Fundoplication Research Articles

Bolus exposure as a novel predictor of postoperative symptom resolution after laparoscopic nissen fundoplication: A two-institutional retrospective cohort study.

Even in the absence of definite evidence of pathological acid reflux, antireflux surgery (ARS) can still effectively improve gastroesophageal reflux symptoms. Nonetheless, predicting postoperative reflux symptom improvement has been primarily dependent on acid-based parameters. No objective index reflecting both acid and non-acid reflux was identified to select ARS candidates. Prospectively collected data of 121 patients with gastroesophageal reflux disease (GERD), who underwent laparoscopic Nissen fundoplication from two institutions, were retrospectively reviewed. The patients reported preoperative and postoperative GERD symptoms using the Korean version of the GERD questionnaire, along with the gastroesophageal reflux disease-health-related quality of life (GERD-HRQL). The patients assessed for reflux symptoms using bolus exposure, acid exposure time (AET), and DeMeester score (DMS) as measurements were selected. For each reflux parameter, its association, correlation, and predictive capacity of the degree of postoperative symptom resolution were analyzed using chi-squared tests, point-biserial correlations, logistic regression analyses, and receiver operating characteristic curve analyses. 72 patients were eligible for this study. Bolus exposure was superior to the other parameters in terms of the degree of association and correlation with resolution of typical symptoms. Bolus exposure also showed a higher diagnostic accuracy in predicting the resolution of epigastric pain (area under the curve [AUC]=0.723, P=0.013) and regurgitation (AUC=0.981, P<0.001). Secondary analyses were performed in patients without pathological reflux, defined as the DMS-negative (DMS<14.7) or AET-negative (AET<6%) groups. In the secondary analyses, bolus exposure showed considerable diagnostic accuracy with statistical significance for all typical symptoms in both in the DMS-negative (heartburn: AUC=0.717, P=0.025; epigastric pain: AUC=0.717, P=0.025; regurgitation: AUC=0.975, P<0.001) and AET-negative (heartburn: AUC=0.681, P=0.045; epigastric pain: AUC=0.749, P=0.009; regurgitation: AUC=0.975, P<0.001) groups. Bolus exposure, a parameter of total reflux, was superior to AET or DMS in defining candidates for ARS. Further studies investigating the surgical indications for ARS in patients with non-acid reflux using bolus exposure are required.

Features Associated With the Presence of Specific Bacterial Strains in Pediatric Tracheostomy.

Tracheostomy bypasses physical barriers that decrease microbial access to the lower airway, which can lead to changes to the lung microbiota. Patients often become chronically colonized with potential pathogens. This study described the incidence and prevalence of specific organisms in a 5-y cohort of children with tracheostomy. This retrospective cohort of children aged 0-18 y with tracheostomy identified associations between microbial species and subject characteristics including reason for tracheostomy, gastrostomy tube (G-tube), fundoplication, and ventilator use using chi-square test or Fisher exact test. Of 113 eligible patients, 79 (57% male) met study inclusion criteria. Reasons for tracheostomy included airway obstruction secondary to craniofacial anomalies in 16 children (20%), upper-airway obstruction in 14 subjects (17.3%), neuromuscular disorder in 19 subjects (24%), bronchopulmonary dysplasia with or without pulmonary hypertension in 17 subjects (21%), and congenital heart disease in 13 subjects (16%). Most (69%) used a ventilator for at least 6 h/d; 63% had a G-tube; 41% also had a Nissen fundoplication. Of the 20% with upper-airway obstruction, one third were ventilator dependent, unlike other diagnoses where 57% used a ventilator. Staphylococcus aureus (52/113), Pseudomonas aeruginosa (43/113), and Stenotrophomonas species (39/113) were the most frequently identified bacterial species. Most microbes identified were not associated with subjects underlying diagnoses, ventilator use, or feeding type. However, there was a significant association between upper-airway obstruction and group B Streptococcus species and G-tube with P. aeruginosa. This retrospective single-site descriptive cohort analysis of pediatric subjects with long-term tracheostomy identified trends in microbial prevalence. The presence of specific bacterial strains was more likely to follow individual subject trajectories than sequential appearance of species. P. aeruginosa was associated with G-tube and Streptococcus species with upper-airway obstruction. Ventilator dependence was not associated with specific microbial profiles.

