Antireflux Procedure Research Articles

A comparison of the effects of anti-reflux procedures during esophagogastrostomy after proximal gastrectomy on the postoperative quality of life.

To investigate the postoperative quality of life (QOL) in patients with proximal gastric cancer (PGC) or esophago-gastric junction cancer, a nationwide multi-institutional study (PGSAS NEXT trial) was conducted. Patients who had undergone radical resection more than 6months previously were enrolled from 70 Japanese institutions between July 2018 and June 2020. The Postgastrectomy Syndrome Assessment Scale (PGSAS)-45 questionnaire was distributed to eligible patients, and responses were collected by mail. The main outcome measures of the PGSAS-45 were then calculated and compared. Questionnaires were retrieved from 1950 participants, and data from 300 patients who had undergone a proximal gastrectomy (PG) with esophagogastrostomy for PGC were analyzed. The mean esophageal reflux subscale value was 1.9 among the 276 patients who underwent an anti-reflux procedure, which was significantly better than the mean value (2.6) for the 21 patients who did not undergo an anti-reflux procedure (p = 0.002). The esophageal reflux subscale values were also compared among 3 major anti-reflux procedures: the double-flap technique (N = 153), the pseudo-fornix and/or His angle formation (N = 67), and fundoplication (N = 44); no statistically significant differences were observed. An anti-reflux procedure during esophagogastrostomy after PG for PGC is necessary to improve postoperative esophageal reflux symptoms, regardless of the type of procedure. The PGSAS NEXT study was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; registration number: 000032221).

Robotic Transgastric Reconstruction of the Double Lumen Esophagus

Double lumen esophagus is an extremely rare condition, developing in most cases as a complication of antireflux procedures or gastroesophageal reflux itself secondary to the severe inflammatory process in and around the lower esophagus. We describe a case of iatrogenic double lumen esophagus after multiple previous Nissen fundoplications for chronic gastroesophageal reflux disease. There is no standard surgical intervention for the management of this complication. We present a first report of successful robot-assisted surgical reconstruction of a double lumen esophagus.

Exploring the paradigm of robotic surgery and its contribution to the growth of surgical volume

BackgroundRobotic surgery is an appealing option for both surgeons and patients. The question around the introduction of new surgical technology, such as robotics, with the potential link to increased procedure-specific volume has not been addressed. We hypothesize that hospital adoption of robotic technology increases the total volume of specific procedures as compared to nonrobotic hospitals. MethodsThe 2010–2020 Florida Agency for Health Care Administration Inpatient database was queried for open, laparoscopic, and robotic colectomy, lobectomy, gastric bypass, and antireflux procedures. International Classification of Diseases, 9th and 10th Revisions, codes were used. Difference in difference method was used to evaluate the impact of robotics on total procedure-specific volume of robotic hospitals versus nonrobotic hospitals before and after adopting robotic technology. Incident rate ratios from the difference in difference analysis determined the significance of adding robotics. Patient demographics were evaluated using χ2 test. ResultsA total of 291,826 procedures were performed at 217 hospitals, 151 with robotic capabilities. Robotic hospitals experienced a 37% increase in surgical volume due to robotic technology (incident rate ratio 1.37, P < .05), which was consistent for each surgery except antireflux procedures (incident rate ratio 0.95). Robotic procedures had significantly higher charges for medical/surgical supplies; however, the mean length of stay for robotic procedures was significantly shorter than that of laparoscopic and open cases. ConclusionHospital adoption of robotic technology significantly increases surgical volume for select procedures. Hospitals should consider the benefits of introducing robotic technology which leads to higher volume and decreased length of stay, benefitting both hospital systems and patients.

