Impact of Age on Long-Term Outcomes of Laparoscopic Nissen Fundoplication-A Single Center Study

Background and objectives: Gastroesophageal reflux disease (GERD) is a common disease affecting approximately 20% of the adult population. This study aimed to compare the results of laparoscopic Nissen fundoplication (LNF) in the treatment of GERD in patients of different age groups. Materials and Methods: A retrospective analysis was performed on patients who underwent LNF in one surgical department between 2014 and 2018. Patients were divided into three groups based on age: under 40 years of age, 40-65 years of age, and over 65 years of age. Results: A total of 111 patients (44.1% women) were analyzed in this study. The mean age was 50.2 ±15 years, and the mean follow-up was 50 months ± 16.6 months. Recurrence of symptoms occurred in 23%, 20%, and 23% in each age group, respectively (p = 0.13), and 85%, 89%, and 80% of patients from the respective groups reported that they would recommend the surgery to their relatives (p = 0.66). Furthermore, 83%, 92%, and 73% of patients from the respective age groups reported that they would undergo the surgery again with the knowledge they now had (p = 0.16). Conclusions: Given these results and observations, LNF has been shown to be a good method of treatment for GERD in every age group. In our study, there were no differences found in terms of satisfaction with surgery and associated recommendations between the studied age groups.

Budget Impact of RefluxStop™ as a Treatment for Patients with Refractory Gastro-oesophageal Reflux Disease in the United Kingdom

Background: Gastro-oesophageal reflux disease (GORD) is a common condition associated with heartburn and regurgitation. Standard of care for GORD patients in the UK involves initial treatment with proton pump inhibitors (PPIs) and laparoscopic antireflux surgery in patients unwilling to continue or intolerant of long-term PPI treatment. Recently, RefluxStop™, a novel, implantable medical device, has proven to be an efficacious and cost-effective treatment for patients with GORD. The current analysis aimed to describe the budget impact of introducing RefluxStop™ within National Health Service (NHS) England and Wales. Objectives: To estimate the more immediate, short-term clinical and economic effects of introducing RefluxStop™ as a therapeutic option for patients with GORD treated within NHS England and Wales. Methods: A model adherent to international best practice guidelines was developed to estimate the budget impact of introducing RefluxStop™ over a 5-year time horizon, from an NHS perspective. Two hypothetical scenarios were considered, one without RefluxStop™ (comprising PPI treatment, laparoscopic Nissen fundoplication, and magnetic sphincter augmentation using the LINX® system) and one with RefluxStop™ (adding RefluxStop™ to the aforementioned treatment options). Clinical benefits and costs associated with each intervention were included in the analysis. Results: Over 5 years, introducing RefluxStop™ allowed the avoidance of 347 surgical failures, 39 reoperations, and 239 endoscopic esophageal dilations. The financial impact of introducing RefluxStop™ was £3 029 702 in year 5, corresponding to a 1.68% increase in annual NHS spending on GORD treatment in England and Wales. Discussion: While the time horizon was too short to capture some of the adverse events of PPIs and complications of GORD, such as the development of Barrett's esophagus or esophageal cancer, the use of RefluxStop™ was associated with a substantial reduction in surgical complications, including surgical failures, reoperations, and endoscopic esophageal dilations. This favorable clinical profile resulted in cost offsets for the NHS and contributed to the marginal budget impact of RefluxStop™ estimated in the current analysis. Conclusions: Introducing RefluxStop™ as a treatment option for patients with GORD in England and Wales may be associated with clinical benefits at the expense of a marginal budget impact on the NHS.

