Antireflux Procedure Research Articles

BN SO42 - Our experience of Emergency Laparoscopic Fundoplication in a DGH

Abstract Background Emergency presentation of hiatal hernias can be life-threatening and is associated with high morbidity and mortality rates. Elective Laparoscopic hiatus and paraoesophageal hernias are commonly performed with fundoplication. However, emergency cases are often repaired without an anti-reflux procedure. We present our experience of emergency Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication in a District General Hospital (Russells Hall Hospital, RHH). Method 6 cases of diagnosed hiatus/ paraoesophageal hernia that underwent Emergency fundoplication from 2019-2024. Results The mean age of the patients was 74 (56-83). All patients had a pre-op CT scan to confirm the diagnosis. 4 patients (66%) had a Type 3 Hiatus hernia and 2 (33%) had a Type 2 classic paraosephageal hernia. All patients underwent Emergency Laparoscopic Hiatus / Para oesophagal hernia repair with fundoplication. 2 patients required mesh for the repair. The mean length of stay was 5 days (3-7). There were no intra or post-op complications and on follow up 1 patient had a recurrence of symptoms after 1 year requiring redo fundoplication. Conclusion The choice of operation is mainly based on the patient’s clinical condition, the complexity of the hernia and the surgeon’s experience. Our experience at RHH shows that Laparoscopic Hiatus/ Paraoesophageal hernia repair with fundoplication is safe and feasible in patients with emergency presentation.

BN SO37 - Upper GI surgical training in the UK: Are there enough training opportunities? 10-year trends in Benign Upper GI index procedures and the impact of COVID-19

Abstract Background Surgical training was adversely impacted during the COVID pandemic, with reports of reduced logbook numbers and challenges in meeting training competencies. Despite a national elective care recovery plan, and interventions aimed at maintaining training opportunities, waiting list expansion has continued and has particularly impacted benign procedures. Upper GI trainees are all required to achieve “Level 4” (independent) competence in Cholecystectomy and Antireflux surgery, however there are anecdotally. fewer opportunities in the post-COVID era to train in these procedures. This study aimed to evaluate trends in these index procedures and to compare the pre- and post- COVID eras. Method The annual Admitted Patient Care (APC) publications draw on Hospital Episode Statistics and summarise activity for each financial year by OPCS4 codes. Codes pertaining to cholecystectomy and antireflux surgery (the “Benign Upper GI” competences on the Joint Committee of Surgical Training New Curriculum Checklist) were screened for inclusion. Data were extracted from APC publications between 2013 and 2023. These data were summarised in a Microsoft Excel Spreadsheet, categorised by index procedure and divided into pre-covid (2013-2019) and post-covid (2019-2023). Trends were evaluated using a Mann-Kendal Non-Seasonal Trend Test. Comparisons were undertaken using a two tailed unpaired t-test. Results Between 2013 and 2023 there was a statistically significant negative annual trend in the number of cholecystectomies from 75934 to 68182 (p=0.02), with a minimum of 47803 in the 2020-2021 financial year and a non-significant positive trend in the subsequent years. There were significantly fewer cholecystectomies in the 4 years following COVID (mean 77357 vs 63882, p=0.015). Antireflux procedures also underwent a significant negative trend from 5467 to 4745 (p=0.02), with a minimum of 2565 in the 2020-2021 financial year and a non-significant positive trend in subsequent years. Mean post-COVID antireflux procedures were also significantly lower (5548 vs 4256, p=0.03). Conclusion The procedures required for training in Benign Upper GI surgery in the UK are occurring with lower frequency than before the COVID pandemic. Whilst this may reflect ongoing operational pressures, or changes in clinical practice, this evidence suggests that training opportunities are now less frequent. This highlights the importance of focussed training and an awareness of training needs amongst both trainees and their mentors.