POS0895 THE ROLE OF SURGERY IN THE ESOPHAGEAL INVOLVEMENT IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

BackgroundAmong gastrointestinal (GI) manifestations in Systemic Sclerosis (SSc) one of the predominant and challenging problems is gastroesophageal reflux disease (GERD), which occurs in ~75% of patients. Although proton pump inhibitors are useful, they are ineffective in 40% of cases with chronic use at high doses, against the background of long-term risks (e.g., cardiovascular disease and infections) which have been identified in the general population. Surgery might be an option following failure of medical therapy but currently, there is no consensus regarding the optimal surgical procedure for refractory GERD in SSc.ObjectivesTo evaluate, among the surgical approaches to GERD, the feasibility of fundoplication (FP) with regards to its safety, efficacy, indications, and timing.MethodsFour research questions based on the PICO framework were developed to guide the systematic literature review that was conducted up to 22 December 2021. The search and performed across different databases including PubMed, MEDLINE (OVID), EMBASE, Cochrane Library, Web of Science, Google Scholar, Emcare and Academic Search Premier. References were independently screened by two reviewers (PMC and AA) who also independently assessed the full text of eligible articles, and extracted data. Due to heterogeneity of retrieved studies, narrative summaries are used to present the data.ResultsThe search yielded 916 papers of which 30 were eligible for full text review. In these studies, out of 2919 clinically heterogeneous patients, 348 SSc patients were identified (mostly female, mean age 52.7 years). Out of these 348, only 257 underwent anti-reflux surgical procedure and were included in the analysis. Most of the studies were conducted in surgical settings and relevant rheumatological data were largely missing. Refractory GERD symptoms, were the commonest indication for surgery, with post-operative dysphagia being the most frequent complication. In 18 studies, FP was effective, whereas 4 studies had equivocal findings and in 5 a lack of efficacy was reported. The Collis-Nissen FP was the most popular procedure overall as well as in earlier studies, followed by Nissen FP, and Dor FP in relatively more recent studies, reflecting the change in surgical strategy over time. The data extracted shows also an acceptable rate of mortality and morbidity related to surgery, and heterogeneous outcome measures were used hampering any comparison of the studies (Table 1). Due to the heterogeneity of the data, it was not possible to separate the mortality and morbidity rate of SSc patients from the rest of the population.Table 1.GERD ASSESSMENT AND SURGICAL OUTCOMESDomain assessed/outcomeInstrument/MeasurementN° of studiesReflux severityDysphagia: 20Number of antireflux medications: 10High dose PPI: 9pH monitoring (pre-procedure): 11Oesophagitis/Barret 4Reflux improvement (post-procedure)Symptom resolution/reduction 24pH monitoring 12Repeat EGDS 8N° of patientsN° of surgical proceduresTotSSc 257Collis-Nissen FP 54Nissen FP 39Dor FP 37Collis-Belsey FP 20Toupet FP 18RYGB 23Others 30Undefined 36Post-operative surgical complications73 (2,5%)*Mortality (n° deaths)8 (0,27%)**rate in total population (2919)ConclusionOur SLR has highlighted that the surgical management of GERD in SSc patients is still highly challenging since the available evidence is scarce and of poor quality. Among the surgical approaches to the problem of GERD, overall FP seems a safe and effective procedure in SSc. Transient post-operative dysphagia was noted in many studies, particularly related with the posterior FP. In the future, it will be necessary to develop minimal requirement to conduct surgical studies in SSc as well as to design studies aimed at defining the clinical criteria for referral to surgery. Indeed, the right timing for surgery and the best surgical procedure in SSc still remains an unmet need.Disclosure of InterestsNone declared

To Wrap or Not? Utility of Anti-reflux Procedure in Infants Needing Gastrostomy Tubes.

PurposeGastrostomy tube (GT) insertion is commonly performed in children with failure to thrive. Pediatric patients' frequently have gastroesophageal reflux (GER) and discerning pathological GER can be challenging. Moreover, there is some evidence that GT insertion may lead to worsening GER and to avoid a subsequent anti-reflux procedure (ARP), though controversial some surgeons advocate considering an ARP concomitantly. The purpose of this report is to assess outcomes in infants who underwent a GT vs. GT with ARP.MethodsRetrospective review of all infants who had a GT placed at a single institution from 2009–2014. The patients were then divided into two cohorts based on the index operation i.e., GT vs GT with ARP and outcomes compared.Results226 operations (104 GT, 122 GT with ARP) were performed. The cohorts were similar in gender, gestational age, race, weight, median age, LOS, and proportion of neurologically impaired patients. Preoperative GER was significantly higher in the GT with ARP cohort (91 vs. 18%). No difference in the rate of immediate complications was noted between the two groups. Postoperative increase in anti-reflux medications was significantly higher in the GT cohort (p = 0.01). Post-op GER needing a secondary procedure (ARP or GJ tube) was noted in 21/104 (20%) patients. Those needing an additional procedure vs. those with GT alone were similar in the proportion of patients with pre-op GER, neurologic impairment, type of feeds, and age.ConclusionIdentifying patients who would benefit from a concomitant ARP remains challenging. A fifth of GT patients needed a subsequent procedure despite most high-risk patients having already undergone an ARP. Since the overall rate of complications remained similar, initial GT approach can be considered reasonable.

