Antireflux Surgery Research Articles

Relationship Between Esophageal Disease and Pulmonary Fibrosis

Esophageal disorders are prevalent among patients with chronic lung diseases, including idiopathic pulmonary fibrosis (IPF). Gastroesophageal reflux disease (GERD) has been associated with IPF prevalence, severity, and respiratory decline. The pathophysiologic relationship between GERD and IPF is likely bidirectional, with aspiration of refluxate leading to lung inflammation and fibrosis, while the restrictive pulmonary physiology may contribute to altered transdiaphragmatic pressure gradient and increased reflux. Esophageal symptoms are frequently absent and do not predict esophageal dysfunction or pathologic reflux in patients with IPF, and objective diagnostic tools including upper endoscopy, ambulatory reflux monitoring, and high-resolution manometry are often needed. Impedance-based testing that identifies both weakly/non-acidic and acid reflux may provide important additional diagnostic value beyond pH-based acid testing alone. Novel metrics and maneuvers, including advanced impedance measures on impedance-pH study and provocative testing on HRM, may hold promise to future diagnostic advancements. The main treatment options include medical therapy with acid suppressants and anti-reflux surgery, although their potential benefits in pulmonary outcomes of IPF require further validations. Future directions of research include identifying phenotypes of IPF patients who may benefit from esophageal testing and treatment, determining the optimal testing strategy and protocol, and prospectively assessing the value of different esophageal therapies to improve outcomes while minimizing risks. This review will discuss the pathophysiology, evaluation, and management of esophageal diseases, particularly GERD, in patients with IPF, as informed by the most recent publications in the field, in hopes of identifying targets for future study and research.

“Comparison of Nissen Rossetti and Floppy Nissen techniques in laparoscopic reflux surgery”

Objective The present study makes a comparative assessment of the Floppy–Nissen (FN) and Nissen–Rossetti fundoplication (NRF) procedures. Methods Included in the study were 80 patients who presented to the General Surgery Department outpatient clinic of Balcalı Hospital of the Cukurova University Faculty of Medicine with gastroesophageal reflux between March 2010 and March 2013 All patients were operated on by the same surgeon using the laparoscopic FN or NRF techniques in a randomized controlled manner. The preoperative and postoperative reflux-specific and nonspecific gastrointestinal symptoms of the patients were compared. Results The duration of symptoms had no effect on the level of satisfaction; regurgitation, bloating and heartburn were more common in those with a longer duration of symptoms Of the patients, 92.5% were satisfied with their resulting condition, and 92.5% were inclined toward the surgery. It was further found that there was no difference between the symptoms or satisfaction levels of the patient groups who underwent the FN procedure and those who underwent the NRF procedure, other than those related to the duration of surgery. laparoscopic NF and the NRF fundoplication treatments, aside from the duration of surgery. Conclusion Our study revealed no significant difference between the laparoscopic NF and the NRF fundoplication treatments, aside from the duration of surgery. KEY MESSAGES The Nissen–Rossetti technique can be used safely based on the similarity of its outcomes with those of the classical Nissen technique. Despite the documented success of laparoscopic anti-reflux surgery, the absence of studies comparing surgery and medical treatments prevents these discussions from being concluded. Comparison of Nissen Rossetti and Floppy Nissen Techniques in Laparoscopic Reflux Surgery

Assessment of quality of life after laparoscopic GERD surgery in children: a prospective study.

There was a significant improvement in symptoms and their frequency after LARS in children, as well as an improvement of QoL, in the short and medium term. The impact of GERD should be taken into consideration in the treatment decision, given that surgery clearly improves the QoL. •Laparoscopic anti-reflux surgery (LARS) is an established and effective treatment option in pediatric patients with severe GERD refractory to medical treatment. •Effect of LARS on the quality of life (QoL) has been mainly investigated in the adult population but there is very little data on the effect of LARS on the QoL in pediatric patients. •Our prospective study was the first to analyze the effect of LARS on QoL in pediatric patients without neurologic impairment using validated questionnaires at two postoperative time points with a significant improvement in postoperative QoL at 3 and 12 months. •Our study emphasizes the importance of evaluating QoL and impact of GERD on all the aspects of daily life and of taking these into consideration in the treatment decision.