BN SO33 - The complex benign multi-disciplinary team meeting - a paradigm shift in decision making for benign oesophagogastric surgery

Abstract Background Decision making in benign OG pathology can be particularly challenging given the overlap with functional disorders, such as reflux hypersensitivity. A specialist benign oesophagogastric (OG) multidisciplinary team (MDT) may improve our ability to triage potential surgical candidates from those with functional conditions. Unlike in OG cancer, there is a paucity of evidence to support an MDT based approach in benign OG surgery. This study aims to report our experience of introducing a specialist benign OG MDT in an OG tertiary centre in the UK, examining the effect on decision making and an assessment of its acceptability and utility to clinicians. Method A review of consecutive cases discussed in the specialist benign OG MDT since inception in 2022 was undertaken. We reviewed indications, treatment plans and outcomes, any alteration in treatment pathway and final decisions. The primary outcome was the proportion of patients with a change in management as a result of MDT discussion. Where applicable, results were reported using descriptive statistics. A seven-item electronic questionnaire was also circulated to MDT members (OG surgeons, specialist gastroenterologists, GI radiographers, GI physiologists, and doctors in training), to assess the acceptability and perceived utility of the meetings. Results 74 patient cases were discussed (median age 57.5 (25-79) years). 71/74 (96.0%) of referrals were made by OG surgeons, most commonly to discuss anti-reflux procedures (53/74 (71.6%)). 34/74 (45.9%) patients had undergone previous surgery, most commonly laparoscopic fundoplication. MDT discussion led to a change in management in 43/74 (58.1%) case with recommendations of further investigation (23.0%), further OG clinic review (18.9%) and 21.6% listed for surgery. 12/74 (16.2%) were referred to other specialist services, including clinical psychology. Survey confirmed that all MDT members found their understanding of oesophageal physiology and subsequent decision-making ability in clinic was greatly enhanced. Conclusion Our results show that the complex benign MDT is an effective tool, demonstrating changes to management in over half of cases discussed, including recommending surgery less frequently following specialist review of physiology investigations. Such tests effectively identify functional disorders, such as rumination, highlighting a need for clear onward referral pathways involving specialist psychologists. The meetings have also proven to be valuable learning tools for all attendees of all grades. We strongly believe that adopting an MDT approach to benign OG conditions will enhance collaborative decision making, improve patient outcomes and therefore should be nationally mandated and recommended through AUGIS guidelines.

BN SO58 - Patient Reported Outcome Measures in Hiatal Surgery: A Feasibility Study

Abstract Background Hiatal surgery is predominantly a quality-of-life procedure rather than a lifesaving intervention. Whilst procedural complications are well understood, they do not necessarily reflect the patient experience. Traditional indicators of patient care are insufficient. Patient Reported Outcome Measures (PROM) are robust indicators of care quality (1) and are being used across surgical specialities to benchmark success and identify areas for improvement (2). We present a three-year review of our PROM data to demonstrate feasibility of data collection. Method Patient reported outcome measure data were collected from the National Hiatal Surgery Registry (3) for our benign centre over a three-year period (November 2021-January 2024). Consent was obtained from all patients for research purposes. Surgical procedures included: anti-reflux surgery, hiatus hernia repair and cardiomyotomy. All patients were asked to complete pre-operative quality of life surveys. Patients are automatically contacted through the registry at 6months, 1 year and then annually for five years and prompted to complete quality of life surveys. Ekhardt score is used in achalasia. GORD-QoL score was used for anti-reflux procedures, with the Hernia-QoL score for hiatal hernia. Results Data were collected for 20 patients. Mean BMI was 28.2. All completed preoperative surveys. At six months there was attrition of one patient, who has since completed 1-year and 2-year data. At the time of writing, six patients have completed 6month data, 5 patients have completed 1-year data and 3 patients have completed 2-year data. Mean Ekhardt score was 9.25 preoperatively; at six months mean score was 0. Five patients underwent LINX, eleven underwent fundoplication; one Dor, ten Toupet. Mean pre-operative quality of life score was 31.1; at six months mean score was 15.5. At one year this was 4. Conclusion The National Hiatal Surgery Registry facilitates easy acquisition of surgeon specific PROM data over a short- and long-term period. Patient attrition is low, demonstrating acceptability. Our data demonstrate significantly improved patient reported quality of life postoperatively for all hiatal surgery.

Is Screening for GERD Necessary in All Asymptomatic Lung Transplant Candidates?