A cost-effectiveness analysis of RefluxStop against relevant therapeutic alternatives for chronic gastroesophageal reflux disease in Sweden

ABSTRACT Introduction The standard treatment for gastroesophageal reflux disease (GERD) is proton pump inhibitors (PPIs). In selected cases, Nissen fundoplication is offered as a surgical treatment option, but alternative endoscopic and minimally invasive surgical alternatives are emerging. RefluxStop is a new technology for the treatment of GERD. Research design and methods A cost-effectiveness analysis of RefluxStop in comparison to PPI therapy and Nissen fundoplication in the Swedish healthcare setting was conducted using a Markov model and available comprehensive population and clinical trial-based long-term data. Benefits were measured in quality-adjusted life-years (QALYs). Uncertainty was determined by deterministic and probabilistic sensitivity analyses. Results The base case incremental cost-effectiveness ratios (ICERs) for RefluxStop in comparison to PPIs and Nissen fundoplications were SEK 48,152 (€ 4,531) and SEK 62,966 (€ 5,925) per QALY gained, respectively. At a cost-effectiveness threshold of SEK 500,000 per QALY gained, RefluxStop has a high likelihood of being cost-effective, with probabilities of 96% and 100% against Nissen fundoplication and PPIs, respectively. The results of the model remained robust with sensitivity analysis. Conclusions RefluxStop may offer a highly cost-effective long-term treatment alternative for chronic GERD patients over lifelong PPI therapy, but also in comparison with laparoscopic Nissen fundoplication.

A comparative study of magnetic sphincter augmentation and Nissen fundoplication in the management of GERD.

Magnetic sphincter augmentation (MSA) is a novel surgical technique investigated at many clinical institutes worldwide. In 2012, it received approval for treating Gastroesophageal reflux disease (GERD) because of its superior benefits compared to drug therapies. This study aimed to explore the safety and efficacy of MSA compared with Laparoscopic Nissen fundoplication (LNF) for GERD treatment. A retrospective analysis was conducted on 40 patients who received preoperative matching features of MSA and LNF. The surgical details and one-year postoperative outcomes were analyzed and reported. Significant improvement in GERD symptoms was observed in both MSA and LNF patients over the one-year surgical follow-up. Dysphagia was a common postoperative complication observed in both procedures, but no cases required endoscopic dilation. MSA had a significantly shorter operative time compared to LNF (112 vs.175min, P < 0.001), with faster postoperative dietary recovery [1(0.5,1.5) vs. 3(1.63,5.38) month(s), P < 0.001] and more preservation of hiccup ability (87.5% vs. 45.83%, P = 0.01). No significant disparities were observed between the two groups regarding hospital duration, recovery of physical strength, and upper gastrointestinal complaints. In conclusion, both LNF and MSA are safe and successful surgical therapies for GERD. The benefits of MSA include reduced surgical time, quicker nutritional recovery following surgery, and preservation of hiccup capacity. However, with both surgeries, postoperative dysphagia is a prevalent problem that emphasizes the significance of improving preoperative communication. When selecting between two surgical techniques, it is crucial to consider the postoperative symptoms associated with each procedure.

Using impedance planimetry (EndoFLIP) to determine ideal distensibility ranges for esophageal motility disorders