Laparoscopic antireflux surgery for refractory gastroesophageal reflux disease: long-term clinical outcomes

Persistent symptoms despite adequate Proton Pump Inhibitors (PPI) treatment are described in up to 40% of patients with Gastroesophageal Reflux Disease (GERD). The efficacy of Laparoscopic Antireflux Surgery (LARS) in PPI non-responder patients is still unclear. This observational study aims to report the long-term clinical outcomes and predictors of dissatisfaction in a cohort of refractory GERD patients submitted to LARS. Patients with preoperative refractory symptoms and objective GERD evidence submitted to LARS between 2008 and 2016 were included in the study. Primary endpoint was overall satisfaction with the procedure, secondary endpoints were long-term GERD symptom relief and endoscopic findings. Univariate and multivariate analyses were performed to compare satisfied and dissatisfied patients, in order to identify preoperative predictors of dissatisfaction. A total of 73 refractory GERD patients who underwent LARS were included in the study. At a mean follow-up of 91.2 ± 30.5 months, the satisfaction rate was 86.3%, with a statistically significant reduction in typical and atypical GERD symptoms. Causes of dissatisfaction were severe heartburn (6.8%), gas bloat syndrome (2.8%), and persistent dysphagia (4.1%). Multivariate analysis showed that a number of Total Distal Reflux Episodes (TDRE) > 75 was a predictive factor of long-term dissatisfaction after LARS while a partial response to PPI was a protective factor against dissatisfaction. LARS guarantees a high level of long-term satisfaction for selected refractory GERD patients. An abnormal TDRE at 24 h-multichannel intraluminal impedance-pH monitoring and the lack of response to preoperative PPI were predictors of long-term dissatisfaction.

Surveillance Endoscopy After Foregut Surgery: Is It Necessary?

Patients undergoing foregut surgeries can have de novo findings or worsening of underlying upper gastrointestinal pathologies including Barrett’s esophagus and gastric intestinal metaplasia. These changes carry a potentially increased risk for malignancy development in the future raising the question of the utility of post-operative surveillance endoscopy after esophagectomy, bariatric and metabolic surgeries (Sleeve gastrectomy and Roux-en-Y Gastric Bypass), achalasia treatment, and anti-reflux surgery. In this narrative review, we conduct a literature exploration of available data on post-operative endoscopic surveillance findings following the procedures summarizing the prevalence of upper gastrointestinal pathologies and recommendations on the utility of postoperative endoscopy from established medical societies.

The Impact of Gastroparesis on Antireflux Surgery

Foregut surgeons will encounter gastroparesis in patients with gastroesophageal reflux disease and prior gastresophageal operations. Clues in the history and diagnostic studies at first consultation will inform surgical decision making. Stepwise progression through multiple treatments may be required for patients to achieve symptom relief from post-surgical gastroparesis. Endoscopic pyloromyotomy and robotic-assisted pyloroplasty are safe, effective and definitive procedures for post-surgical gastroparesis.

Antireflux surgery versus medical management of gastro-oesophageal reflux after lung transplantation.