Background: Gastroesophageal reflux disease (GERD) is a known contributor to allograft dysfunction after lung transplantation. Evaluation for GERD has been advocated for all lung transplant candidates. The aim of this study is to evaluate the outcomes of GERD testing in lung transplant patients without GERD symptoms and determine if a subset can skip/defer these tests. Methods: A retrospective chart review was conducted on lung transplant candidates who had pre- transplant GI evaluation at our institution between 2019 and 2022. Adult patients were included if they reported no GERD symptoms and completed GERD screening with Multichannel intraluminal impedance-pH testing. Demographics and results of prior testing were collected for included patients. Results were analyzed using STATA. Results: 176 patients met inclusion criteria. 88 (50%) tested positive for GERD and 88 (50%) tested negative. 68/88 (77.3%) were positive by pH alone. Only 20/176 (11%) had elevated reflux episodes and were recommended to undergo anti-reflux procedures. There were no statistically significant differences in evaluated variables differentiating GERD+ versus GERD- patients. Conclusion: Lung transplant candidates without symptoms concerning for GERD tested positive for GERD 50% of the time with no reliable pre-test characteristics to stratify patients. The large majority of positive results were from high acid exposure time alone without elevated reflux episodes—a low risk phenotype for allograft dysfunction. Only 11% had increased reflux episodes and thus were recommended for anti-reflux procedures. Thus, deferring GERD screening in asymptomatic low-risk candidates until post-transplant is unlikely to impact clinical management while benefiting patients and health systems.

Retrospective cost analysis of robotic and laparoscopic anti-reflux surgery and paraesophageal hernia repair.

Increased adoption of robotics in foregut surgery evokes questions regarding efficacy, safety, and cost. To many, cost remains a barrier to adoption of a robotic approach. The authors' aim to determine the difference in cost of a robotic (R-) vs laparoscopic (L-) approach for paraesophageal hernia repair (PEHR). Patients 18years and older who underwent PEHR between July 2016 and June 2021 at a university health network were included. Variables of interest included 30 day outcomes, 1 year recurrence rates, and several cost variables including hospital length of stay, operating room (OR) time, chargeable supplies and implants, non-chargeable supplies, and indirect cost. Cost data were stratified by type and the presence of fundoplication, as well as the elective versus urgent nature of the procedures. Statistical analysis consisted of parametric and non-parametric analyses, with p < 0.05 denoting statistical significance. 405 patients were included in the study (n = 188 for R-, n = 217 for L-). Significant differences were observed in the type of anti-reflux procedure performed (p < 0.001), use of mesh (R- 70.2% vs. L- 59.0%, p = 0.019), and whether a Collis gastroplasty was performed (R- 4.3% vs. L- 10.2%, p = 0.023). No differences in 30-day readmission or reoperation rates, Clavien-Dindo complication rates, or 1-year hernia recurrence rates were observed. For elective cases, regardless of the type of anti-reflux procedure performed, a robotic approach was associated with a significantly greater cost (p < 0.002). Comparing all procedures, a statistically significant increase in cost was seen with a robotic approach (R- $29,706.88 vs. L- $23,457.07, p < 0.001). Complication rates and surgical outcomes between the two approaches were similar; however, cost is significantly increased when a robotic approach is utilized. Future studies are needed to delineate which drivers of cost are modifiable with the robot.

How I Do It—Transoral Incisionless Fundoplication with Concomitant Hiatal Hernia Repair

AbstractTransoral incisionless fundoplication with concomitant hiatal hernia repair (cTIF) is an antireflux procedure that combines hiatal hernia repair with TIF. As such, it restores the antireflux barrier using a two-step, hybrid procedure utilizing both minimally invasive surgery and endoscopy in one operative procedure. In this article, we discuss the procedure as well as its role in the armamentarium of interventions for gastroesophageal reflux disease and outline technical details.