Evaluation of Antireflux Mucosectomy for Severe Gastroesophageal Reflux Disease: Medium-Term Results of a Pilot Study.

Background Antireflux mucosectomy, a new endoscopic treatment for gastroesophageal reflux disease, consists of endoscopic mucosal resection at the esophagogastric junction. This study aim was to evaluate the medium-term efficacy of the antireflux mucosectomy technique for patients with severe gastroesophageal reflux disease symptoms (proton pump inhibitor treatment-dependent or proton pump inhibitor treatment-resistant gastroesophageal reflux disease). Methods Between January 2017 and June 2018, 13 patients with severe gastroesophageal reflux disease without hiatal hernia, with positive pH reflux, were included in this monocentric prospective pilot study. The primary outcome was clinical success, defined by improvement evaluated by the Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire at 24 months. Secondary outcomes were technical success, decreased use of proton pump inhibitors, patient satisfaction, and adverse events. Results Thirteen patients [females = 8 (62%)], mean age 59 (range, 54-68), were included. The antireflux mucosectomy procedure had technical success in all patients. At 24 months, for 11 patients, gastroesophageal reflux disease symptoms were significantly improved, and mean gastroesophageal reflux disease score decreased from 33 (range, 26-42) to 3 (range, 0-7) (p = 0.001). Ninety-one percent (n = 10) of patients had a lower proton pump inhibitor intake at 24 months. One patient had 3 endoscopic balloon dilatations for EGJ stenosis, two patients had melena ten days after procedure, and seven patients had thoracic or abdominal pain. Patient's satisfaction at 24 months was 81%. Conclusions In patients with severe gastroesophageal reflux disease, despite occurrence of several short-term adverse events, antireflux mucosectomy seemed effective in improving gastroesophageal reflux disease symptoms at 24 months. This trial is registered with ClinicalTrials: NCT03357809.

ЛАПАРОСКОПИЧЕСКАЯ ФУНДОПЛИКАЦИЯ НИССЕНА У НЕДОНОШЕННЫХ ДЕТЕЙ, НАХОДЯЩИХСЯ В УСЛОВИЯХ ПАЛАТЫ ИНТЕНСИВНОЙ ТЕРАПИИ

The present study focuses on registration of early postoperative changes based on a comparison of the clinical parameters of respiratory and nutritional support after laparoscopic Nissen fundoplication in premature infants in an intensive care unit. Materials and methods of research: a retrospective continuous single-center study was carried out. In the course of the study, the medical records of all infants with a body weight of less than 2500 g and gestational age less than 37 weeks, who underwent laparoscopic antireflux procedures, were studied for the period from January 2012 to December 2019. 25 patients met this criteria, 12 (48%) of which were female and 13 (52%) were male. Standard laparoscopic procedure was Nissen fundoplication. At the final stage of the study, perioperative data and complications that occurred in the early and longterm follow-up period were studied. Results: the average weight of patients was 1560.0±450.4 g (median 1600.0 [1200.0; 1950.0] g). Infants with gastroesophageal reflux were on various modes of respiratory therapy: 50% – mechanical ventilation (MV), 50% – oxygen therapy. The average duration of operation was 35.4±8.2 min (median 35.0 [30.0; 40.0] min). The average daily weight gain before and after surgery, measured during the first 28 days after surgery, was 15.3±2.1 g/day, respectively (median 15.0 [14.0; 16.0] g/day) and 24.9±1.8 g/day (median 25.0 [24.0; 26.0] g/day) (p&lt;0.001). The assessment of the severity of lung disease based on the determination of the concentration of O2 in the inhaled mixture (FiO2) before surgery and 7 days after it, a statistically significant (p&lt;0.001) decrease in the child's body oxygen demand for adequate gas exchange from 34.4±3,9% (median 35.0 [30.0; 37.5]%) to 23.1±3.4% (median 21.0 [21.0; 25.0]%). The need for invasive MV significantly decreased from 68 [47; 85]% up to 20 [7; 41]% (p&lt;0.001), in noninvasive MV – from 32 [15; 54]% up to 20 [7; 41]%, but this decrease was statistically insignificant (p=0.084). The ability to breathe spontaneously appeared in 60% of patients (0 [0; 14]% versus 60 [39; 79]%; p=0.002). Postoperative complications included recurrent reflux was in one patient (4 [0; 20]%), which required repeated fundoplication in the long-term follow-up period. Conclusions: thus, laparoscopic antireflux surgery is possible in premature infants. These surgical procedures are well tolerated by infants and can improve their quality of life.

