Antireflux Procedure Research Articles

The Art of Sleeve Gastrectomy.

Sleeve gastrectomy (SG) has historically evolved from gastroplasty and anti-reflux procedures into one of the most commonly performed primary metabolic surgeries in the United States and worldwide. Initially initiated in the 1980s as part of the duodenal switch procedure, its standalone effectiveness and simplicity have led to increasing popularity globally. The rise in obesity rates transcends age boundaries, alarmingly affecting not only adults but also the younger demographic. This escalating trend is concerning, as it predisposes these populations to numerous future health complications, as well as highlighting the critical necessity for a safe and potent weight loss strategy. Although sleeve gastrectomy carries a higher risk for gastroesophageal reflux disease (GERD) compared to other bariatric procedures, it stands out as a reliable, safe and effective surgical solution for obesity. It is particularly beneficial for adolescents and patients with complex medical comorbidities, including, but not limited to, heart failure and immunocompromisation. It has also served as a bridge for transplants in morbidly obese patients with end-stage heart, liver and kidney disease due to its favorable safety profile.

Perioperative outcomes of the surgical management of achalasia in two tertiary Cameroonian hospitals: a cohort study

IntroductionAchalasia is a rare esophageal disease with potentially lethal complications. Knowledge of the outcomes of the different surgical treatment modalities for achalasia by Heller’s cardiomyotomy (HCM) helps to choose the safest and most effective option. However, data on the management of achalsia using a Heller myotomy is limited in Africa. Thus, our aim was to determine the perioperative morbidity, mortality and short-term functional outcomes of HCM in Cameroon.MethodologyWe conducted a cohort study throughout a 10-year chart review of patients who underwent HCM for achalasia and were followed up postoperatively for at least three months at two tertiary health centers in Cameroon. We analyzed demographic data, preoperative clinical and imaging data, treatment details, and outcomes at three to twelve months after HCM using the Eckardt score.ResultsWe enrolled 29 patients with achalasia having a mean age of 24 ± 16 years and predominantly females (M/F of 1/3.8). The mean symptom duration was 51 ± 20 months. In 80% of cases, the diagnosis was made through a conventional x-ray contrast imaging or “barium swallow test” (93%) and/or an upper gastrointestinal endoscopy (86%). The gold standard diagnostic method via esophageal manometry was unavailable. Preoperatievly, all patients had symptoms suggestive of an active achalasia. HCM was performed via laparotomy in 75% as opposed to 25% laparoscopic HCM procedures. Dor’s anterior partial fundoplication was the main anti-reflux procedure performed (59%). Mucosal perforations were the only intraoperative complications in eight patients (2 during laparoscopy vs. 6 during laparotomy; p > 0.5) and were managed successfully by simple sutures. Postoperative complications were non-severe and occurred in 10% of patients all operated via laparotomy. The mean postoperative length of hospital stay was 7 ± 3 days for laparotomy vs. 5 ± 2 days for laparoscopy; p > 0.5. The perioperative mortality rate was nil. Overall, the short-term postoperative functional outcome was rated excellent; average Eckardt score of 1.5 ± 0.5 (vs. preoperative Eckardt Score of 9 ± 1; p < 0.0001).ConclusionAchalasia is diagnosed late in this resource-limited setting. HCM yields satisfactory outcomes, especially via laparoscopic management. An improvement in diagnostic esophageal manometry and mini-invasive surgical infrastructure and the required surgical training/skills are needed for optimal achalasia care.

Enhanced recovery after surgery may mitigate the risks associated with robotic-assisted fundoplication in lung transplant patients.

A history of lung transplantation is a risk factor for poor outcomes in patients undergoing laparoscopic fundoplication. We wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks. We performed a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures from 1/2018 to 2/2021 under the enhanced recovery after surgery program using robotic assistance. We identified the patient and surgical characteristics, morbidity, length of stay, and 30-day readmission rates. Among 386 patients who underwent barrier creation, 41 had previously undergone a lung transplant, either bilateral (n = 28) or single (n = 13). There were no significant differences in postoperative complications (9.8% vs. 5.2%, p = 0.27), median hospital length of stay (1 d vs. 1 d, p = 0.28), or 30-day readmission (7.3% vs. 4.9%, p = 0.46). Bivariate analysis showed that older age (p = 0.03), history of DVT/PE (p < 0.001), history of cerebrovascular events (p = 0.03), opioid dependence (p = 0.02), neurocognitive dysfunction (p < 0.001), and dependent functional status (p = 0.02) were associated with postoperative complications. However, lung transplantation was not associated with an increased risk of postoperative complications (p = 0.28). The risk of surgical complications in patients with a history of lung transplantation may be mitigated by the combination of ERAS and minimally invasive surgery such as robot-assisted surgery.