405. SELECTIVE ANTERIOR GASTROPEXY WITH OR WITHOUT FUNDOPLICATION FOR THE TREATMENT OF GRADE III/IV HIATAL HERNIA

Abstract Background The optimal approach to a paraoesophageal hernia (PEH) repair is unclear. Several steps during the procedure are still for discussion. Most surgeons dealing with PEH surgery agree on removal of the hernia sac from the mediastinum and a hiatoplasty with non-absorbable suture. Whether to perform an anti-reflux procedure or/and a gastropexy is unclear. Few studies exist on the subject but without clear favor of an anti-reflux procedure and/or a gastropexy. The aim of this upcoming study is to test if the anti-reflux procedure is redundant for patients suffering from PEH with obstructive rather than regurgitation symptoms. Methods We are setting up a pragmatic, prospective, multicentre, two-armed study. Study beginning June 2024. Sample size calculation with 108 patients in each arm. Both arms will do hernia sac excision, closure of hiatus and gastropexy. One arm will in addition do an anti-reflux procedure. Our objectives are 1) To assess safety of anterior gastropexy with and without fundoplication regarding peri- and postoperative complications. 2) To compare efficacy of anterior gastropexy with and without fundoplication regarding symptom control and clinical recurrence. 3) To assess health related quality of life pre- and post-surgery in patients treated with the two strategies for PEH. Results Our primary outcome is disease specific and health related quality of life before surgery and 3-6-12 months after surgery. Secondary outcomes are per- and post-operative complications according to the clavien-dindo score and radiological status/recurrence 12 months after surgery. Conclusion The study will add on to existing knowledge about essential technical steps of PEH surgery. Do the patients benefit from a fundoplication or is this potentially complicating procedure redundant regarding long-term symptom control.

565. LAPAROSCOPIC TREATMENT OF HIATAL HERNIAS COMBINED WITH MODIFIED TOUPET FUNDOPLICATION. SURGICAL TECHNIQUE

Abstract Introduction Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias. Aim This study aims to describe our surgical technique of laparoscopic repair in hiatal hernias, including sliding, paraesophageal and mixed types. Material and Methods A total of 65 consecutive patients underwent laparoscopic hiatal hernia repair by the same surgical team within 4 years. Results Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac en bloc, 3 cm of intra-abdominal esophageal length, crural closure and an effective anti-reflux procedure as our modified Toupet fundoplication. Conclusions Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have significant reflux disease, an operative repair is required. A minimally invasive approach is safe and can provide excellent outcomes in the hand of experts. https://we.tl/t-KgcOuSyEMt

615. ROBOTIC REDO LAPAROSCOPIC HELLER’S CARDIOMYOTOMY

Abstract Introduction Robotic Heller’s cardiomyotomy is the preferred treatment option for achalasia cardia. However, following Heller’s cardiomyotomy up to 20% of patients experience dysphagia and regurgitation in the long term. The ideal management option for such patients needs to be determined. Surgical Steps The procedure is carried out with patient in supine position, legs abducted with the knees in slightly flexed position in reverse Trendelenburg position of approximately 30°.The pneumoperitoneum is created by closed Veress needle technique. After Relasing Adhesions, the gastrohepatic ligament is divided and the right crus is identified and retrocardiac window is formed; proximal short gastric vessels are divided for posterior wrap. The esophagus is separated by blunt dissection from the crus, the peritoneum and phrenoesophageal membrane are divided and the left crus is identified. If an anterior partial fundoplication is planned as antireflux procedure, the mobilization is limited to the lateral and anterior aspects. The anterior vagus nerve is identified and should be dissected and lifted away from the distal esophagus and proximal stomach in order to facilitate transhiatal dissection, myotomy and also to prevent injury to the esophagus and vagal trunks. Dissection is continued cranially around the esophagus for a distance of about 2–3 cm onto the dilated segment of the esophagus in the posterior mediastinum. If posterior partial wrap (Toupet) is planned, esophagogastric dissection is performed posteriorly from both crura and median arcuate ligament to get tension free wrap. Fundus of the stomach is dissected off the diaphragm and if needed two or three short gastric vessels are divided. Posterior vagal trunk is dissected along with esophagus. Conclusion Redo Robotic Heller’s cardiomyotomy can safely be performed with good symptomatic relief for patients who present with recurrent symptoms following Heller’s cardiomyotomy. Long term follow-up with larger sample size is needed to confirm these findings. https://drive.google.com/file/d/1uFgx0Aal92o5FE-Ndp-tAsCg01NJ6Crm/view?usp=sharing