Gastro-oesophageal reflux disease after lung transplantation may be associated with chronic lung allograft dysfunction. Aspiration may continue on medical management of reflux, but antireflux surgery potentially reduces all reflux. We compared outcomes between medical and surgical management of reflux in lung recipients. Lung recipients with an elevated DeMeester score (≥14.72) on post-transplant reflux testing between 2015 and 2020 were included. Patients were divided into 2 groups: group A (underwent surgery) and group B (medically managed). Endpoints were pulmonary function, allograft dysfunction-free survival and overall survival. Further analysis included subgroups: A1 (early surgery, <6 months) and A2 (late surgery, >6 months), and B1 (DeMeester <29.9) and B2 (DeMeester ≥30). A total of 186 included subjects were divided into groups A [n = 46 (A1, n = 36; A2, n = 10)] and B [n = 140 (B1, n = 78; B2, n = 62)]. Compared to medically managed patients, patients who underwent surgery had a higher prevalence of hiatal hernia (P < 0.001) and a lower prevalence of oesophageal motility disorders (P = 0.036). Recipients who underwent surgery had superior pulmonary function at 5 years compared to group B (P < 0.05) and longer allograft dysfunction-free survival than subgroup B2 (P = 0.028). Furthermore, early surgery was associated with longer survival than late surgery (P = 0.021). Antireflux surgery in recipients with reflux improved long-term allograft function, and early surgery showed a survival benefit. Allograft dysfunction-free survival of lung recipients who underwent surgery was significantly better than that of medically managed patients with DeMeester ≥30. We present an algorithm for appropriate selection of candidates for antireflux surgery after lung transplantation.

Postoperative Timing of Chemoprophylaxis and Its Impact on Thromboembolism and Bleeding Following Major Abdominal Surgery: A Multicenter Cohort Study

BackgroundMajor abdominal surgery is associated with bleeding and venous thromboembolism (VTE) risks. Chemoprophylaxis prevents VTE but increases bleeding risk. When compared with pre- and intra-operative chemoprophylaxis, recent evidence suggests that starting chemoprophylaxis postoperatively lowers the risk of bleeding without compromising VTE protection. This study investigates whether an optimal window exists in the postoperative period for initiating chemoprophylaxis in patients undergoing major abdominal surgery.MethodsAnalysis of pooled data from four multicenter PROTECTinG studies, which investigated the timing of perioperative chemoprophylaxis on bleeding and VTE outcomes following major abdominal surgery. Patients that commenced chemoprophylaxis postoperatively were separated into quartiles based on timing of administration within the first 24 h post-surgery.ResultsOverall, 4729 (Abdominal visceral resection N = 668, cholecystectomies N = 573, major ventral hernia repair N = 1701, antireflux surgery N = 1787) consecutive patients had chemoprophylaxis commenced within 24 h following elective surgery. Baseline characteristics were comparable between quartiles. Across quartiles and within each procedural type, the timing of starting chemoprophylaxis was not associated with bleeding (2.6, 1.7, 2.7 and 3.2%, p = 0.130) or clinical VTE (0.8, 0.2, 0.8 and 0.5%, p = 0.131), and did not predict their occurrences on multivariate analysis. ConclusionChemoprophylaxis can be safely started at any time within 24 h post-skin closure in major abdominal surgery, without affecting bleeding or VTE risks. This finding encourages the standardization of chemoprophylaxis timing in the postoperative period to pre-defined times during the day to improve workflow efficiency and chemoprophylaxis compliance.

Outcomes of surgical treatment for physiological cardia insufficiency in hiatal hernias andgastroesophageal reflux disease