ObjectiveUse of impedance planimetry (EndoFLIP) has shown distensibility index ranges associated with improved patient-reported outcomes after antireflux surgery. Questions remain whether the previously described ideal distensibility index range can be used for patients with esophageal motility disorders. We hypothesized that patients with esophageal motility disorders would have a different ideal distensibility range for optimal outcomes. MethodsA retrospective review of a prospectively maintained gastroesophageal database was performed for all patients undergoing Toupet and Nissen fundoplication and impedance planimetry. Demographic data, perioperative outcomes, and quality-of-life indicators (Reflux Symptom Index, Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire, and gas/bloat and dysphagia scores) were analyzed and compared between patients by use of the χ2 and Wilcoxon rank-sum tests. ResultsFrom 2015 to 2024, 475 patients underwent laparoscopic fundoplication and impedance planimetry evaluation. Of those, 160 had a final distensibility index score in the ideal range, 165 with a final distensibility index score <2.5, and 150 with a final distensibility index >3.6. In the ideal-range cohort, there were no statistically significant differences between those with normal and abnormal motility in regards to outcomes or quality of life indicators. In the low distensibility index cohort, patients with abnormal motility had worse Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire, gas/bloat, and dysphagia scores at 1 year postoperatively compared with those with normal motility. More patients in the low distensibility index cohort required dilations postoperatively, and more patients in the high distensibility index cohort had recurrences compared with those in the ideal range cohort. ConclusionThe previously described ideal distensibility index range of 2.5–3.6 for patients undergoing laparoscopic fundoplication may be used for patients with certain esophageal motility disorders.

Revision of Failed Nissen Fundoplication Using Combined Antireflux Mucosal Ablation and Endoscopic Full Thickness Fundoplasty

Revision of Failed Nissen Fundoplication Using Combined Antireflux Mucosal Ablation and Endoscopic Full Thickness Fundoplasty

Comparative analysis of readmission rates and outcomes: Sleeve gastrectomy with versus without Nissen fundoplication using a National Database.

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure. To study the safety of LSG done with Nissen Fundoplication (NF) in patients affected by obesity and GERD and assess the complication rate. A retrospective cohort study using the Nationwide Readmissions Database from 2016 to 2019. A total of 236111 patients underwent LSG with and without NF. A matched cohort of 1096 without NF and 548 with NF was obtained. The median age of patients was 47 years old. Median length of hospital stay was higher in the LSG with NF group. Median total charge was higher in the LSG with NF group. There was no statistically significant difference in 30-day readmission rates in patients with obesity and GERD who received LSG with NF compared to those who received LSG alone. Complications after both procedures were low, which highlights the safety of both procedures.

614. LAPAROSCOPIC RE DO FUNDOPLICATION

Abstract Background Laparoscopic fundoplication though an effective form of therapy for patients with refractory gastroesophageal reflux disease, can fail due to poor patient selection or compromised surgical technique. Re do laparoscopic fundoplication for failed anti reflux surgery is a challenging task prone to further failures if not properly done. Methods Retrospective analysis of consecutive patients who underwent laparoscopic redo fundoplication in a tertiary care center between January 2012 and March 2022. Results There were a total of 24 patients that underwent redo fundoplication during the study period. Wrap migration was noted in 8 (33.3%) patients while the wrap was too tight which led to dysphagia in 5 (20.8%) patients. Two patients had previously undergone laparoscopic redo fundoplication while one patient initially underwent open Nissen’s fundoplication. All the patients were managed successfully laparoscopically without any conversion. The median time interval between the first surgery and the redo operation was 8 months (3 months to 12 years). Symptomatic improvement was observed in 20 (83.3%) while 4 (16.7%) patients continued to have symptoms. Conclusion Laparoscopic redo fundoplication can yield satisfactory results in patients after initially failed anti reflux surgery when performed in experienced centers. Proper case selection and meticulous surgical technique to address the primary cause of failure is paramount.

Long-Term Outcomes of Magnetic Sphincter Augmentation: A Comparative Study to Nissen Fundoplication

