Fundoplication Research Articles

Comparative analysis of laparoscopic nissen fundoplication and rossetti modification in gastroesophageal reflux disease: A focus on life quality enhancement

ObjectiveThis study aims to investigate the focus of surgical treatment of gastroesophageal reflux disease (GERD) on enhancing life quality beyond symptom relief. The comparison involves laparoscopic Nissen fundoplication and Rossetti modification techniques. MethodsPatients intolerant to or experiencing relapse after medical therapy underwent either standard Nissen procedure (Group 1, n=61) or Rossetti modification (Group 2, n=42). A disease-specific quality of life questionnaire for GERD was utilized for evaluating life quality preoperatively and 2 years postoperatively. Symptom scores and patient satisfaction were also assessed. ResultsPreoperatively, groups were similar in symptom duration, hiatal hernia presence, and DeMeester scores (p=0.127, p=0.427, and 0.584, respectively). Both groups exhibited a statistically significant increase in life quality postoperatively (p<0.001), with no significant intergroup difference. Symptoms decreased after both surgeries, except for dysphagia and bloating. Bloating significantly increased in both groups after surgery (p=0.018 and p=0.017, respectively), and dysphagia increased significantly only in Group 2 (p=0.007). The surgery refusal rate was significantly higher in Group 2 for similar preoperative symptoms (p=0.040). ConclusionDespite increased life quality scores, the combination of increased dysphagia and bloating in patients undergoing Rossetti modification resulted in a decreased satisfaction rate.

Corrigendum to ‘‘Laparoscopic Toupet fundoplication utilizing the remnant stomach for treatment of GERD after Roux-en Y gastric bypass: How I do It’’

Corrigendum to ‘‘Laparoscopic Toupet fundoplication utilizing the remnant stomach for treatment of GERD after Roux-en Y gastric bypass: How I do It’’

A rare presentation of gastric outlet obstruction following a robotic-assisted Nissen fundoplication: a case report

A rare presentation of gastric outlet obstruction following a robotic-assisted Nissen fundoplication: a case report

Cost-effectiveness of the RefluxStop device for management of refractory gastroesophageal reflux disease in Switzerland

Background One of the most prevalent conditions in Western societies is gastroesophageal reflux disease (GERD). In Switzerland, the standard treatment for GERD is proton pump inhibitor (PPI)-based medical management, but surgical options such as Nissen fundoplication and magnetic sphincter augmentation (MSA) are available. RefluxStop is a novel device that offers an alternative solution. The purpose of this report is to evaluate the cost-effectiveness of RefluxStop compared to PPIs and existing surgical treatments. Methods A model (Markov) was developed using the Swiss healthcare payer perspective with a lifetime horizon, 1-month cycle length, and a 3% annual discount rate for costs and benefits. Adverse events specific to treatment arms were incorporated, and benefits were measured in quality-adjusted life-years (QALYs). Clinical efficacy data for RefluxStop was obtained from its CE mark study, and comparator treatments were based on published literature. Deterministic and probabilistic sensitivity analyses were used to explore uncertainty. Since there are no head-to-head studies between RefluxStop and PPI therapy, Nissen fundoplication, or MSA, a limitation of this study is the use of naïve, indirect comparison of clinical effectiveness between the studied treatment options. Results Higher QALYs and lower costs were provided by RefluxStop compared to Nissen fundoplication and the MSA system. The incremental cost-effectiveness ratio (ICER) for RefluxStop was CHF 2,116 in comparison to PPI-based medical management. At a cost-effectiveness threshold of CHF 100,000 per QALY gained, the probability of RefluxStop being cost-effective was high, with probabilities of 100%, 97%, and 100% against PPI-based medical management, Nissen fundoplication, and MSA, respectively. The robustness of the analysis was provided by deterministic and probabilistic sensitivity analyses. Conclusion This cost-effectiveness analysis demonstrates that there is a high likelihood of RefluxStop being a cost-effective treatment modality in adults with GERD when compared with other treatment options available in Switzerland.