511. IS IT SAFE TO USE NONABSORBABLE MESH IMPLANTATION FOR HIATAL REINFORCEMENT DURING PRIMARY ANTIREFLUX PROCEDURES?

Abstract Background Laparoscopic Fundoplication (LF) is highly effective in surgical treatment of GERD and the prevention of disease progression. Currently it is the gold standard of treatment and allows to achieve good and excellent postoperative results in majority patients. However, despite the gained experience, failures of primary LF and hiatus repair like hiatal hernia recurrence demonstrate that current surgical techniques are not optimal. One of the decisions is mesh implantation for hiatal reinforcement in GERD. However, due to the different types of complications (mesh erosion, scarring, dysphagia) safety use of mesh are still controversial. Method Laparoscopic Total Fundoplication (LTF) with nonabsorbable and composite light mesh implantation for hiatal reinforcement during 2022 – 2023 years were performed in 71 patients. We use macroporous nonabsorbable polypropylene or composite (polypropylene/monocryl) light mesh repair routinely by own proposed surgical technique. Our decision did not depend on size of hiatal hernia and hiatal surface area. We use U-shaped mesh posteriorly on the approximated crura by previous interrupted suturing not around the esophagus (Fig. 1). The mesh fixes with staples to the muscular and ligamentous structures of crura. We compared our results with the group of LTF without mesh implantation. Result All patients underwent completed validated questionnaires, esophagogasroduodenoscopy, contrast video esophagram, 24-hour impedance-pH monitoring after surgery. Some patients underwent computed tomography. Along with the disappearance of GERD symptoms, no mesh erosion and long (&amp;gt;3 month) postoperative follow-up dysphagia were marked in any patient with mesh repair. There are no significant difference in comparison with these results of LTF without mesh implantation. During the early postoperative period (&amp;lt; 12 months) no recurrence of hiatal hernia was diagnosed in the group with mesh implantation. Conclusion According to our study, in comparison with no-mesh repair, the proposed surgical technique is safe. Nonabsorbable and composite light mesh implantation for hiatal enforcement during primary antireflux procedures may be used routinely to prevent hiatal hernia recurrence effectively. Further, longer-term follow-up will be continued to confirm this position.

778. ROBOTIC-ASSISTED EPIPHRENIC DIVERTICULECTOMY: 9 YEAR EXPERIENCE OF A TERTIARY CENTER

Abstract Background Epiphrenic esophageal diverticula are rare and often associated with esophageal motor disorders. Surgery is reserved for larger diverticula with symptoms that significantly impair quality of life. When possible, a transhiatal approach can reduce pulmonary complications by preserving pleural integrity; more proximal diverticular openings require a combined transthoracic and abdominal approach to achieve complete excision. Robotic surgery assists in precise dissection and preservation of delicate mediastinal structures. Currently, few reports are available on larger patient cohorts of robotic diverticulectomy. We describe all consecutive cases of robotic-assisted epiphrenic diverticulectomy performed at a high-volume tertiary center, since robotic surgery became available in 2015. Methods A retrospective chart review was conducted and, for all consecutive diverticulectomy cases, surgical techniques, patient characteristics and short and long-term outcomes were recorded. All patients underwent preoperative EGDS and esophagogram. Diverticulectomy was always accompanied by esophagogastric Heller myotomy (&amp;gt;7 cm) and Dor fundoplication with the Xi DaVinci system was performed. One to two SIGNA linear stapler firings were used for diverticular resection. Symptoms, demographic data, and short and long-term surgical outcomes were recorded, including morbidity and mortality and post-operative symptoms. Results Four cases required both an abdominal and intrathoracic approach, none was converted. Intraoperative complications included one occurrence of splenic bleeding controlled by hemostatic. Intraoperative blood loss was negligible. In two cases an esophageal leiomyoma was found incidentally and excised. The only postoperative complication was trocar-related abdominal wall bleeding that led to reintervention for cauterization; mortality was zero. All patients underwent a post-op esophagogram, negative for leaks or strictures, and resumed soft feeding within 7 days. All reported substantial symptom relief at six months. At one year, one patient reported reflux, and two reported dysphagia recurrence without evident structures or recurrences. Conclusion Robotic-assisted diverticulectomy is safe and effective for epiphrenic diverticula. The abdominal approach allows for a thorough esophageal myotomy associated with a For antireflux procedure to reduce recurrences of the disease and long-term dysphagia. In some cases a transthoracic approach is also needed, when employed by experienced upper GI surgeons it doesn't significantly affect surgical outcomes. Quality of life improves after surgery, although symptomatic reflux might occur. Further prospective or experimental studies are needed to evaluate short and long-term outcomes of the robotic approach compared to other surgical approaches.