Background. The purpose was to determine the effectiveness of the developed method of surgical treatment for insufficiency of the physiological cardia in hiatal hernias (HH) and gastroesophageal reflux disease (GERD). Materials and methods. From January 2013 to September 2021, 141 patients were treated laparoscopically for HH and GERD at the clinic of the Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine, 44 (31.2%) men and 97 (68.8%) women aged 21–70 (36.5±4.2) years. To evaluate the immediate and long-term results in the follow-up period lasting from 11 months to 3 years, a randomized comparative study was conducted between groupI— 45 patients after classical antireflux operations and group II— 34 patients after surgery to restore the physiological cardia. X-ray examination of the esophagus and stomach was performed to diagnose HH. Endoscopic examination was used to evaluate the condition of the mucous membrane of the esophagogastroduodenal zone. Results. In 141 patients, the following types of laparoscopic surgical interventions were performed: Nissen fundoplication— in 84 (59.6%), Toupet fundoplication— in 12 (8.5%), Dor fundoplication— in 11 (7.8%), restoration of the physiological cardia according to the proposed method, namely, medial cruroplication, anterior cardiogastroplication with gastrodiaphragmopexy,— in 34 (24.1%) cases. Crurorrhaphy was carried out in 100.0% of patients: posterior— in 64 (45.4%), anterior and posterior (combined)— in 27 (20.1%), medial cardiocrurorrhaphy and lateral cardiofundocrurorrhaphy according to the proposed method— in 34 (19.1%). Alloplasty of the esophageal hiatus was performed in 16 (11.3%) cases. By the frequency of intraoperative and early postoperative complications, a significant difference was detected in favor of group II (5 (11.1%) vs. 1 (2.9%), p&lt;0.05, and 14 (31.1%) vs. 2 (5.8%), p&lt;0.05, respectively, Fisher’s exact test). Depending on the frequency of anatomical (5.8 vs. 17.7%, p=0.003, χ2 test), functional (5.8 vs. 13.3%, p=0.045, χ2 test) and a combination of anatomical and functional (11.1 vs. 2.9%, p=0.003, χ2 test) relapses, a significant difference is revealed in favor of group II. In terms of the frequency of pylorospasm and dysphagia, a significant difference was detected in favor of groupII (2.9 vs. 17.7%, p=0.009, and 2.9 vs. 28.9%, p=0.007, respectively, Fisher’s exact test). Conclusions. The analysis of the immediate results of using the proposed method of surgical treatment for the restoration of the physiological cardia has shown that it ensures the elimination of pathological changes in HH, in comparison with classical antireflux methods, reduces the frequency of intraoperative (2.9 vs. 11.1%) and early postoperative (5.8 vs. 31.1%) complications. In the long-term period after surgical treatment of HH with the proposed method, the frequency of HH recurrence is reliably reduced compared to the outcomes when using classical antireflux methods, particularly the frequency of anatomical (5.8 vs. 17.7%, p=0.003, χ2 test) and functional (5.8 vs. 13.3%, p=0.045, χ2 test) relapses.

Comparative study of laparoscopic Nissen fundoplication versus Hill-Snow procedure for the treatment of gastroesophageal reflux disease in children: a single-blinded randomized controlled trial

BackgroundGastroesophageal reflux disease (GERD) is a common condition in children. Complete fundoplication provides better reflux control but it results in more dysphagia and gas-bloat symptoms. Antireflux surgery without wrap has fewer adverse effects but a higher failure rate in controlling reflux. Until now, there is little evidence as to whether complete or partial fundoplication is the optimal procedure in this age group.ObjectiveThis study aimed to compare the safety and efficacy of laparoscopic Nissen fundoplication versus Hill-Snow procedure among children with GERD.MethodsWe conducted a randomized, single-blinded, comparative trial that included 40 children with a diagnosis of GERD, who were scheduled to undergo surgery. Children were randomly allocated to undergo laparoscopic Nissen fundoplication or Hill-Snow procedure.ResultsWhile the incidence of postoperative dysphagia was similar between both groups, the duration of dysphagia was significantly shorter in the Hill-Snow group. Likewise, the incidence of bloating was significantly lower in the Hill-Snow group than the Nissen group (0% versus 55%, respectively). We found three recurrent Hill-Snow cases versus two recurrent Nissen cases. The operative time was significantly longer in the Hill-Snow procedure (150 ± 52 min) than in the Nissen group (120 ± 48 min).ConclusionsThe Hill-Snow procedure is an effective alternative to Nissen fundoplication with no bloating and much less dysphagia, leading to faster recovery of ordinary eating patterns.

Management of gastro-esophageal reflux disease: Practice-oriented answers to clinical questions

Gastro-esophageal reflux disease (GERD) is a condition which is frequently faced by primary care physicians and gastroenterologists. Improving management of GERD is crucial to maximise both patient care and resource utilization. In fact, the management of patients with GERD is complex and poses several questions to the clinician who faces them in clinical practice. For instance, many aspects should be considered, including the appropriateness of indication to endoscopy, the quality of the endoscopic examination, the use and interpretation of ambulatory reflux testing, and the choice and management of anti-reflux treatments, i.e., proton-pump inhibitors and surgery. Aim of the present review was to provide a comprehensive update on the clinical management of patients with GERD, through a literature review on the diagnosis and management of patients with GER symptoms. In details, we provide practice-oriented concise answers to clinical questions, with the aim of optimising patient management and healthcare resource use.