PHASIX™ ST MESH FOR CRURAL REINFORCEMENT DURING GIANT HIATAL HERNIA REPAIR: PRESENTATION OF SURGICAL TECHNIQUE

Abstract Aim Crural mesh reinforcement during large hiatal hernia repair has been advocated to defend against early recurrences. However, the optimal mesh material and configuration remain in question. This study presents the rationale and surgical technique for crural repair augmentation using Phasix™ ST Mesh. Methods We present a case of a giant hiatal hernia and outline the rationale and surgical technique for using Phasix™ ST Mesh in the repair. Results A 72-year-old man presented with a giant type IV hiatal hernia. A massive mediastinal protrusion of intra-abdominal fat and viscera, and an associated crucial cardiorespiratory compromise were noted. A preoperative CT scan revealed a widened hiatus measuring 9.2 × 7.6 cm. The patient underwent laparoscopic hiatal hernia repair and Nissen fundoplication. During the procedure, following visceral reduction and hernia sac dissection and excision, a widened round hiatus and significantly thinned crura were found. To reinforce the primary crural suturing, two strips of Phasix™ ST Mesh, each measuring 1.5 × 4 cm, were used, and a U-shaped mesh was placed onlay to augment the repair. The procedure lasted 214 minutes, and the patient was discharged on the 3rd postoperative day without complications. Conclusions The application of Phasix™ ST Mesh in the repair of giant hiatal hernias offers the dual benefits of reconstructing the original anatomy and reinforcing the hiatus, while avoiding the implantation of permanent foreign material around the esophagus.

Magnetic sphincter augmentation in the management of gastro-esophageal reflux disease: A systematic review and meta-analysis.

Magnetic sphincter augmentation (MSA) through placement of the LINX device is an alternative to fundoplication in the management of gastro-esophageal reflux disease (GERD). This systematic review and meta-analysis aimed to assess efficacy, quality of life and safety in patients that underwent MSA, with a comparison to fundoplication. A literature search of MEDLINE, Embase, Emcare, Scopus, Web of Science and Cochrane library databases was performed for studies that reported data on outcomes of MSA, with or without a comparison group undergoing fundoplication, for GERD from January 2000 to January 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. Thirty-nine studies with 8,075 patients were included: 6,983 patients underwent MSA and 1,092 patients had laparoscopic fundoplication procedure. Ten of these studies (seven retrospective and three prospective) directly compared MSA with fundoplication. A higher proportion of individuals successfully discontinued proton-pump inhibitors (P<0.001; WMD 0.83; 95% CI 0.72-0.93; I2=96.8%) and had higher patient satisfaction (P<0.001; WMD 0.85; 95% CI 0.78-0.93; I2=85.2%) following MSA when compared to fundoplication. Functional outcomes were better after MSA than after fundoplication including ability to belch (P<0.001; WMD 0.96; 95% CI 0.93-0.98; I2=67.8) and emesis (P<0.001; WMD 0.92; 95% CI 0.89-0.95; I2=42.8%), and bloating (P=0.003; WMD 0.20; 95% CI 0.07-0.33; I2=97.0%). MSA had higher rates of dysphagia (P=0.001; WMD 0.41; 95% CI 0.17-0.65; I2=97.3%) when compared to fundoplication. The overall erosion and removal rate following MSA was 0.24% and 3.9% respectively, with no difference in surgical re-intervention rates between MSA and fundoplication (P=0.446; WMD 0.001; 95% CI -0.001-0.002; I2 =78.5%). MSA is a safe and effective procedure at reducing symptom burden of GERD and can potentially improve patient satisfaction and functional outcomes. However, randomized controlled trials directly comparing MSA with fundoplication are necessary to determine where MSA precisely fits in the management pathway of GERD.

Long-term results after laparoscopic revision fundoplication: a retrospective, single-center analysis in 194 patients with recurrent hiatal hernia.

After laparoscopic fundoplication, 10-20% of patients experience symptom recurrence-often due to resurgence of the hiatal hernia. The standard surgical treatment for such cases remains laparoscopic revision fundoplication. However, there is little data on the time frame and anatomic patterns of failed fundoplications. Additionally, few large studies exist on the long-term efficacy and safety of laparoscopic revision fundoplication. In a single-center, retrospective analysis of 194 consecutive revision fundoplications for recurrent reflux disease due to hiatal hernia, we collected data on time to failure and patterns of failure of the primary operation, as well as on the efficacy and safety of the revision. The median time to failure of the primary fundoplication was 3years. Most hiatal defects were smaller than 5cm and located anteriorly or concentric around the esophagus. Laparoscopic redo fundoplication was technically successful in all cases. The short-term complication rate was 9%, mainly dysphagia requiring endoscopic intervention. At a mean follow-up of 4.7years, 77% of patients were symptom-free, 14% required daily PPI, and 9% underwent secondary revision. Cumulative failure rates were 9%, 23%, and 31% at 1, 5, and 10years. The majority of failed fundoplications occur within 3years of primary surgery, with most patients exhibiting anterior or concentric defects. For these patients, laparoscopic revision fundoplication is a safe procedure with a low rate of short-term complications and satisfactory long-term results.