Laparoscopic proximal sleeve gastrectomy as an alternative for management of giant hiatal hernias

Background and aim: Large anatomic defects of the diaphragmatic hiatus known as giant hiatal hernias could be associated with reflux esophagitis disease (GERD) and other life-threatening complications such as gastric volvulus, ischemia and perforation, thus surgical repair is warranted. Although usually the key steps to surgical repair are reduction of the herniated stomach, complete excision of the sac, hiatus repair, and an antireflux procedure, surgery in these cases is associated with a great rate of anatomic and functional failure, therefore different techniques have been described since the original description of Collis gastroplasty designed to lengthen the short esophagus. Methods: We report here the technique and results performing proximal vertical gastrectomy or proximal sleeve gastrectomy (PSG) as an alternative in cases in which the possibility of recurrence of the hiatal hernia (HH) is high. Results: After years of follow-up after surgery, all the case patients presented here are free of gastroesophageal reflux or dysphagia symptoms, with no necessity for acid suppression medication, and no side effects of the surgery. Conclusion: The treatment of giant HH is a complex and challenging disorder to treat. PSG seems to be a good surgical alternative for the treatment of some special cases of giant HH minimizing the GERD symptoms and possible recurrences.

Short term safety of magnetic sphincter augmentation vs minimally invasive fundoplication: an ACS-NSQIP analysis

PurposeMagnetic Sphincter Augmentation (MSA) is an FDA-approved anti-reflux procedure with comparable outcomes to fundoplication. However, most data regarding its use are limited to single or small multicenter studies which may limit the generalizability of its efficacy. The purpose of this study is to evaluate the outcomes of patients undergoing MSA vs fundoplication in a national database.Materials and MethodsThe 2017–2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Registry was utilized to evaluate patients undergoing MSA or fundoplication. Patients requiring Collis gastroplasty, paraesophageal hernia repair, and emergency cases, were excluded. Patient outcomes included overall complication rates, readmissions, reoperations, and mortality.ResultsA total of 7,882 patients underwent MSA (n = 597) or fundoplication (n = 7285). MSA patients were younger (51 vs 57, p < 0.001), and more often male (49.6 vs 34.3%, p < 0.001). While patients undergoing MSA experienced similar rates of reoperation (1.0 vs 2.0%, p = 0.095), they experienced fewer readmissions (2.2 vs 4.7%, p = 0.005), complications (0.6 vs 4.0%, p < 0.001), shorter mean (SD) hospital length of stay(days) (0.4 ± 4.3 vs 1.8 ± 4.6, p < 0.001) and operative time(min) (80.8 ± 36.1 vs 118.7 ± 63.7, p < 0.001). Mortality was similar between groups (0 vs 0.3%, p = 0.175). On multivariable analysis, MSA was independently associated with reduced postoperative complications (OR 0.23, CI 0.08 to 0.61, p = 0.002), readmissions (OR 0.53, CI 0.30 to 0.94, p = 0.02), operative time (RC − 36.56, CI − 41.62 to − 31.49. p < 0.001) and length of stay (RC − 1.22, CI − 1.61 to − 0.84 p < 0.001).ConclusionIn this national database study, compared to fundoplication MSA was associated with reduced postoperative complications, fewer readmissions, and shorter operative time and hospital length of stay. While randomized trials are lacking between MSA and fundoplication, both institutional and national database studies continue to support the use of MSA as a safe anti-reflux operation.

Proton pump inhibitors in esophageal atresia: A systematic review and meta-analysis.

