophageal reflux disease

Introduction

Gastroesophageal reflux disease (GERD) has a negative impact on global quality of life (QOL) of patients. In patients affected by GERD, laparoscopic Nissen fundoplication is one of the most commonly performed laparoscopic procedures worldwide.

Aim

To prospectively analyze the dynamics of QOL as well as severity of pain in patients with GERD, before and after laparoscopic floppy Nissen fundoplication.

Material and methods

The study involved 104 consecutive patients operated on for GERD in whom laparoscopic floppy Nissen fundoplication was performed. QOL was assessed before surgery and 1, 3, 6, 12 and 24 months after. The following instruments were used: FACIT-G, FACIT-TS-G, GIQLI, GERD symptom scale.

Results

It was found that symptom relief and quality of life improvement presented different dynamics in the postoperative course. Observations revealed relief of symptoms 1 month after surgery and improvement in QOL related to the gastrointestinal tract and pain 3 months after surgery. Global QOL increased significantly as late as 12 months after surgery.

Conclusions

Gastroesophageal reflux disease is a chronic disease of long duration, leading to impairment of quality of life. Patients, apart from typical symptoms of GERD, suffer from pain of significant severity. QOL improves significantly after surgery. Surgical treatment results in relief of GERD symptoms, which leads to gradual improvement of QOL.

[Complicated gastroesophageal reflux disease in the presence of congenital esophageal shortening]

The paper presents a clinical case of complicated gastroesophageal reflux disease (GERD) and describes problems in the differential diagnosis of malignant esophageal lesion in patients with GERD and a treatment modality used in this clinical case.

Laparoscopic robotic total gastrectomy

Minimally invasive gastrectomy has become the standard of care in many centers in Asia but remains unpopular in Europe. The aim of this article is to present the technique of laparoscopic robot-assisted total gastrectomy. The presented case involved a 66-year-old female patient with an advanced gastric cancer on the lesser curvature of the stomach. The laparoscopic part of the procedure involved opening the lesser sac, mobilization of the greater curvature and transection of the duodenum. A robot was used for the D2 lymphadenectomy and creation of the anastomosis. In summary, we have found that during a total gastrectomy for advanced gastric cancer a successful oncological resection can be achieved using a minimally invasive approach. We have also found that by combining conventional laparoscopy with robotic assistance we could overcome the technical difficulties with regards to lymph node dissection and anastomosis.

Laparoscopic treatment of type III and IV hiatal hernia - authors' experience

Introduction

There are four types of hiatal hernias, and diagnosis is established on the basis of gastroscopy in the majority of cases. Type III represents a mixed type in which the abdominal esophagus as well as the gastric cardia and fundus protrude into the thorax through the pathologically widened esophageal hiatus. Type IV, the so-called upside down stomach, can be considered an evolutionary form of type III, and refers to herniation of nearly the whole stomach (except for the cardia and pylorus) into the thorax. Types III and IV of hiatal hernias represent a group of rare diaphragmatic defects; thus, most centers do not possess considerable experience in their treatment. Frequently, laparoscopic treatment is implemented, although, according to some authors, conversion to laparotomy, thoracotomy, or thoracolaparotomy is necessary in selected cases.

Aim

To analyze the outcomes of laparoscopic treatment of the largest hiatal hernias, i.e. type III and IV hernias.

Material and methods

A total of 25 patients diagnosed with type III and IV hiatal hernia were included in further analysis.

Results

As many as 19 out of 25 patients (76%) assessed the outcome of the surgery as evidently positive and reported marked improvement in the quality of life.

Conclusions

The laparoscopic technique constitutes an excellent and safe method of repair of even the most complex defects in the esophageal hiatus. Therefore, the minimally invasive technique combined with an anti-reflux procedure should be the method of choice in patients with type III and IV hernia.