BackgroundMagnetic sphincter augmentation (MSA) demonstrates improvement in gastroesophageal reflux disease (GERD) across multiple short-term studies. Long-term, single-arm studies show durable outcomes, but there is limited comparative data to Nissen fundoplication (NF). MethodsWe performed a retrospective propensity-matched cohort study of patients with GERD undergoing MSA or NF between 2012 and 2018. Patients were matched on age, sex, body mass index, size of hiatal hernia, length of Barrett esophagus, and motility in a 1:1 fashion. A total of 523 patients (177 MSA, 346 NF) underwent surgery and after matching 177 MSA and 177 NF cases were analyzed. ResultsAt 1 year, GERD quality of life scores improved (22 to 5 MSA vs 24 to 5 NF, P = .593). Proton pump inhibitor use was 14% vs 5% (P = .010). pH testing demonstrated improved DeMeester scores (42 to 21 vs 46 to 7, P < .001). At 5 years, GERD quality of life scores were stable (5 to 5 vs 5 to 4, P = .208). Proton pump inhibitor use was 31% vs 26% (P = .474). The incidence of endoscopic dilation was similar between MSA and NF (7% vs 10%, P = .347). Reoperation rates were higher for MSA (10% vs 4%, P = .022) and recurrent hiatal hernias were found in 18% vs 7% (P = .007). Compared to NF, MSA undergoing complete dissection showed no difference in dilation (5% MSA vs 7% NF, P = .527), reoperation (8% MSA vs 6% NF, P = .684) or hernia recurrence (10% MSA vs 6% NF, P = .432). ConclusionsMSA achieves similar improvements in quality of life and freedom from medical therapy compared to NF, especially with complete hiatal repair.

495. LAPAROSCOPIC FUNDOPLICATION IMPROVES ESOPHAGEAL MOTILITY IN PATIENTS WITH GERD A HIGH VOLUME SINGLE CENTER CONTROLLED STUDY IN HIGH-RESOLUTION MANOMETRY ERA

Abstract Background Pathophysiology of GERD is complex and esophageal motility disorders are frequently contributing to the disease. Most of the existing literature demonstrates that Laparoscopic Fundoplication (LF) is safe in the setting of ineffective or weak peristalsis, however the effect of the wrap on esophageal motility is still debated. This study aimed to assess how a functioning and effective fundoplication could impact the esophageal motility in patients with GERD. Methods We analyzed prospectively collected data on patients who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication for GERD between 2010-2022. We selected patients who have been treated with LF according to the GERD international guidelines. The exclusion criteria were: patients with a giant hiatal hernia and patients with a proof of a too-tight LF. Patients were evaluated with the GerdQ questionnaire, barium-swallow, endoscopy and HRM and 24-hour pH-Impedance before and after surgery. The HRM were reviewed by 2 experts (Chicago Classification v4.0). LF failure was recorded in case of an abnormal postoperative pH-MII using the Lyon 2.0 criteria. Results We recruited 124 patients (M:F=89:35). Fifty-eight LN and 66 LT were recorded. A good outcome at the 24-hour pH-Impedance was registered in 103 patients (GLF) and a failure in 21 patients (FLF). As shown in Figure 1, in GLF patients, 29 had a preoperative motility disorder (24 IEM and 5 DES), and postoperatively 22 (76%) of these patients had a normalization of the esophageal motility. Ten FLF patients had a preoperative motility disorder (9 IEM and one DES); 4 (40%) of them showed normal motility after LF. There was a significant association between GLF and normalization of esophageal motility (p&amp;lt;0.05). Conclusion This study demonstrates that LF is an effective and functioning treatment in patients with GERD associated with an esophageal motility disorder. Moreover, our results indicate that LF could determine a normalization of the disordered esophageal motor function in patients with GERD.