362. DELAY IN SOLID GASTRIC EMPTYING IS ASSOCIATED WITH SILENT REGURGITATION EVENTS, PULMONARY MICROASPIRATION AND LARYNGOPHARYNGEAL REFLUX DISEASE

Abstract Background Pulmonary micro-aspiration (PMA) is a feared complication of severe and sometimes silent gastroesophageal reflux disease (GORD). A novel scintigraphic test that shows refluxate contamination of the pharynx, upper and lower airways has recently been developed. This test and multiple observations allowed the development of a hypothesis that prolongation in solid gastric emptying (SGE) may be a more critical than delays in liquid gastric emptying (LGE) in micro-aspiration into the airways. Methods Standard LGE and SGE studies together with the novel microaspiration test were evaluated in paired studies in patients with medially resistant symptoms GORD to measure rates of micro-aspiration after each meal. Either water labelled with 99m Technetium Phytate for the LGE or a labelled egg sandwich for the solid meal was utilised. Major symptoms were noted and the cough and reflux severity index (CSI &amp; RSI) obtained in all patients. Results A total of 131 patients were included in this study (59M/72F). The age range was 21 to 83 years with a mean of 52 years. Patients were in the overweight range for body mass index (BMI), with a mean of 26.8. Major symptoms were of bloating, nausea, belching and dyspepsia as well as cough, throat clearing and globus. Less than 20% complained of heartburn. Results. SGE was abnormal in 92% (Mean 766 min) and LGE was abnormal in 53% (Mean 82 min). PMA was shown in 35% after the SGE and in 71% after the LGE. PMA positive patients were older. SGE and PMA were significantly correlated (p&amp;lt;0.00) but not LGE. The only significant symptom in the PMA group was bloating. RSI was abnormal in 64% and CSI in 46%. Conclusion The majority of patients with PMA do not complain of heartburn. Bloating in patients with severe GORD should raise the possibility of gastroparesis and PMA. Prolonged SGE may be critical in the physiology of atypical reflux and present another treatment goal with addition of pyloroplasty to anti-reflux procedure of choice.

Efficacy and safety of anti-reflux surgery in gastroesophageal-related cough: a systematic review and meta-analysis.

Gastroesophageal reflux disease (GERD) is a prevalent condition that manifests a spectrum of symptoms, including gastroesophageal-related cough (GERC). Anti-reflux procedures have been employed to alleviate these symptoms, yet their efficacy varies. This systematic review and meta-analysis aim to evaluate the improvement in gastroesophageal-related cough and other reflux symptoms following anti-reflux procedures. A systematic review was performed by searching PubMed, Embase, and Cochrane Library. All observational studies reporting the improvement of GERC and other reflux symptoms after the anti-reflux procedures. Data were extracted and pooled using a random effects model to assess the overall effect size and heterogeneity between studies. We found that anti-reflux surgery has some clear benefits for common reflux-related symptoms. Fifty-nine eligible studies with 7431 patients with GERD were included in this study. The pooled cough remission rate was 80.0% (95%CI 75.4-84.2) and the mean time of follow up was 35.8 months. Anti-reflux surgery significantly improved overall reflux-related symptom scores (all P<0.001). We also assessed the rate of remission of other reflux symptoms. The pooled heartburn remission rate was 87.7% (95%CI 82.3-92.2) and the pooled regurgitation remission rate was 91.2%(95%CI 87.8-94.1). Anti-reflux procedures significantly improve gastroesophageal-related cough and other reflux symptoms. These findings support the use of anti-reflux procedures as a viable treatment option for patients with GERD symptoms. Further research is needed to identify predictors of success and to optimize patient selection for anti-reflux procedures.