Laparoscopic Nissen fundoplication: a five-year single-center clinical experience and results.

The current surgical approach in the treatment of hiatal hernia with gastroesophageal reflux disease is known as hernioplasty together with antireflux surgical procedures. Among the antireflux surgical treatment procedures, the most applied approach is the laparoscopic Nissen fundoplication. In this study, we aimed to examine the results and effectiveness of laparoscopic Nissen fundoplication and to share our clinical experiences. Patients who underwent laparoscopic Nissen fundoplication operation between January 2017 and January 2022 in the general surgery clinic of a tertiary healthcare center were included in the study. The clinical data, preoperative, operative, and postoperative findings and results of the cases were investigated. The mean age of the patients was 46.2 ± 14.7 years, and the female/male ratio was 1.5/1. According to the Clavien-Dindo classification system, 9.9% of the patients had grade I, and 18.3% grade II complications. The patients were followed up for a mean of 32.6 ± 14.8 months. During the follow-up, reoperation was planned in 5.6% of the patients due to recurrence. Laparoscopic Nissen fundoplication is a well-defined technique. It is a safe and effective surgical method with appropriate patient selection.

Evaluation of antireflux surgery effectiveness in patients with hiatal hernia

The generally accepted gold standard in the surgical treatment of hiatal hernias is laparoscopic fundoplication with cruroplasty. At the same time, the problem of choosing the best method of fundoplication to improve the results of surgical intervention remains disputable. Aim. Determination of the effectiveness of antireflux interventions and the frequency of postoperative dysphagia in patients with esophageal hernia. Materials and methods. The results of 38 patients in the early and late postoperative period, operated with the use of Nissen and Toupet fundoplication, with an integrated exhaustive examination of the manifestations of dysphagia syndrome were analyzed. 17 (44.7 %) patients (first group) underwent laparoscopic posterior crurorraphy with Nissen fundoplication in the Short-Floppy-Nissen modification, and 21 (55.3 %) patients (second group) underwent posterior crurorraphy with Toupet fundoplication. Results. In the postoperative period, the intensity of pain on the rating scale was minimal in 70.6 % and 71.4 %; moderate in 23.5 % and 14.3 %; strong in 5.9 % and 14.3 % of the patients in the first and second groups, respectively. The first degree of dysphagia (the ability to ingest liquid food and fluids) was observed in 5 of 17 (29.4%) patients of the first group, with subsequent regression in 4 of 5 patients within 5 days; in the second group there was no dysphagia. When comparing the results of all scales of integrated analysis of the quality of life of the patients of both groups, no significant difference was found between them. Conclusions. The obtained data demonstrate the compatibility of both methods, in the absence of differences in quality of life and patient’s satisfaction in the late postoperative period. Differences in the frequency of dysphagia syndrome after surgery indicate the need for a more differentiated approach to the choice of fundoplication technique.

Removal of the magnetic sphincter augmentation device: an assessment of etiology, clinical presentation, and management