Anti-reflux surgical treatment for Barrett’s oesophagus

The aim of the study. To improve the effectiveness of surgical treatment for patients with hiatal hernia (HH) and gastro-esophageal reflux disease (GERD) in combination with Barrett’s esophagus by developing a new method for surgical correction of the physiological cardia incompetence. Materials and methods. The study was conducted in the Department of Digestive Surgery of the State Institution “Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine” in 2020–2021 and involved 56 patients with HH and GERD, among them axial HH was detected in 42 patients (75.0 %) – type I; paraesophageal HH – in 6 patients (10.7 %) – type II; mixed HH – in 8 patients (14.3 %) – type III (code ICD-10 – K44). The diagnosis was established using esophagogastroduodenoscopy (by high-resolution NBI mode), X-ray and histological examinations, manometry. Results. When the diagnosis of HH in combination with Barrett’s esophagus was confirmed, a two-stage treatment was performed. During the first stage, argonoplasmic coagulation of the altered esophageal mucosa was done. Anti-reflux procedures constituted the second stage to remove HH and restore an excessive dilatation of the esophageal orifice of the diaphragm by cruroraphy with correction of anti-reflux function of the cardia by fundoplication, angle of His reconstruction and providing free food passage. 11 (19.6 %) patients underwent surgery according to a new technique that provided reliable recovery of cardia physiological functions and preservation of the anatomical relation between the diaphragm and the esophageal-gastric junction and included cruroraphy and fundoplication. Conclusions. Thus, the proposed two-stage method of surgical treatment for patients with HH and GERD in combination with Barrett’s esophagus is highly effective. The application of the proposed method provides the elimination of pathological changes which are visible on conventional endoscopy in the esophageal mucosa, reliable restoration of cardia physiology and preservation of the anatomical relation between the diaphragm and the esophageal-gastric junction. In the post-surgical period, the proposed method of surgical treatment reduces the likelihood of recurrent failure of cardia physiological functions, dysphagia and Barrett’s esophagus.

Robotic Surgery for the Treatment of Achalasia Cardia: Surgical Technique, Initial Experiences and Literature Review.

BackgroundThe outcomes of surgical interventions for achalasia treatment improved with the advent of minimally invasive surgery and the introduction of robotic surgery. This article describes the technical details of robotic achalasia surgery, shares our initial experiences, and discusses why robotic surgery will become the first choice for the surgical treatment of achalasia.MethodsThe records of patients with a diagnosis of achalasia who underwent robotic surgery were evaluated retrospectively. The patients’ data were examined in terms of demographic parameters, duration of complaints, treatment options applied previously, robotic surgery technique, and postoperative outcomes.ResultsOf the six patients evaluated, four (66.7%) were males and two (33.3%) were females. Their mean age was 32 years (20-51 years), and the mean symptom duration was 4.6 years (2-9 years). All of the patients underwent robotic Heller cardiomyotomy surgery. After the myotomy procedure, five of the six patients (83.3%) underwent partial anterior fundoplication (Dor) as an antireflux procedure. The cruroraphy procedure was performed in one patient (16.7%) due to accompanying hiatal hernia, whereas the procedures were completed in five patients (83.3%) without performing posterior dissection of the oesophagus. In the postoperative follow-up period, no surgical problem was encountered, while reflux symptoms developed in one patient (16.7%) and were controlled by medical therapy.ConclusionsThe success of surgical treatment of achalasia is incontrovertible. Due to the various advantages of robotic surgery, it is now frequently used in narrow-area surgeries, such as achalasia surgery.