Patient Satisfaction after Laparoscopic Nissen Fundoplication-Long-Term Outcomes of Single-Center Study

Up to 33% of the population suffers from gastroesophageal reflux disease (GERD). Given its high prevalence, the negative impact on quality of life, and the possible progression to esophageal cancer, the definitive treatment of GERD should be used more frequently. This study aims to assess long-term patient satisfaction after laparoscopic Nissen fundoplication (LNF). We reviewed the prospectively collected data of patients who underwent LNF for GERD in our department in 2014–2018. Each patient completed a preoperative questionnaire according to GERD Impact Scale (GERD-IS). Postoperative survey consisted of GERD-IS, the need for PPIs, and two “yes or no” questions to assess satisfaction with the outcome. The mean follow-up time was 50 months (21.2–76.3 ± 16.6 months). There was a statistically significant improvement in each GERD-IS question (p < 0.001). A total of 87 patients (78.4%) would recommend the surgery to their relatives. Patients without symptom recurrence and without the need for chronic PPI use after surgery were significantly more likely to recommend surgery and to undergo the procedure again (p < 001). The age of patients did not influence patients’ recommendations (p = 0.75). A total of 17 patients (15.3%) would not undergo LNF again. There was no significant correlation between the answer and patient’s complications or age (p > 0.05). LNF is a good treatment for GERD with a satisfaction rate of 78.4%.

Pre- and Postgastrostomy Evaluation of Gastroesophageal Reflux in Children Using 24-Hour pH Monitoring

Background: The aim of this study was to evaluate 24-hour pH monitoring results before and after gastrostomy in neurological impaired (NI) children who underwent gastrostomy or Nissen fundoplication (NF) concurrently with gastrostomy. Materials and Methods: Between March and December 2018, NI patients who had previously received pre- and postgastrostomy (Group 1) or gastrostomy + NF (Group 2) underwent pH monitoring pre- and postoperatively. Results: Twenty patients [12 males (60%) and the median age of 5.6 (14 months-14.7 years) years] with NI were followed up during the study period. When pre- and postgastrostomy weight and BMI z-scores were compared, the results were significantly higher in both groups after procedure (P = .043, P = .040, respectively). The clinical results of the patients after the operation showed improvement in both groups. The pH index of Group 1 (n = 11) was 2.32 (0-3.8) before gastrostomy and 3.18 (2.1-6.9) after gastrostomy (P = .061) and in Group 2 (n = 9) it was 5.85 (4.9-15.8) and 0.61 (0.3-1.3), before and after procedure (P < .001). There was a statistically significant difference in reflux index of each group. This difference was not statistically significant between the groups (P = .072). When the total bolus exposure index was compared, it was 4.01 (2.1-5.2) before gastrostomy and 5.67 (4.6-6.3) after gastrostomy in Group 1 (P = .041). In group 2, that index was found to be 9.8 (8.3-10.2) before and 1.28 (0.5-1.4) after (P < .001). There was a statistically significant difference in index after gastrostomy in Groups 1 and 2 (P = .023). Conclusions: Gastrostomy feeding is an effective and safe option to achieve enteral feeding in NI children. NF concurrent with gastrostomy should be decided according to the individual patient. Clinical trials protocol registration ID number was PRS NCT00445112.

Short- and long-term results after laparoscopic floppy Nissen fundoplication in elderly versus non-elderly patients

Background:

Laparoscopic anti-reflux surgery could be of benefit in a subset of elderly patients with gastroesophageal reflux disease. However, there are few reports that have evaluated the long-term results. This study examined the effects of age on the short- and long-term (for at least 5 years) outcomes after laparoscopic Nissen fundoplication (LNF).

Patients and Methods:

Patients were divided into four groups as follows: young (18–49); adult (50–69); and elderly (70–84), and very elderly (85–91). The database (recorded prospectively) included operating duration, conversion, intra- and early post-operative complication and late outcomes. Mean follow-up was 14.5 years (range 5–24 years).

Results:

Five hundred and sixty-nine patients met the inclusion criteria: young n = 219 (38.4%); adult n = 248 (43.5%); elderly n = 91 (16.0%) and very elderly n = 11 (1.9%). Hiatal hernia (type I and III) was significantly less frequent in young and adult patients (P < 0.0001). The operation was significantly longer in elderly and very elderly patients (P < 0.001); the use of drains (P < 0.001) and grafts (P < 0.0001) for hiatal hernia repair was less in young and adult patients. The hospital stay, conversion (5.4%), intra-operative and early post-operative complications were not influenced by age. Dysphagia was evenly distributed among the groups. Forty-eight (8.4%) patients had recurrence: 15 in the young group (6.8%), 18 in the adult group (7.2%), 11 in the elderly group (12%) and 4 in the very elderly group (36.3%) (P < 0.0001).