Gastroesophageal reflux disease (GERD) is frequent and prolonged in esophageal atresia (EA) pediatric patients requiring routine use of proton pump inhibitors (PPIs). However, there are still controversies on the prophylactic use of PPIs and the efficacy of PPIs on GERD and EA complications in this special condition. The aim of the study is to assess the prophylactic use of PPIs in pediatric patients with EAand its complications. We, therefore, performed a systematic review including all reports on the subject from 1980 to 2022. We conducted meta-analysis of the pooled proportion of PPI-and no PPI groups using random effect model, meta-regression, and estimate heterogeneity by heterogeneity index I2 . Thirty-eight reports on the topic met the criteria selection, representing a cumulative 6044 patients with EA. Prophylactic PPI prescription during the first year of life does not appear to prevent GERD persistence at follow-up and is not associated with a significantly reduced rate of antireflux surgical procedures (ARP). PPIs improve peptic esophagitis and induce remission of eosinophilic esophagitis at a rate of 50%. Their effect on other GERD outcomes is uncertain. Evidence suggests that PPIs do not prevent anastomotic stricture, Barrett's esophagus, or respiratory complications. PPI use in EA can improve peptic and eosinophilic esophagitis but is ineffective on the other EA complications. Side effects of PPIs in EA are almost unknown.

Prophylactic anti-reflux procedure for children undergoing laparoscopic gastrostomy: Rethinking of the routine practice.

Laparoscopic gastrostomy is a frequently performed procedure in children requiring long-term enteral nutrition. The role of prophylactic anti-reflux surgery during gastrostomy placements is controversial. The current study aims to evaluate the role of prophylactic anti-reflux procedures during gastrostomy placement. A retrospective single-center analysis of all children without reflux receiving laparoscopic gastrostomy from January 2005 through December 2021 was performed. Demographics and clinical outcomes were compared between patients receiving gastrostomy placement alone and patients receiving gastrostomy with prophylactic anti-reflux surgery. A total of 79 patients had a confirmed absence of reflux by a 24-h pH/impedance study before operation. Thirty-six of these patients underwent prophylactic anti-reflux surgery (PAR) while 43 received gastrostomy (PG) alone. The operative time and conversion rate were significantly higher in the PAR group (140.5±67.5 vs. 80.2±66.8min, p=0.0001 and 8.3% vs. 0%, p=0.04). There were no major complications in either group. De novo reflux was detected in five patients (11.6%) in the PG group. None of these patients progressed to require anti-reflux surgery. The occurrence of de novo reflux after laparoscopic gastrostomy was low and could be managed without anti-reflux surgery. A routine pre-operative pH study is helpful for appropriate patient selection to avoid unnecessary anti-reflux surgery, which lengthens operative time and increases the conversion rate.

Malpractice claims after antireflux surgery and paraesophageal hernia repair: a population-based analysis

BackgroundThe complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts.MethodsA population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register.ResultsDuring the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery.ConclusionsThe rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications.

Application of gastric plication in the treatment of obesity

Bariatric surgery, as the most effective approach to treating obesity at present, encompasses a wide array of procedures. However, due to the significant anatomical changes to the gastrointestinal tract caused by most of these procedures, they are associated with certain risks of complications. In the pursuit of minimizing trauma, bariatric surgeons have begun exploring new surgeries in addition to traditional procedures. Gastric plication surgeries encompass various procedures such as gastric fundoplication, gastric greater curvature plication, endoscopic sleeve gastroplasty, combined gastric fundoplication with gastric greater curvature plication, and combined gastric fundoplication with sleeve gastrectomy, among others. The efficacy and risks of complications associated with these procedures fall between those of medical therapy and sleeve gastrectomy. Gastric fundoplication, functioning as an anti-reflux procedure, can also be integrated into weight loss surgical interventions to effectively address obesity-related gastroesophageal reflux disease in obese patients. Both gastric greater curvature plication and endoscopic sleeve gastroplasty yield favorable weight loss outcomes. Beyond the impact of folding procedures on body mass, gastric plication surgeries can also be combined with other techniques. The combination of gastric fundoplication with sleeve gastrectomy or greater curvature plication can reduce body mass and mitigate reflux, while the combination of greater curvature plication with gastric bypass and similar procedures can further enhance weight loss and metabolic improvements.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review.

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

Current management of symptomatic vesicoureteral reflux in pediatric kidney transplantation-A European survey among surgical transplant professionals.