Complete versus non-complete fundoplication in surgical treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease is a common disorder accounting for approximately 75% of esophageal pathology. It seriously compromises quality of life. It develops when the reflux of gastric content causes troublesome symptoms or complications. During the last decades significant changes have occured in the role of surgery for gastroesophageal reflux disease. Initially antireflux surgery was reserved only for patients who had failed any kind of medical therapy. Now the range of indications for antireflux procedures is wide. Operations for gastroesophageal reflux disease are now well established and have good short- and long-term results, but no unique laparoscopic antireflux technique has been accepted so far, and a number of different antireflux procedures with numerous modifications have been reported. A total of 102 consecutive patients with gastroesophageal reflux disease were operated in the clinic of Republican Medical Center ‘’Armenia’’ (Yerevan, Armenia) and Mickaelyan Institute of Surgery (Yerevan, Armenia) from 2010 to 2021. In all cases the esophagogram showed hiatal hernia. Nissen, Nissen-Rossetti and Toupet fundoplications were performed as antireflux procedures. In all cases of combination of hiatal hernia and Gastroesophageal reflux diseasemesh reinforcement was performed. The results of follow-up assessment of the operated patients were compared. The results in early postoperative period were assessed with contrast X-ray examination and 24-hour pH-metry on the 5-th to 7-th days after surgery. The quality-of-life evaluation by the questionnaire showed a significant difference between the two groups, improvement of results in the laparoscopy group with complete fundoplication in comparison with not complete fundoplication. Complete fundoplication is a more reliable method of antireflux procedures for surgical treatment of gastroesophageal reflux disease. The division of short gastric vessels helps to prevent persistent dysphagia. The repair of esophageal hiatus of diaphragm is mandatory in antireflux procedures.

An early experience in the surgical management of Achalasia Cardia: Laparoscopic Heller’s Cardiomyotomy.

Background. The surgical treatment of achalasia cardia is Heller’s cardiomyotomy with the intent of relieving symptoms. Most studies have included an antireflux procedure. With the advent of minimal access surgery, surgical results and patient satisfaction have improved significantly. This article describes our initial experiences with laparoscopic Heller’s myotomy without antireflux in the treatment of achalasia. Methods. This was a prospective study from February 2019 to February 2022. We recruited 19 patients with AC undergoing laparoscopic Heller’s myotomy and analyzed their data in terms of demography, symptoms, duration, investigations, and postoperative outcomes. The primary outcome was the relief of their symptoms, mainly dysphagia, heartburn, and regurgitation. Results. All patients with suspected AC were investigated with endoscopy and high-resolution manometry to confirm the diagnosis. Fourteen patients opted for surgery as a primary modality, while five opted for surgery after failed pneumatic dilatation. All underwent laparoscopy with no conversion. There were no significant morbidity and mortality. In the immediate follow-up period, there was a 100% resolution of their symptoms. However, on long-term follow-up, 2 (10.5%) patients developed reflux symptoms, 3 (15.8%) developed heartburn, and 1 (5.3%) developed mild dysphagia. All underwent endoscopy, which showed an excellent myotomy with a scope negotiating through the LES without resistance. Their symptoms resolved with conservative treatment. Conclusions. Laparoscopic Heller’s myotomy without antireflux procedure is a good treatment option in achalasia, with a resolution of symptoms and without significant reflux symptoms.

Routine Intraoperative Use of Esophageal Bougie in Minimally Invasive Hiatal Hernia Repair is Not Necessary.