Conclusions:

Age does not influence short- and long-term outcomes following LNF. Control of reflux in the elderly is worse than adult patients. Therefore, ageing is a relative contraindication to LNF.

A comparison between Belsey Mark IV and laparoscopic Nissen fundoplication in patients with large paraesophageal hernia

OBJECTIVES

Laparoscopic Nissen fundoplication is the most commonly performed operation for the repair of large hiatal hernias. We compared outcomes between the Belsey Mark IV fundoplication and the laparoscopic Nissen fundoplication.

METHODS

A retrospective review was performed over a 10-year period on patients who had repair of large paraesophageal hernia. Patients who received the Belsey Mark IV (n = 118) were matched 1 to 1, by year of surgery, gender, and age, with patients who received laparoscopic Nissen fundoplication. We compared these 2 groups, examining recurrence, need for reoperation, perioperative outcomes, and symptomatic follow-up as defined by the Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire.

RESULTS

Recurrence rates were similar between patients who had a Belsey Mark IV and laparoscopic Nissen fundoplication (8.4% vs 16.1%, P = .11). However, the esophageal leak rate was higher in patients who received a laparoscopic Nissen fundoplication compared with the Belsey Mark IV (6.8% vs 0%, respectively, P = .006), and patients who received a laparoscopic Nissen fundoplication had higher rates of reoperation (9.3% vs 2.5%, respectively, P = .05). Gastroesophageal Reflux Disease-Health Related Quality of Life symptom scores were similar between groups with symptoms in laparoscopic Nissen fundoplication and Belsey Mark IV, being excellent (74.4% vs 81.4%), good (9.3% vs 7.0%), fair (9.3% vs 0), and poor (7.0% vs 11.6%), respectively (P = .52).

CONCLUSIONS

Laparoscopic Nissen fundoplication for large paraesophageal hernias was associated with an increased incidence of leak and reoperation when compared with Belsey fundoplication. Belsey Mark IV fundoplication should be considered when deciding on what operation to perform in patients with large paraesophageal hernias.

Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial

Background

A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF).

Materials and Methods

Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO₂) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated.

Results

A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiO₂group patients in comparison with the 80% FiO₂group (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO₂group; no changes were noted in 80% FiO₂group (P < 0.05).

Conclusions

This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.

Mesh hiatal reinforcement in laparoscopic Nissen fundoplication for neurologically impaired children is safe and feasible

Fundoplication is a standard treatment for gastroesophageal reflux disease (GERD) in neurologically impaired children. However, it has a high recurrence rate due to wrap herniation and disruption resulting from the failure or enlargement of the esophageal hiatus suture site. In adult patients with GERD, reinforcement of the sutured esophageal hiatus with a mesh significantly reduces the recurrence rate after surgery for esophageal hiatus hernia. In children, there are no big series of fundoplication with mesh reinforcement. Therefore, we confirmed the safety and feasibility of an expanded polytetrafluoroethylene mesh hiatal reinforcement with fundoplication as an additional procedure for neurologically impaired children. Neurologically impaired children (age, ≥5 years) who underwent laparoscopic fundoplication and gastrostomy at our institution between 2011 and 2013 were included in this study. The operative time, bleeding amount, complications, and recurrence were retrospectively evaluated. Thirteen patients were included in this study. The mean age at operation was 147.2 ± 37.8 months, and mean body weight was 18.5 ± 7.9 kg. The complication rate of epilepsy and scoliosis was 100% and 84.6%, respectively. The operative time was 265.1 ± 38.1 minutes, and mean blood loss was 26.5 ± 34.7 mL. There were no peri- or postoperative complications. None of the patients showed recurrent symptoms such as repeated vomiting and aspiration pneumonia during the mean follow-up period of 2.5 ± 0.6 years. The mesh hiatal reinforcement with fundoplication for neurologically impaired children is safe and feasible.