Vesicoureteral reflux (VUR) is common in children and adolescents undergoing kidney transplantation (KTx) and may adversely affect allograft kidney function. To explore the current management of symptomatic native and allograft VUR in pediatric KTx recipients, an online survey was distributed to European surgical transplant professionals. Surgeons from 40 pediatric KTx centers in 18 countries participated in this survey. Symptomatic native kidney VUR was treated before or during KTx by 68% of the centers (all/selected patients: 33%/67%; before/during KTx: 89%/11%), with a preference for endoscopic treatment (59%). At KTx, 90% favored an anti-reflux ureteral reimplantation procedure (extravesical/transvesical approach: 92%/8%; preferred extravesical technique: Lich-Gregoir [85%]). Management strategies for symptomatic allograft VUR included surgical repair (90%), continuous antibiotic prophylaxis (51%), bladder training (49%), or noninterventional surveillance (21%). Redo ureteral implantation and endoscopic intervention for allograft VUR were equally reported (51%/49%). This survey shows uniformity in some surgical aspects of the pediatric KTx procedure. However, with regard to VUR, there is a significant variation in practice patterns that need to be addressed by future well-designed and prospective studies. In this way, more robust data could be translated into consensus guidelines for a more standardized and evidence-based management of this common condition in pediatric KTx.

Effect of SASI procedure (Single Anastomosis Sleeve Ileal) on the symptoms of gastroesophageal reflux disease in bariatric patients - a review of the literature.

The problem of gastroesophageal reflux disease among bariatric patients is constantly growing. While bariatric surgery is the most effective method of treating obesity and related diseases, not all surgical procedures lead to improvement or resolution of gastroesophageal reflux disease. The search for the &quot;ideal&quot; surgical procedure for this group of patients is ongoing. The relatively recently introduced SASI procedure seems to have a beneficial effect on GERD symptoms and may be an alternative anti-reflux procedure in obese patients. The presented paper is a review of the latest literature on the impact of SASI procedure on the symptoms of gastroesophageal reflux disease.

Endoscopic anti-reflux mucosectomy (ARMS) and endoscopic anti-reflux ablation (ARMA) as a potential treatment for gastroesophageal reflux - preliminary report.

&lt;b&gt;&lt;br&gt;Introduction:&lt;/b&gt; Gastroesophageal reflux (GERD) is one of the most common disorders of the alimentary tract. Apart from troublesome symptoms, untreated GERD can lead to Barrett's esophagus and, as a consequence, esophageal adenocarcinoma. As for now, the most common treatment of GERD is PPI pharmacotherapy. However, in a number of cases, this treatment is not sufficient or the patient does not tolerate PPI-group drugs. In such cases, interventional therapy is recommended. So far, laparoscopic fundoplication has been the only suggested option. Other, minimally invasive procedures such as Stretta, MUSE, TIFF, or EsophyX were not recommended due to the lack of clinical data. In 2014, Professor H.Inoue from the Digestive Diseases Center, Showa University in Japan reported on the first series of novel, endoscopic, anti-reflux procedures: anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA).&lt;/br&gt; &lt;b&gt;&lt;br&gt;Methods:&lt;/b&gt; We conducted our prospective, single-center study in 30 patients (14 female, 16 male) with PPI-refractory GERD. All patients underwent FSSG and GERD-HRQL evaluation and GE junction pressure study prior, 6 weeks and 6 months after the procedures. After the procedure, all patients received PPI treatment for 4 weeks.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Results:&lt;/b&gt; We successfully completed the procedures in all 30 patients. The mean procedure time was 42 minutes. No complications occurred. In 86.67% (26) of our patients, we achieved total remission of GERD symptoms, FSSG scores &lt; 6 and GERD-HRQL scores &lt; 8.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Conclusions:&lt;/b&gt; The results of our study show that ARMS and ARMA are simple, safe, improve GERD-related symptoms, and restore the GE junction's anti-reflux capacity.&lt;/br&gt.

Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient: New surgical proposals

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Feasibility of Anti-reflux Gastric Bypass for Massive Paraesophageal Hernia in Obese Patients With Gastroesophageal Reflux Disease.