BackgroundMagnetic sphincter augmentation (MSA) erosion, disruption or displacement clearly requires device removal. However, up to 5.5% of patients without anatomical failure require removal for dysphagia or recurrent GERD symptoms. Studies characterizing these patients or their management are limited. We aimed to characterize these patients, compare their outcomes, and determine the necessity for further reflux surgery.MethodsThis is a retrospective review of 777 patients who underwent MSA at our institution between 2013 and 2021. Patients who underwent device removal for persistent dysphagia or recurrent GERD symptoms were included. Demographic, clinical, objective testing, and quality of life data obtained preoperatively, after implantation and following removal were compared between removal for dysphagia and GERD groups. Sub-analyses were performed comparing outcomes with and without an anti-reflux surgery (ARS) at the time of removal.ResultsA total of 40 (5.1%) patients underwent device removal, 31 (77.5%) for dysphagia and 9 (22.5%) for GERD. After implantation, dysphagia patients had less heartburn (12.9-vs-77.7%, p = 0.0005) less regurgitation (16.1-vs-55.5%, p = 0.0286), and more pH-normalization (91.7-vs-33.3%, p = 0.0158). Removal without ARS was performed in 5 (55.6%) GERD and 22 (71.0%) dysphagia patients. Removal for dysphagia patients had more complete symptom resolution (63.6-vs-0.0%, p = 0.0159), freedom from PPIs (81.8-vs-0.0%, p = 0.0016) and pH-normalization (77.8-vs-0.0%, p = 0.0455).Patients who underwent removal for dysphagia had comparable symptom resolution (p = 0.6770, freedom from PPI (p = 0.3841) and pH-normalization (p = 0.2534) with or without ARS. Those who refused ARS with removal for GERD had more heartburn (100.0%-vs-25.0%, p = 0.0476), regurgitation (80.0%-vs-0.0%, p = 0.0476) and PPI use (75.0%-vs-0.0%, p = 0.0476).ConclusionsMSA removal outcomes are dependent on the indication for removal. Removal for dysphagia yields excellent outcomes regardless of anti-reflux surgery. Patients with persistent GERD had worse outcomes on all measures without ARS. We propose a tailored approach to MSA removal-based indication for removal.Graphical abstract

Long-term outcomes of robot-assisted and laparoscopic operations for cardiofundal and subtotal hiatal hernias

Aim. To compare the long-term outcomes and qualitive of life (QOL) of robot-assisted fundoplication (RAF) and laparoscopic fundoplication (LF) in patients with cardiofundal and subtotal hiatal hernias (HH). Materials and methods. The study included 62 patients with HH, who underwent antireflux surgery in the clinic of Faculty Surgery No. 1 of Sechenov University in the period from January 2015 to February 2021. The main group included 32 patients who underwent robot-assisted fundoplication (RAF) according to A. F. Chernousov, the comparison group included 30 patients who underwent laparoscopic fundoplication (LF). Complaints of the patient, X-ray, endoscopic studies, PH-impedance-metry in the long-term period were evaluated. To assess the quality of life, the questionnaires SF 36 (The Short Form-36) and GERD-HRQL (Health-Related Quality of Life in Patients with Gastroesophageal Reflex Disease) were used. Results. Periodic heartburn in the long-term period was noted by 2 (6%) patients of the RAF group and 4 (13%) in the LF group. Endoscopic signs of mild esophagitis were detected in 1 (3%) patient from each group. X-ray in 9 (28%) patients of the RAF group and 11 (37%) patients of the LF group showed migration of the esophageal-gastric junction above the diaphragm level with complete preservation of the antireflux function of the fundoplication cuff. The QOL indicators of the SF 36 questionnaire did not differ in both groups and were comparable to the population of “conditionally healthy” people. The indicators of the GERD-HRQL questionnaire were better in the RAF group, but the differences had no statistical significance (RAF - 2.53 ± 5.1 points versus LF - 5.23 ± 9.4 points, p-value = 0.321). Conclusion. RAF and LF in the modification of A. F. Chernousov are equally effective in the treatment of RE and GPOD in the long-term period and provide good indicators of quality of life that do not differ statistically from each other.