Long-Term Quality of Life Outcomes Following Nissen Versus Toupet Fundoplication in Patients with Gastroesophageal Reflux Disease

INTRODUCTION

Laparoscopic fundoplication is the gold standard treatment for gastroesophageal reflux disease (GERD) refractory to medical management. Although many studies have compared Nissen fundoplication (NF) to Toupet fundoplication (TF), it is unclear which operation provides the best long-term reflux control. The objective of this study was to evaluate long-term quality-of-life (QoL) outcomes after NF versus TF.

METHODS

Clinical data from our single academic institutional foregut database were used to identify patients who underwent NF or TF (June 2010 to May 2016). Postoperative QoL was assessed through telephone at 1, 3, or 5 years postsurgery, using GERD-health related quality of life (GERD-HRQL), Gastroparesis Cardinal Symptom Index (GCSI), and Eckardt Dysphagia scores. Proton pump inhibitor (PPI) use and satisfaction with surgery were also obtained. Trends in outcomes over time were analyzed by logistic regression or Cochran-Armitage trend test.

RESULTS

Our cohort included 155 TF and 161 NF patients. TF patients reported baseline dysphagia at higher rates (42.6% versus 19.9%; P < .001) and had worse preoperative esophageal dysmotility than NF patients. There were no significant differences in GERD-HRQL or GCSI scores between TF and NF patients at any time point postoperatively. Long-term satisfaction was equivalent between TF and NF patients 5 years postoperatively (70.0% versus 77.4%; P = .67). NF patients had higher Eckardt dysphagia scores 1 year after surgery compared to TF patients, but this difference was not present at 3 or 5 years postoperatively. Over time, PPI use increased and there was a trend toward increased GERD-HRQL scores in the TF group.

CONCLUSIONS

Both TF and NF provide excellent long-term satisfaction for patients with GERD. NF and TF patients reported similar postoperative QoL scores. Our finding of increasing PPI use and a trend toward worsening GERD scores following TF warrants additional investigation regarding the long-term durability of TF.

Esophageal hypermotility: cause or effect?

Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring. Postoperatively, all 38 patients had normal distal esophageal acid exposure. Of these 38 patients, symptoms resolved in 28 and improved in 10. Of six patients (one with NE, two JHE, and three with HTLES) that underwent postoperative esophageal manometry, five exhibited normal motility. Typical reflux symptoms are common among patients with esophageal hypermotility disorders. Abnormal 24-hour pH monitoring is present in the majority of patients with who report typical reflux symptoms and almost half of patients who report respiratory symptoms. Conversely, the majority of patients who report dysphagia or chest pain have normal distal esophageal acid exposure. Based on a small number of patients in this study, it also appears that motility disorders often improve after LNF. LNF is associated with resolution or improvement in reflux related symptoms and esophageal motility parameters in patients exhibiting abnormal esophageal acid exposure. This suggests that patient symptoms are due to abnormal acid exposure and not the motility disorder.

Outcome of Stretta radiofrequency and fundoplication for GERD-related severe asthmatic symptoms