Analysis of reconstructive interventions in case of failures in hiatal hernia surgery

INTRODUCTION. The method of laparoscopic fundoplication for hiatal hernia is today the most common surgical intervention for this pathology. However, there are a significant number of complications, one of the most severe is relapse of the disease. Today, according to the world literature, there is not enough information about the causes of relapse, methods of prevention and long-term postoperative results of reconstructive operations.The OBJECTIVE was to analyze of reconstructive surgeries in patients who underwent surgery for gastroesophageal reflux disease associated with hiatal hernia.METHODS AND MATERIALS. The work was performed on the basis of data from two clinics – Oncology Department ¹ 2 of the RCOD of the Ministry of Health of the Republic of Tatarstan and Thoracic Department ¹ 2 of the RCB of the Ministry of Health of the Republic of Tatarstan. 1,661 laparoscopic interventions were performed in patients with hiatal hernia. The basis of the work is the analysis of reconstructive operations in 99 patients.RESULTS. The most common reasons for reconstructive operations were relapses of diseases in gastroesophageal reflux disease associated with a hiatal hernia: destruction and (or) migration of the fundoplication cuff – 77 (77 %) cases, recurrence of paraesophageal hiatal hernia – 10 (11 %). Reconstructive surgery in patients with relapse of hiatal hernia remains the method of choice and leads to positive results in 83 % of cases.CONCLUSION. Surgical treatment of hiatal hernia should be carried out in a specialized hospital and experienced surgeons who own both laparoscopic and open methods of treating this pathology.

Pediatric nutritional surgery and its implications: results from a unicentric retrospective analysis

PurposeExisting guidelines provide weak recommendations on the surgical management of nutritional problems in children. The objective was to design a management pathway to address the best nutritional surgery (NS) procedure in a given patient.MethodsRetrospective analysis of children treated at our department from January 2015 to December 2019. The sample was divided into two groups according to presence or absence of neurological impairment (NI). Patients with NI (Group 1) were classified in three subgroups based on presenting symptoms: A-Dysphagia without gastroesophageal reflux (GER); B-GER with or without dysphagia; C-Symptoms associated with a delayed gastric emptying.ResultsA total of 154 patients were included, 111 with NI. One-hundred-twenty-eight patients underwent only one procedure. Complications and mortality were superior in Group 1. In subgroup A, isolated gastrostomy was the first NS in all patients. In subgroup B most of patients were subjected to a Nissen fundoplication, while in 5 cases total esophagogastric dissociation (TEGD) was the first intervention. Considering the entire sample, 92.3% patients who underwent a TEGD did not require further procedures.ConclusionNS encompasses various procedures depending on presenting symptoms and neurological status. A management flowchart for these patients is proposed.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service.

Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution. We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed. We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%. LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

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

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

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

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

Serotonin blood level study, anxiety-depressive states indicators and patients life quality after laparoscopic treatment of gastroesophageal reflux disease

Nowadays effective treatment of gastroesophageal reflux disease (GERD) remains a difficult and still unsolved problem. The use of various antisecretory drugs in combination with surgical treatment does not allow to achieve a long lasting improvement of the quality of life and reliable prevention of complications. In this regard, special attention is paid to study humoral factors influencing the pathogenesis of GERD, data on which will improve the results of therapeutic and surgical treatment. It is promising to study the dynamics of serotonin after laparoscopic treatment of various types of GERD, especially in combination with dyspepsia, anxiety or depressive disorders, as well as the possibility of using drugs that affect the metabolism of this hormone to correct the above mentioned disorders and achieve long lasting recovery after laparoscopic fundoplication. The aim of the work was to study the dynamics of serotonin in the blood during laparoscopic total fundoplication and analyze the correlation of this hormone with the psychological well-being of patients before and after surgical treatment of GERD. Materials and methods. Laparoscopic fundoplication by Short Floppy Nissen modification was performed in 35 patients with GERD. There were 26 (74.3 %) women, 9 (25.7 %) men. Age – 55.3 ± 11.3. The comparison group consisted of 20 healthy volunteers (women – 14 (70.0 %); men – 6 (30.0 %), average age – 56.7 ± 10.6), who did not undergo surgery. The groups were comparable by gender and age. The studies were carried out in venous blood plasma, samples of which were maintained using standard methods and stored in a low-temperature freezer at a temperature of -80 °C. Tests for serotonin (Serotonin ELISA, RE59121, IBL) were studied on the immunoenzyme complex ImmunoChem-2100 (USA) of the Department of Clinical Laboratory Diagnostics in the Zaporizhzhia State Medical and Pharmaceutical University. The concentration of the last indicators was expressed in ng/ml. The presence of concomitant anxiety, depression and level of psychological well-being was assessed using the GAD-7, PHQ-9 and SF-36 questionnaires. Statistical assessment of the research results was carried out using the Statistica for Windows 13 software package (StatSoft Inc., No. JPZ804I382130ARCN10-J). Differences were considered statistically significant at p &lt; 0.05. Results. The serotonin level in the blood of practically healthy people was 5.8 ± 1.5 ng/ml. In the main group serotonin values before surgical treatment were 3.1 ± 1.3 ng/ml. After surgical treatment the serotonin level increased to 5.4 ± 1.8 ng/ml and was not statistically different from the level of practically healthy patients. The dynamics of serotonin levels correspond to the dynamics of the patients number with signs of anxiety and depression before and after surgery in the main group, as well as the improvement in the psychological state of patients after surgery compared to preoperative data on the scales of the “psychological component” of SF-36 health questionnaire: Vitality (VT), Social Functioning (SF), Role-Emotional (RE), Mental Health (MH). Conclusions. Laparoscopic crurorrhaphy and fundoplication in the Short Floppy Nissen modification through the mechanism of serotonin helps to improve the psychological state of patients with GERD in the postoperative period, eliminate anxiety and depression, improve quality of life and achieve a lasting antireflux effect. The obtained dynamics of serotonin levels confirms its participation in the formation of behavioral reactions in GERD, helping to improve the results of surgical treatment.