Platelet-Rich Plasma in Large Paraesophageal Hernia Repair: A Feasibility Study

Background: The Achilles heel of antireflux surgery is hiatal hernia recurrence, and no treatment modalities to date have improved this outcome. Platelet-rich plasma (PRP) is an autologous therapy that promotes wound healing by upregulating extracellular matrix proteins, and it has excellent results in numerous surgical fields. Animal studies evaluating PRP use in hiatal hernia repair show favorable outcomes, yet its application in hiatal hernia repair in humans has not been described. Methods: This is a feasibility study of patients with large (&gt;5 cm) paraesophageal hernia (PEH) who underwent PEH repair with PRP from 2/2021 to 1/2022. Safety, feasibility, and postoperative outcomes were investigated. Results: PRP was successfully administered during PEH repair in 12 consecutive patients. There were no significant adverse events. The methods for applying PRP to the repair were modified several times to optimize the technique. Administering PRP added an average of 5 minutes to the operative time. There were no significant postoperative complications or hernia recurrence on diagnostic imaging at latest follow up, with good subjective reflux control. Conclusion: PRP has excellent clinical outcomes in other surgical fields and may become an important new adjunct in antireflux surgery. This study shows PRP is safe and feasible in PEH repair, with little effect on operative time.

Evaluation of ICARUS Guidelines and Recommendations Not Supported by Randomized Controlled Trials

BackgroundThe ICARUS guidelines are a systematic review and Delphi process that provide recommendations in the treatment and management of patients with gastroesophageal reflux disease (GERD). Many of the recommendations were supported by randomized trials; some were not. This study assesses guidelines with limited evidence and weak endorsement. MethodsFour ICARUS guidelines were chosen: the role of fundoplication for patients with BMI > 35, regurgitation, chest pain, and extra-esophageal symptoms. A multicenter database of patients undergoing fundoplication surgery for GERD between 2015 and 2020 was used. Outcomes assessed were anatomic failure and symptom recurrence. Multivariable regression was performed. ResultsFive institutions performed a fundoplication on 461 patients for GERD with a median of follow-up of 14.7 months (IQR 14.2). On multivariate analysis, patients with the chosen pre-operative comorbidities achieved comparable post-operative benefits. Patients with a BMI > 35 were not more likely to experience anatomic failure. Patients with pre-operative regurgitation had similar symptom recurrence rates to those without. Patients with non-cardiac chest pain had comparable rates of symptom recurrence to those without. Reporting a pre-operative chronic cough attributable to reflux was not associated with higher rates of post-operative symptom recurrence. DiscussionAmong the ICARUS guidelines and recommendations, a small proportion was lacking evidence at low risk for bias and endorsement. The results of this multicenter study evaluated outcomes of patients with various pre-operative conditions: BMI > 35, chest pain attributable to reflux, extra-esophageal symptoms attributable to reflux, and regurgitation. Our findings endorse patients with these characteristics as candidates for anti-reflux surgery.

Criteria of patient selection for magnetic sphincter augmentation.

This article is an expert review of published literature with the goal of defining the ideal patient selection for Magnetic Sphincter Augmentation (MSA) in Anti-reflux Surgery (ARS). The authors performed a literature search of outcomes after MSA for different patient populations. Although MSA utilization has expanded to include patients with advanced gastroesophageal reflux disease (GERD), obese patients, and patients with a history of bariatric surgery there is still a paucity of data to support its definitive use in these cohorts. We concluded that younger patients with mild/moderate GERD as evidenced by objective studies in conjunction with normal motility on manometry have the most favorable outcomes after MSA. MSA should be avoided in patients with allergies to nickel, titanium, stainless steel, or ferrous materials. As the utilization of MSA in ARS continues to expand and as more robust data emerges the ideal patient for this device will likely expand as well.

Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review

Summary Background The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force. Methods An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence. Results Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia. Conclusion A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.

Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy.

The pylorus plays a key role in the control of gastric content outflow. Impairment of pyloric physiology has been observed in gastroparesis, particularly when associated with diabetes mellitus or opioid intake or after antireflux surgery. New tools have been developed to identify pyloric dysfunction in routine care, including functional luminal impedance planimetry (FLIP). As such, a new therapeutic strategy targeting the pylorus, namely endoscopic pyloromyotomy (G-POEM), has received increasing attention and emerged as a promising treatment for gastroparesis. The present review details the involvement of the pyloric pathophysiology in gastroparesis, as well as clinical results of G-POEM according to the current literature.