Laparoscopic hiatal hernia repair can be performed with an antireflux procedure. Routine use of an esophageal bougie has been advocated to avoid an excessively tight fundoplication. The use of an esophageal bougie carries a risk of iatrogenic complications, such as perforation or laceration of the viscera. However, there is equivocal evidence for the routine use in the surgical literature. We present a retrospective analysis of patients with Types 3 and 4 paraesophageal hiatal hernias who underwent laparoscopic hiatal hernia repair with fundoplication without the use of an esophageal bougie, between December 1, 2010 and February 28, 2020, by a single surgeon at a community-based, academic hospital. Patients with a diagnosis of achalasia and gastroesophageal dysmotility were excluded. Perioperative outcome measures included: recurrence; prolonged postoperative proton pump inhibitor use; dysphagia; re-operation, and mortality. A total of 174 patients (34 males, 140 females) underwent laparoscopic hiatal hernia repair with fundoplication. The average age was 63-years old. Four patients (2.3%) developed dysphagia with narrowing of the gastroesophageal junction, with one patient (0.6%) requiring postoperative esophageal dilation with bougie and eventual re-operation. Postoperative proton pump inhibitor use was 31.0% after 1 month. Overall hernia recurrence rate was 14.9% and the rate of re-operation was 6.3%. Overall mortality was 0.6%. We conclude that laparoscopic hiatal hernia repair with fundoplication without an esophageal bougie is safe, effective, and efficient. Furthermore, bougie related risks are obviated with a comparable reported incidence of postoperative dysphagia and hiatal hernia recurrence.

Achalasia at the Crossroads Between Specialties.

Background: Achalasia is a condition that can be treated either by surgery, such as Heller myotomy associated with an antireflux procedure, or by pneumatic dilation, the choice of type of treatment being a widely debated topic nowadays. Methods: We selected patients with the diagnosis of achalasia, calculating the Eckardt score on admission and they were treated by pneumatic dilation, respectively by myotomy associated with fundoplication. Therapeutic success at the end of treatment was analyzed, as well as that in subsequent follow-ups. At the same time, other important aspects of the study were quality of life and complications. Results: Forty-eight patients were included, 20 in the group of those treated by pneumatic dilation, and 28 treated by surgery. The results of the therapeutic success were to the advantage of the surgery, both after the completion of the treatment, and in the follow-ups from one year to 2 years (96.4% vs 90%, respectively 92.9% vs. 85%). The quality of life was better in patients with pneumatic dilation throughout the period. Conclusions: Surgical treatment of achalasia has a higher success rate than pneumatic dilation, but the latter is associated with a better quality of life.

Results in Antireflux Surgery, an Analysis of Case-Controlled Cohorts versus Multicenter Studies and Meta-Analyses.

Introduction: With the advent of minimally invasive techniques, laparoscopic Nissen fundoplication and Toupet partial fundoplication have been very successful in the management of GERD. In the past 10 years, a number of very attractive new technologies have entered the market around therapeutic GERD-management such as Transoral Incisionless Gastroplication, other endoscopic plication techniques, and the implantation of the magnetic sphincter augmentation (MSA). These new technologies are excessively promoted by the respective companies, propagating their techniques as causing fewer side effects. The purpose of this paper is an overview on the successrates of these differently used techniques and technologies and, in addition, different study-designs. Methods: A literature review was performed searching for publications on laparoscopic fundoplication (LF), Transoral Incisionless Fundoplication (TIF), and laparoscopic MSA. The reported classified were separated according to their design into (group 1) large case-controlled series or comparative studies (n 100 cases) from high-volume centers and into (group 2) trials between different technologies of antireflux procedures, multicenter-studies, and meta-analyses of GERD-trials. Results: In total, 4030 abstract were screened according to the selected key words. Following the section criteria, 19 publications were selected and analyzed. Regarding group 1 and LF (selected studies 2565 patients), the morbidity ranged from 2.0-4.8 % of cases. With a follow-up time of 36-222 months most of these patients were followed 5 years. In group 2, more than 150 studies and several multicenter-registries were summarized in these 9 selected publications. The overall follow-up periods were substantially shorter with a range of 7-48 months. Conclusions: It can be concluded that special efforts in patient management in high volume centers and a vast experience may substantially contribute to excellent results for several antireflux techniques, which may reach a level of quality above results of registries and meta-analyses.