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

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

Esophago-gastric junction findings on high resolution impedance manometry in children with esophageal atresia.

Using high resolution impedance manometry (HRIM), this study characterized the esophago-gastric junction (EGJ) dynamics in children with esophageal atresia (EA). Esophageal HRIM was performed in patients with EA aged less than 18 years. Objective motility patterns were analyzed, and EGJ data reported. Controls were pediatric patients without EA undergoing investigations for consideration of fundoplication surgery. Seventy-five patients (M:F = 43:32, median age 1 year 3 months [3 months-17 years 4 months]) completed 133 HRIM studies. The majority (64/75, 85.3%) had EA with distal tracheo-esophageal fistula. Compared with controls, liquid swallows were poorer in patients with EA, as evident by significant differences in distension pressure emptying and bolus flow time (BFT). The integrated relaxation pressure for thin liquid swallows was significantly different between EA types, as well as when comparing patients with EA with and without previous esophageal dilatations. The BFT for solid swallows was significantly different when compared with EA types. We have utilized HRIM in patients with EA to demonstrate abnormalities in their long-term EGJ function. These abnormalities correlate with poorer esophageal compliance and reduced esophageal peristalsis across the EGJ. Understanding the EGJ function in patients with EA will allow us to tailor long-term management to specific patients.

Medium term (> 12 months) outcomes after laparoscopic hiatal hernia repair without conventional fundoplication using PH4B-mesh implant (Phasix™) in 176 reflux patients: experience and technique.

Hiatal mesh repair remains a controversial topic among anti-reflux surgeons. Biosynthetic mesh cruroplasty may prevent early recurrence while avoiding late esophageal erosion and strictures associated with non-resorbable materials. So far, medium-term results on hiatal PH4B (Poly-4-Hydroxybutyrate) mesh repair from high-volume centers are lacking. We analyzed the medium-term efficacy and safety of PH4B mesh cruroplasty in 176 consecutive patients (≥ 18years) with symptomatic hiatal hernias. Treatment failure was defined as the clinical recurrence of reflux symptoms. Patients could choose between mesh augmented hiatal repair (combined with a modified anterior hemifundoplication and fundophrenicopexy), Nissen fundoplication, and magnetic sphincter augmentation at their discretion. We also describe the surgical approach to mesh augmented hiatal repair used at our center. On average, patients were 55 (± 14) years old and followed up for 22 (± 7; sum: 3931) months. Treatment failed in 6/176 (3%, 95% CI: 2-7%) patients. The 24-month Kaplan-Meier failure estimate was 2.8% (95% CI: 0.4-5%). Each centimeter in hernia size increased the risk of failure by 52% (p = 0.02). Heavier patients (BMI > 27) had an 11% higher probability of clinical symptom recurrence (p = 0.03). The dysphagia and bloating/gas rate were 13/176 (7%), each. 8 (5%) patients required endoscopy due to dysphagia but without intervention. No serious complications, including mesh infection and erosion, or fatalities, occurred. Augmented PH4B mesh cruroplasty without conventional fundoplication shows excellent intermediate-term results in patients with reflux disease due to hiatal hernia. Around one in thirty patients experience treatment failure within 2years of surgery. Hernia size and overweight are key determinants of treatment failure.