Background The objective of this study is to demonstrate the safety and feasibility of anti-reflux gastric bypass (ARGB) as a treatment for symptomatic massive paraesophageal hernias (PEH) in the obese population. Both gastroesophageal reflux disease (GERD) and PEH are particularly prevalent in the obese patient population, and obesity adversely affects the long-term outcomes of all anti-reflux procedures. Methods This is a single-center, retrospective reviewof 17 obese adults who underwent ARGB for the treatment of massive PEH between September 2019 and December 2021. Massive PEH was defined as >5 cm in a singular direction, and obesity as BMI ≥30 kg/m2. Patients without preoperative diagnostic testing were excluded. We reviewed and analyzed patient demographic data, postoperative symptom resolution, weight loss, and complications using descriptive statistics, change from baseline, and comparison of proportions. Results Sixteen of the 17 subjects were female. The median age was 48, and the median BMI was 39.10 kg/m2(30.0-49.3 kg/m2). The average PEH size on imaging was 6.48 (H) x 6.25 (W) cm. The resolution of heartburn was 93.8% (p<0.001), and the resolution of nausea and vomiting was 80.0%. The mean postoperative length of follow-up was 9.12 months. Median excess body weight loss percentages at one, three, six, and 12 months were 16.43% (p<0.001), 35.92% (p<0.001), 40.64% (p=0.001), and 58.58% (p<0.01), respectively. Five patients experienced adverse events requiring additional intervention or hospitalization. There were no symptomatic hernia recurrences or mortality. Conclusion This study demonstrates that ARGB is feasible and potentially effective in treating symptomatic massive paraesophageal hernias in the obese patient population. Further investigation is needed to determine efficacy and long-term outcomes compared to standard surgical repair.

149. LAPAROSCOPIC HELLER CARDIO-MYOTOMY IS NOT ALWAYS A SAFE OPERATION

Abstract Background Laparoscopic Heller cardio-myotomy is the standard surgical treatment of achalasia. Although POEM (Per-oral endoscopic myotomy) has gained wide acceptance among gastroenterologists, yet many surgeons are still loyal to this operation. One of the complications of the operation which could happen is esophageal or gastric perforation during the myotomy. Intra-operative detection of the perforation and meticulous repair is very important to prevent serious sequelae. Methods Between may 2021 and Jan 2023, 46 cases of achalasia (Type I and II) were treated by laparoscopic Heller cardio-myotomy and anti-reflux procedure (Dor or Toupet). Myotomy was performed using muscles splitting combined with either harmonic or hook diathermy. Intra-operative perforations were reported and were repaired in all cases and tested for absence of leakage. Post-operative follow up of cases having intraoperative perforations and its management were documented. For those having perforations postoperative gastrographin swallow and meal was done and oral fluids intake started second postoperative day. Results Perforations occurred in 11 cases (24%) and were repaired using 3 l0 suture: monofilament non-absorbable suture: prolene (polypropyelene, J&amp;J MedTech) in 4 cases, monofilament absorbable suture monocryl (poliglecaprone 25, J&amp;J MedTech) in 3 cases and vicryl (polyglactin 910, J&amp;J MedTech) in 4 cases. Smooth post-operative recovery was noted in 7 cases having perforations (64%). Four patients (36%) developed Leakage second postoperative day confirmed by investigations. All these cases were repaired with Vicryl. Endoscopic stent was inserted with improvement of the condition in 3 cases (75%). One patient required reoperations twice and expired in the 29th day postoperative from ARDS. Conclusion Although perforations could happen during laparoscopic Heller cardio-myotomy, it has a benign postoperative course in most cases. This doesn’t mean that it is a simple operation. Laparoscopic Heller cardio-myotomy should be done in highly specialized esophageal center because its complications could lead to death if badly managed.

341 Safe and Effective Delivery of Anti-Reflux Surgical Standards at a District General Hospital

Abstract Aim Up to 20% of adults in UK suffer from Gastro-oesophageal Reflux Disease (GORD). Surgery offers better short-to-medium term benefit compared to sole medical management. However, practice varies significantly nationwide. The volume of cases performed in our district general hospital (DGH) has increased from one in 2015, to 24 in 2022. We aimed to establish feasibility and safety of laparoscopic anti-reflux surgery (LARS) at a DGH, by matching our outcomes with the AUGIS national standards. Method Data from patients undergoing LARS between January - December 2022 have been collected prospectively and recorded both locally and on National Hiatal Surgery Register (NHSR). Pre-operative symptoms and investigations, intraoperative findings and post-operative short and medium-term outcomes were analysed. Average follow up was 6 weeks. Results 24 laparoscopic anti-reflux procedures were performed (21 Nissen and 3 Toupet), including 6 paraoesophageal hernia repairs. All patients underwent primary repair and fundoplication. Average length of hiatus hernia preoperatively was 4.1cm for sliding, and 7.6cm for para oesophageal. 23/24 patients were inpatients, 1 was a day case. Mean length of stay was 4 days. Conversion to open rate was 0%. 22 patients had no complications. One patient experienced a mediastinal collection, another patient had post-operative hypotension, both not requiring intervention (Clavien-Dindo 2). 30-day return to theatre rate was 0%, as was 30-day readmission rate. Conclusions At our DGH, we significantly increased the volume of LARS performed whilst achieving AUGIS national standards. Anti-reflux surgery can be offered safely and effectively by experienced laparoscopic Upper GI surgeons in a DGH.