State of evidence and future perspectives in minimally invasive management of gastroesophageal reflux disease (GERD)

The future of minimally invasive treatment of gastroesophageal reflux disease (GERD) will be realized through collaborative precision medicine more than any foreseeable new technology. Multidisciplinary foregut societies are fostering the collaboration and expertise needed to provide a personalized treatment of GERD. Patient-centric therapy will consider combination therapies’ clinical successes. Taking a patient uncontrolled on medication to controlled via a combination of medicine and a procedure will replace the historical mutual exclusivity of acid-suppressive medication or surgery as a treatment for GERD. Research directed at precision medicine will focus on subgroup analysis rather than randomized controlled trials. Recognition of the crural diaphragm as a reflux barrier which fails in GERD patients regardless of the presence of an axial hernia has resulted from modalities such as 3-D high-resolution impedance manometry, endoscopic ultrasound, functional luminal impedance planimetry. More precise patient selection for purely endoscopic therapies will be possible.The concept of hernia reduction will be replaced by calibration of the crural repair to restore its sphincteric function. Partnering a surgically calibrated hernia repair partnered with interventional gastrointestinal endoscopic reinforcement of the lower esophageal sphincter will foster physician alliances and offer patient-centric alternatives to traditional fundoplication. As such, laparoscopic Nissen Fundoplication will lose its historical primacy and be relegated to the most severe GERD. Magnetic sphincter augmentation (LINX®), varing degrees of partial fundoplication, and endoluminal therapies with or without hiatal hernia repair will become the mainstay of GERD AntiReflux Procedures. Radio Frequency modulation (Stretta®) may be an alternative to neuromodulators in treating the acid-sensitive esophagus. The nascent era of endoscopic robotics will improve precision, reproducibility and revive natural orifice transluminal endoscopic surgery.

Endoscopic Removal of an Eroded LINX® Device Using a Mechanical Biliary Lithotriptor

Background: Magnetic sphincter augmentation (MSA) via the surgical placement of a LINX® device (LINX® Reflux Management System, Torax Medical, Shoreview, MN, USA) is an increasingly performed minimally invasive outpatient anti-reflux procedure with a low erosion rate. The most common initial approach to eroded LINX® devices is endoscopic removal. Often endoscopy centers do not have specialized devices to cut through the newer, more durable LINX® systems. In this paper we describe a unique approach for removal of a LINX® with intraluminal erosion using a commonly stocked mechanical biliary lithotripsy device. Case description: A 63-year-old male with a history of GERD and symptomatic type III paraesophageal hernia (PEH) underwent a robotic PEH repair with magnetic sphincter augmentation (1.5T, 17 bead) at an outside hospital. He developed an acute recurrence of his PEH, and subsequent upper endoscopy and contrast esophagram four weeks postoperatively revealed a gastric erosion of the LINX device, which had migrated 6 cm onto the stomach. Attempted endoscopic LINX® removal using the OVESCO remove DC Cutter device was unsuccessful. Using principles of prior endoscopic bariatric lap band foreign body removal, the entire LINX® device was successfully removed with the described biliary lithotriptor technique. Conclusion: Using a common biliary mechanical lithotriptor device and a guidewire to transect the newer 1.5T LINX® Reflux Management System is a safe, effective and familiar technique for endoscopic removal of an eroded MSA device.

O-BN04 Laparoscopic assisted robotic Heller’s cardiomyotomy in achalasia: a 12-year experience

Abstract Background Heller’s cardiomyotomy (HC) using a computer-enhanced (robotic) laparoscopic platform allows for a more precise dissection. This is achieved by utilizing the superior optics of a 3D camera and greater degrees of freedom provided by robotic instrumentation. Our aim was to assess short to long term outcomes in terms of mucosal integrity, hospital stay and symptom improvement and quality of life. Methods A retrospective review of prospectively collected data was performed of patients who underwent robotic HC between July 2009- May 2021. HC was performed using a Da Vinci robot S and Xi (Intuitive Surgical Inc.) with 4 laparoscopic ports and liver retractor. Anterior mobilization of the oesophagus was performed leaving the posterior component of phreno-oesophageal ligament intact. A longitudinal myotomy was made extending into the proximal stomach. An anti-reflux procedure (ARP) was not routinely performed. Data collected including demography, Eckardt symptom score, Quality of Life (QoL) with SF-36, surgical technical data and surgical outcome (post-op morbidity, mortality, hospital stay). Results Fifty-seven patients underwent surgery (28 males). Median age was 46 years (18-71). Two had surgery for recurrent dysphagia following laparoscopic HC elsewhere. Median length of myotomy was 8cm (5-11). No mucosal breaches were identified at surgery, but one had postoperative leak. Median length of hospital stay was 2 days (1-148). One had chest infection and another DVT. Median follow-up was 61 months (2- 86). There was no mortality. Three patients (5%) needed oesophageal dilatation during follow-up. There was a significant improvement in Eckardt score from 10 (9-12) to 2 (0-6), and in all components of QoL (p &amp;lt; 0.05). Conclusions Heller’s myotomy can be performed very precisely using a Da Vinci Robot. It minimises the risk of mucosal breach reflecting in the low leak rate. No patient had developed troublesome reflux which may well be due to the preservation of the posterior component of the phreno-oesophageal ligament. It also improves symptoms and quality of life for many years. Robotic HC may become the standard treatment for achalasia in the very near future.