This study aimed to investigate the outcome of treatment with Stretta radiofrequency (SRF) or laparoscopic Nissen fundoplication (LNF). A total of 137 gastroesophageal reflux disease (GERD) patients with severe asthmatic symptoms who responded inadequately to medical treatment for asthma were investigated. The patients were followed up 1 year and 5 years after SRF (n = 82) or LNF (n = 55) treatment. A questionnaire covering 29 related symptoms and medication use was employed. Digestive, respiratory, and ear-nose-throat (ENT) symptom scores significantly decreased after antireflux treatment. Symptom scores respectively changed from 17.2 ± 10.1, 31.9 ± 6.6, and 21.1 ± 11.8 to 5.0 ± 6.2, 11.5 ± 10.2, and 6.3 ± 6.8 at 1 year and to 5.6 ± 6.5, 13.1 ± 10.1, and 7.8 ± 7.2 at 5 years (P < 0.001). The outcome of LNF was significantly better than that of SRF in terms of digestive (P < 0.001, P = 0.001), respiratory (P = 0.006, P = 0.001), and ENT symptoms (P = 0.006, P = 0.003) at both 1 year and 5 years. SRF and LNF were both effective against the digestive symptoms of GERD as well as GERD-related severe asthmatic and ENT symptoms, with better outcomes exhibited by the LNF group. Severe asthmatic symptoms and GERD were closely associated, and this finding warrants further study.

[Comparison of surgical patients with gastroesophageal reflux disease and Barrett's esophagus]

INTRODUCTION

Barrett's esophagus (BE) is the only known precursor of adenocarcinoma occuring in the lower third of the esophagus. According to statistics, severity and elapsed time of gastroesophageal reflux disease (GERD) are major pathogenetic factors in the development of Barrett's esophagus.

PATIENTS AND METHODS

In a retrospective study between 2001 and 2008, we compared the preoperative results (signs and sympthoms, 24 hour pH manometry, esophageal manometry, Bilitec) and treatment efficacy of 176 GERD patients and 78 BE patients, who have undergone laparoscopic Nissen procedure for reflux disease.

RESULTS

The two groups of patients had similar demographic features, and elapsed time of reflux sympthoms were also equal. Both groups were admitted for surgery after a median time of 1.5 years (19.87 vs. 19.20 months) of ineffective medical (proton pump inhibitors) treatment. Preoperative functional tests showed a more severe presence of acid reflux in the BE group (DeMeester score 18.9 versus 41.9, p < 0.001). On the other hand, mano-metry - despite confirming lower esophageal sphincter (LES) damage - did not show difference between the two groups (12.10 vs. 12.57 mmHg, p = 0.892). We did not experience any mortality cases with laparoscopic antireflux procedures, although in two cases we had to convert during the operation (1 due to extensive adhesions, and 1 due to injury to the spleen). 3 months after the procedure - according to Visick score - both groups experienced a significant decrease, or lapse in reflux complaints (group I: 73%, group II: 81% of patients), LES functions improved (17.58 vs.18.70 mmHg), and the frequency and exposition of acid reflux decreased (DeMeester score 7.73 vs. 12.72).

CONCLUSION

The severity of abnormal acid reflux occuring parallel with the incompetent function of the damaged LES triggers not only inflammation in the gastroesophageal junction (GEJ), but also metaplastic process, and the development of Barrett's esophagus. Laparoscopic Nissen procedure for reflux disease can further improve outcome among patients with GERD not responding to conservative therapy.

Nissen fundoplication for gastroesophageal reflux: No deterioration of gastric emptying measured by C-acetate breath test

Aim:

To study the gastric emptying 30 days after laparoscopic Nissen fundoplication (NF) in gastroesophageal reflux.

Materials and Methods:

Three patients were evaluated with ¹³C-acetate breath test (ABT) performed pre and post-NF. The liquid test meal consisted of Racol^™ mixed with ¹³C-acetate.

Results:

In the patient without neurological impairment (NI), the preoperative t_½ex and t lag were 0.900 and 0.510 hours, respectively. The postoperative t_½ex and t lag were 0.959 and 0.586 hours, respectively. In one patient with NI, the preoperative t_½ex and t lag were 1.828 and 1.092 hours, respectively. The postoperative t_½ex and t lag were 2.081 and 1.025 hours, respectively. In the other patient with NI, the preoperative t_½ex and t lag were 2.110 and 0.980 hours, respectively. The postoperative t_½ex and t lag were 1.118 and 0.415 hours, respectively.

Conclusions:

Our findings suggest that ¹³C-ABT parameters did not worsen in any of the children after laparoscopic NF.