WTP5.9 Does anti-reflux surgery offer durable symptom remission in a tertiary centre?

Abstract Aims Anti-reflux surgery success can be affected by multiple factors. We sought to evaluate pre-operative and technical factors influencing medium-term outcomes. Methods A retrospective analysis of laparoscopic anti-reflux surgery in a tertiary centre between 2016 and 2019. Patients were identified through clinical coding. Electronic patient records were reviewed with minimum follow up of 3 years. Outcomes analysed included pre-operative work-up, type of fundoplication, remission and relapse of symptoms at follow up and revision surgery. Results 104 patients underwent fundoplication. The majority were Nissen 68 (65%) and the remaining were partial wrap configuration.18 (19%) of these patients were revisional anti-reflux procedures. Pre-operative investigations noted most underwent endoscopy 85 (81.7%) and oesophageal physiology in 74 (71.2%) with barium swallow in 34 (32.7%). 15/104 (14%) underwent all three studies. 50 (48.1%) patients were symptomatic at initial follow up with dysphagia (21.3%) and dyspepsia (13.5%) most prevalent. Of these 104 patients, 15 (14.4%) required revisional surgery. 6/36 (17%) partial and 9/68 Nissen (13.2%) fundoplications underwent re-operation. Timing of revision varied: 8 (53.3%) within one year including early 30-day re-operation for complications. 3 (20%) at 1-3years and 4 (26.7%) after 3 years. Subsequent revision rate was higher for revisional patients: 4/18 (22.2%) compared to primary 11/86 (12.7%). Conclusion Almost half of the patients had at least one symptom at initial follow up, however only 14.4% patients required revisional surgery by 3 years follow up. Partial fundoplication and previous fundoplication surgery had higher revision surgery rates.

Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD.

Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35kg/m2 and 30kg/m2 respectively ascutoff for the RYGB. 89% viewedRYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary tofailed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGBfor GERD indications in their patient populations. For many patients,GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.

Laparoscopic Toupet fundoplication: a safe and effective anti-reflux option in lung transplant recipients.

Fundoplication is known to improve allograft outcomes in lung transplant recipients by reducing retrograde aspiration secondary to gastroesophageal reflux disease, a modifiable risk factor for chronic allograft dysfunction. Laparoscopic Nissen fundoplication has historically been the anti-reflux procedure of choice, but the procedure is associated with discernable rates of postoperative dysphagia and gas-bloat syndrome. Laparoscopic Toupet fundoplication, an alternate anti-reflux surgery with lower rates of foregut complications in the general population, is the procedure of choice on our institution's lung transplant protocol. In this work, we evaluated the efficacy and safety of laparoscopic Toupet fundoplication in our lung transplant recipients. A prospective case series of 44 lung transplant recipients who underwent laparoscopic Toupet fundoplication by a single surgeon between September 2018 and November 2020 was performed. Preoperative and postoperative results from 24-h pH, esophageal manometry, gastric emptying, and pulmonary function studies were collected alongside severity of gastroesophageal reflux disease and other gastrointestinal symptoms. Median DeMeester score decreased from 25.9 to 5.4 after fundoplication (p < 0.0001), while percentage of time pH < 4 decreased from 7 to 1.1% (p < 0.0001). The severity of heartburn and regurgitation were also reduced (p < 0.0001 and p = 0.0029 respectively). Overall, pulmonary function, esophageal motility, gastric emptying, severity of bloating, and dysphagia were not significantly different post-fundoplication than pre-fundoplication. Patients with decreasing rates of FEV1 pre-fundoplication saw improvement in their rate of change of FEV1 post-fundoplication (p = 0.011). Median follow-up was 32.2months post-fundoplication. Laparoscopic Toupet fundoplication provides objective pathologic acid reflux control and symptomatic gastroesophageal reflux improvement in lung transplant recipients while preserving lung function and foregut motility. Thus, laparoscopic Toupet fundoplication is a safe and effective antireflux surgery alternative in lung transplant recipients.