P-BN25 Redo-Antireflux surgery long term quality of life retrospective study

Abstract Background Gastro-oesophageal reflux disease (GORD) can have a significant effect on patients quality of life, especially in sever cases. Laparoscopic Antireflux surgery is the most common approach which offers promising long-term outcomes. However, Failure of antireflux procedures are reported in 5% to 10% of the patients who might require a redo-antireflux surgery (Redo-ARS). This study aims to assess the long-term outcomes of Redo-Antireflux surgeries regarding symptoms control and patient satisfaction. Methods Retrospective study for patients who underwent Redo-ARS with a single consultant in the south of England. Follow up was done using The GORD Health-Related Quality-of-Life (GORD-HRQL) scale and patients reported their scores before and after the redo-surgery. Exclusion criteria included follow up less than one year and failure of contacting the patient. Results All patients who underwent Redo-ARS between 2009-2019 were enlisted and 18 -out of the identified 22- were included in the study. Overall, There was a significant decrease in heartburn severity after the redo operation with a median reported severity of 4.5 preoperatively which decreased to 2 after the operation with a P value of 0.00062. This was observed in assessment of heartburn symptoms severity during sleep, laying flat, standing and after meals which all showed improvement after the operation with P values &amp;lt;0.005. There was no statistically significant improvement of dysphagia, odynophagia or bloating. The median follow up was 5 years. Conclusions Redo laparoscopic antireflux operations are technically challenging, however, significant heartburn symptoms control is feasible. Further evaluation of types of surgeries and patient selection can guide decisions regarding further management and guidelines.

Current surgical concepts for type III hiatal hernia: a survey among members of the Swiss Society of Visceral Surgery.

Surgery for large hiatal hernias has greatly evolved over the last decade, but there is an ongoing controversy regarding many technical aspects, such as the use of meshes or the necessity to add a fundoplication. The purpose of this survey was to assess the current spectrum of surgical care for mixed axial and paraoesophageal hiatal hernias (type III hiatal hernia) in Switzerland. In April 2020, we conducted a web-based survey comprising 25 questions on surgical management of type III hiatal hernia among members of the Swiss Society for Visceral Surgery. The survey focused exclusively on primary hernias in an elective setting. Responses were graded on a five-point Likert scale and analysed using descriptive statistics. Consensus was defined as agreement (agree or strongly agree) ≥75%. Forty-seven visceral surgeons with a median annual institutional caseload of 15 (interquartile range 10-30) type III hiatal hernia participated in the survey (response rate 15%). Agreement ≥75% was found for several basic technical steps (access via laparoscopy, hernia sac resection, preservation of vagus nerves, preservation of aberrant left hepatic artery, single-stitch posterior suture repair of hiatus with braided, non-resorbable material, complementary antireflux procedure). In contrast, consensus was not achieved for several important surgical details (mesh hiatoplasty, type of antireflux procedure, gastropexy, management of short oesophagus). A high percentage of participating surgeons experienced mesh related complications in their own or assigned patients: erosions (15% and 36%, respectively), stenoses (26% and 24%, respectively) and pericardial tamponades (9% and 15%, respectively). Nevertheless, hiatal reinforcement with mesh (in all or in selected cases) was reported by 91% of participants without consensus regarding mesh type, shape, placement and fixation technique. Apart from a few generally accepted technical steps, surgical management of type III hiatal hernia is highly variable amongst visceral surgeons in Switzerland. Although mesh-related complications appear to be common, most Swiss surgeons report routine mesh use for hiatal reinforcement.

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

AbstractPeroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy &gt; 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.