Laparoscopic floppy Nissen fundoplication with valve calibration: a safe and efficient procedure.

A floppy Nissen fundoplication with valve calibration (FNF-VC) performed by laparotomy has been described, to reduce postoperative dysphagia and gas bloating after 360°-fundoplication. As laparoscopy is the gold standard for fundoplication, this study reports the first results of a modified FNF-VC adapted for laparoscopy (LFNF). Seventy-two consecutive patients, who underwent LFNF for refractory GERD between 2012 and 2021, were included. Postoperative outcomes and quality of life (QoL) by GERSS, GERD-HRQL, and GIQLI scores before and after surgery were assessed. The main symptoms were pyrosis (81%), regurgitation (39%), Ear-Nose-Throat symptoms (22%), and thoracic pain (24%). Hiatal hernia was present in 85% (n = 61) of the patients. There was no postoperative mortality, and the severe postoperative morbidity rate (Dindo-Clavien ≥ III) was 6%. After a median follow-up of 3.6years, only 8% of patients were still taking proton-pump inhibitors. Long-term residual dysphagia was noted in 15% of the patients, but none required reoperation or interventional endoscopic procedures. QoL improved, with a significant reduction in GERSS and GERD-HRQL scores and a postoperative GIQLI of 101.75 (75-117.5). This series reports the safety and efficacy of an FNF-VC adapted for laparoscopy to treat GERD with a limited rate of residual dysphagia.

Proposal of set-up standardization for general surgery procedures with the CMR Versius system, a new robotic platform: our initial experience.

The article describes our initial experience using CMR Versius platform for several procedures in general surgery. Between September 2022 and April 2023, seventy patients underwent robotic surgery in a multi-robotic referral center (San Paolo University Hospital, Milan, Italy). Three surgeons with only laparoscopic experience performed 24 cholecystectomies, 13 inguinal hernia repairs, 9 ventral hernia repairs, 7 right hemicolectomies, 11 left hemicolectomies, 1 sigmoidectomy, 1 ileocecal resection, 1 ventral rectopexy, 1 Nissen fundoplication, 1 total splenectomy, and 1 exploration with multiple biopsies. All surgeries were full-robotic, with only one conversion to laparoscopy. The short length of stay and low rate of severe morbidity are promising findings. Although operative time was lengthened, clinical outcomes were not affected. Our experience demonstrates that the adoption of Versius system is safe and feasible in general surgery. The standardization of port placement and BSU set-up can certainly reduce the operative time.

Laparoscopic surgery of a rare giant paraesophageal hernia: a case report

Introduction and Importance: In the case of a hiatal hernia, the weakening of the esophageal hiatus allowed part of the stomach to slide to the mediastinum. Although the identification of hernias in esophageal hiatus is prone to subjectivity because of anatomical diversity, it is thought to occur often in radiological or endoscopic tests, with a range of 10–20% in the western population. Although asymptomatic, a rare form of hiatal hernia called a paraesophageal hernia (PEH) can be linked to serious, perhaps fatal consequences such as stomach volvulus. Only symptomatic patients should receive surgical treatment. In this case study, the authors present and discuss a giant PEH patient treated with laparoscopic hernial repair and fundoplication. A laparoscopic approach to PEH is important because of the shorter length of stay and fewer complications. Case Presentation: A 46-year-old Asian entered the hospital with symptoms of frequent dyspepsia syndrome, and from a computed tomography (CT) scan, she was diagnosed with a giant paraesophageal hernia. Hernia repair and fundoplication were performed laparoscopically. She was discharged three days after the surgery without significant complications. Clinical Discussion: This report represents a rare case of giant PEH. Although there are some limitations to laparoscopic surgery, it might be associated to fewer complication rate, a shorter stay in the hospital, and a faster recovery. Conclusion: Laparoscopic hernia repair and fundoplication is a safe and applicable surgery for people with symptomatic PEH.

Laparoscopic Redo Fundoplication – Indications and Challenges: A Case Report with Review of Literature

Herein, we report the case of a 72 year old female patient who underwent surgery for hiatus hernia – Laparoscopic Nissen’s Fundoplication in some other hospital. She developed progressively worsening dysphagia in the postoperative period. Multiple sessions of Endoscopic balloon dilatation were attempted, but to no lasting symptomatic relief. She then underwent a successful redo laparoscopic surgery, after due investigations.