EndoFLIP Use in De Novo and Revisional Foregut Surgery

AbstractEndoFLIP technology, utilizing impedance planimetry, has revolutionized the assessment of gastrointestinal sphincters by providing real-time measurements of cross-sectional area and pressure to calculate distensibility. This review explores its application in de novo and revisional foregut surgeries. Preoperatively, EndoFLIP has demonstrated efficacy in evaluating gastroesophageal reflux disease, hiatal hernia, and esophageal motility disorders, including achalasia, by distinguishing motility patterns and identifying sphincter incompetence. In gastroparesis, EndoFLIP's measurement of pyloric distensibility correlates with gastric emptying and symptom severity, guiding therapeutic decisions for pyloric interventions. Intraoperatively, EndoFLIP optimizes surgical outcomes in antireflux procedures, such as fundoplication and hiatal hernia repairs, by balancing effective reflux control with minimizing postoperative complications like dysphagia and gas bloat. For esophageal myotomy, including Heller myotomy and per oral endoscopic myotomy, EndoFLIP ensures adequate sphincter relaxation, reducing reflux risks. Additionally, during endoscopic pyloromyotomy for gastroparesis, EndoFLIP predicts clinical success by assessing postprocedural distensibility. While promising, further research is essential to establish standardized intraoperative protocols and ideal measurement targets, enhancing the reproducibility and accuracy of EndoFLIP applications. Overall, EndoFLIP offers a significant advancement in foregut surgery, improving diagnostic precision and therapeutic outcomes.

Antireflux Procedures in Children With Neurologic Impairment: A National Survey of Physician Perspectives.

Decision-making about antireflux procedures (ARPs) to treat gastroesophageal reflux disease in children with neurologic impairment and gastrostomy tubes is challenging and likely influenced by physicians' experience and perspectives. This study will explore physician attitudes about ARPs and determine if there are relationships to clinical practice and personal characteristics. This is a national observational cross-sectional study that used an electronic questionnaire addressing reported practice, attitudes regarding the ARPs, and responses to clinical vignettes. Participants were physicians in Canadian tertiary-care pediatric settings. Descriptive statistics were used to analyze physician attitudes. Multivariable logistic regression modeling was used to determine associations between physician and practice characteristics and likelihood to consider ARP. Eighty three respondents represented 12 institutions, with a majority from general or complex care pediatrics. There was a wide disparity between likelihood to consider ARP in each clinical scenario. Likelihood to consider ARP ranged from to 19% to 78% depending on the scenario. Two scenarios were equally split in whether the respondent would offer an ARP. None of the demographic characteristics were significantly associated with likelihood to consider ARP. Often, gastrojejunostomy tubes alone were considered (56% to 68%). There is considerable variability in physician attitudes toward and recommendations regarding ARPs to treat gastroesophageal reflux disease. We did not find a significant association with clinical experience or location of practice. More research is needed to define indications and outcomes for ARPs. This is a scenario where shared decision-making, bringing together physician and family knowledge and expertise, is likely the best course of action.

Gas and Bloat in Female Patients after Antireflux Procedures: Analysis of 934 Cases.

Antireflux procedures (ARPs) are effective treatments for GERD. However, variation in objective and patient-reported outcomes persists. Limited evidence and anecdotal experience suggest that patient sex may play a role. The objective of this study was to compare outcomes after ARPs between male and female patients. We performed a retrospective review of a prospectively maintained database at a single institution. All patients who underwent an ARP for GERD were included. Demographic, clinical, and patient-reported outcomes data (GERD health-related quality of life [HRQL] and reflux symptom index), and radiographic hernia recurrence were collected and stratified by sex. Univariable and multivariable logistic and mixed-effects linear regression were used to control for confounding effects. Between 2009 and 2022, 934 patients (291 men and 643 women) underwent an ARP. Reflux symptom index, GERD-HRQL, and gas and bloat scores improved uniformly for both sexes, though female patients were more likely to have higher gas and bloat scores 1 year postprocedure (mean ± SD 1.7 ± 1.4 vs 1.4 ± 1.3, p = 0.03) and higher GERD-HRQL scores 2 years postprocedure (6.3 ± 8.1 vs 4.7 ± 6.8, p = 0.04). Higher gas and bloat scores in women persisted on regression controlling for confounders. Hernia recurrence rate was low (85 patients, 9%) and was similar for both sexes. A final intraprocedural distensibility index 3 mm 2 /mmHg or more was significantly associated with a 7 times higher rate of recurrence (95% CI 1.62 to 31.22, p = 0.01). Although patients of either sex experience symptom improvement and low rate of recurrence after ARPs, women are more likely to endorse gas and bloat compared with men. Final distensibility index 3 mm 2 /mmHg or more carries a high risk of recurrence. These results may augment how physicians prognosticate during consultation and tailor their treatment in patients with GERD.

Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes.

Anti-reflux operations are effective treatments for GERD. Despite standardized surgical techniques, variability in post-operative outcomes persists. Most patients with GERD possess one or more characteristics that augment their disease and may affect post-operative outcomes-a GERD "phenotype". We sought to define these phenotypes and to compare their post-operative outcomes. We performed a retrospective review of a prospective gastroesophageal database at our institution, selecting all patients who underwent an anti-reflux procedure for GERD. Patients were grouped into different phenotypes based on the presence of four characteristics known to play a role in GERD: hiatal or paraesophageal hernia (PEH), hypotensive LES, esophageal dysmotility, delayed gastric emptying (DGE), and obesity. Patient-reported outcomes (GERD-HRQL, dysphagia, and reflux symptom index (RSI) scores) were compared across phenotypes using the Wilcoxon rank-sum test. 690 patients underwent an anti-reflux procedure between 2008 and 2022. Most patients underwent a Nissen fundoplication (302, 54%), followed by a Toupet or Dor fundoplication (205, 37%). Twelve distinct phenotypes emerged. Non-obese patients with normal esophageal motility, normotensive LES, no DGE, with a PEH represented the most common phenotype (134, 24%). The phenotype with the best post-operative GERD-HRQL scores at one year was defined by obesity, hypotensive LES, and PEH, while the phenotype with the worst scores was defined by obesity, ineffective motility, and PEH (1.5 ± 2.4 vs 9.8 ± 11.4, p = 0.010). There was no statistically significant difference in GERD-HRQL, dysphagia, or RSI scores between phenotypes after five years. We have identified distinct phenotypes based on common GERD-associated patient characteristics. With further study these phenotypes may aid surgeons in prognosticating outcomes to individual patients considering an anti-reflux procedure.

Toupet fundoplication to prevent progression of scleroderma-associated interstitial lung damage: a study protocol

Summary Background Systemic sclerosis (SSc) is a rare autoimmune and multiorgan disorder. Hallmarks of the disease include inflammation, endothelial dysfunction, and dysregulation of fibroblasts leading to fibrosis of the skin and internal organs. The esophagus is often involved, with up to 80% of patients developing gastroesophageal reflux disease (GERD). Reflux can be associated with hiatal hernia and several complications such as erosive esophagitis, peptic stricture, Barrett’s esophagus, aspiration pneumonia, and chronic microaspiration. Silent aspiration can lead to interstitial lung disease (ILD) in up to 50% of patients with scleroderma and accounts for up to 40% of mortality. Treatment of GERD in patients with SSc is challenging. Proton pump inhibitors (PPI) have been shown effective in relieving typical GERD symptoms, but up to 40% of patients are non-responders. Various antireflux surgical procedures have been proposed to treat GERD and to modify the natural course of the disease by preventing lung damage in these patients. However, current algorithms consider only the degree of esophageal dilation as a marker of disease severity/progression, and results of antireflux surgery remain controversial. Methods We propose a feasibility, observational, multicenter, single-arm trial including adult patients diagnosed with SSc. Criteria for inclusion are individuals with GERD symptoms refractory to PPI, absence of peptic stricture at baseline endoscopy, high-resolution computed tomography (HRCT) scan showing no or less than 10% lung fibrosis, forced vital capacity at least 40% of the predicted value, and diffusing capacity of lung for carbon monoxide 30–89% of the predicted value. A laparoscopic partial posterior fundoplication according to the Toupet technique will be performed. Primary study outcome is the efficacy of fundoplication to reduce reflux exposure measured with a pH-impedance study or 4‑day wireless pH recording. Secondary outcomes include endoscopic, HRCT, and respiratory function tests findings as well as quality of life at 12-month follow-up. Conclusions The expected reduction of reflux burden in SSc patients selected for Toupet fundoplication may improve GERD symptoms/complications, pulmonary function, and quality of life, and may be associated with a reduced risk for lung transplant.

The Role of High-Resolution Manometry Prior to and Following Antireflux Surgery: The Padova Consensus.

In the last two decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiologic information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision making. A multi-disciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre- and post- ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM prior to ARS and the role of HRM following ARS. This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre- and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.