806. MINIMALLY INVASIVE REVISION FUNDOPLICATION, IS IT SAFE AND FEASIBLE? SINGLE CENTER EXPERIENCE

Abstract Introduction Laparoscopic fundoplication has become standard of care for patients with refractory gastroesophageal reflux disease, large and symptomatic hiatal hernia. Failure rate for laparoscopic fundoplication was between 2 to 17%. Doing Revisional Antireflux surgery is technically difficult. Our aim is to analyse symptomatic improvement post surgery, safety and durability of procedure in patients who underwent revision fundoplication at our centre Patients and Methods 22 patients underwent Minimally invasive revision fundoplication between January 2019 to January 2022 were taken into study, of them 12 gentlemen and 10 women were noted. Modified DeMeester score was calculated in all patients preoperatively and on 6 months follow up. Results All patients underwent primary surgery laparoscopically. 14 patients (63.6%)had recurrent reflux symptoms and 8 patients (36.3%) had severe dysphagia. Revision fundoplication was done laparoscopically in 20 patients and 2 patients Robotic surgery was done. Intraoperatively 11 patients had wrap migration, 8 patients had tight wrap, 3 patients had twist of wrap. In the re-do anti-reflux surgery (ARS) procedure, floppy Nissen fundoplication was performed in 86.4% of the patients, which amounts to 19 patients., and 3 patient underwent a 270-degree Toupet fundoplication. In 2 patients, additional composite mesh reinforcement was employed. 13.6 % of patients had intraoperative complications, 9.09 % of patients had pleural injury, 4.7 % had intraoperative bleeding, 9.09% of patients had gallstone disease, for which cholecystectomy was done. All patients anterior and posterior vagus identified and preserved. On follow up 80% of patients had resolution of symptoms, 18% needed intermittent PPI. At a median follow up of 18 months, no surgical failure was noted in endoscopy. Conclusion Laparoscopic revision fundoplication is a safe procedure when operated in a high volume centre by an expert surgeon.

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

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

788. LAPAROSCOPIC TOUPET FUNDOPLICATION - PERSONAL EXPERIENCE 174 CASES REPORT

Abstract Background Gastroesophageal Reflux Disease (GERD) is one of the most important disorders of the gastrointestinal system, affecting 20% t o 40% of the population of the United States of America, and 12% on the world. There are several surgical techniques for treating this disease, including the Toupet Fundoplication technique, which reduce the postoperative complications, like dysphagia, Gas Bloating Syndrome and incapacity to belch. Methods Prospective cohort study with 174 patients in two hospitals, one public and the other private, in the city of Natal, Brazil. All patients were evaluated postoperative as the following: 1) first week after the surgery were interviewed by the master surgeon; 2) fifty days after surgery were submitted to a Barium Swallow; 3) three months after the surgery the endoscopy was performed. The follow-up was carried out in relation to the symptom of postoperative dysphagia, ability to belch, feeling of fullness and gastroesophageal reflux. Results A total of 174 patients were observed, who were submitted for the Toupet Fundoplication procedure. Of this total, 145 patients were followed-up. 143 patients had improvement of symptoms related to esophageal disease and are clinically satisfied. One patients had recurrence of reflux symptoms. One patient had Gas Bloating Syndrome. Conclusion Toupet Fundoplication was a standard procedure in the study and achieved good results in 98,62% of the cases followed during follow-up of GERD control and relief symptoms with a minimal rate of adverse effects in the postoperative period.

274. ROBOTIC REVISIONAL HIATAL HERNIA REPAIR (R-RHR): DOES IT MAKE SENSE?

Abstract Background The gastroesophageal reflux disease (GERD) is increasing among our population and Nissen Fundoplication still remains as the most widely performed technique. The robotic approach to the hiatal hernia repair has been proven to be safe and feasible. Precision and comfort seem to be some reasons that it makes, at least, comparable to the laparoscopic approach. Revisional hiatal hernia is a challenging situation to the operator due the adhesions and fibrosis of the tissues so our concern is that the best technology available is needed. Methods From June 2019 to November 2023 our division performed 14 cases of Robotic Revisional Hiatal Hernia Repair (R-RHR). Demographic items such as Gender, Age, Body Mass Index (BMI), Previous surgery, Time from first surgery and Postoperative outcomes as Operation Time, Length of stay (LOS), Mesh use, Complications and Readmissions were recorded. Results 10 women and 4 men were recruited. In all cases the DaVinci robotic platform X and Xi (Intuitive) was used. Mean age resulted in 63.5 years old (sd 12.25). Mean BMI was 26.97 (sd 3.52). In 71.4% cases the Previous HH Surgery was Nissen Fundoplication. 49.3 months was the mean time from the first surgery to the revisional procedure. 163.5 (sd 83.7) minutes was the mean operation time. Mean Lenght Of Stay resulted in 3.4 days (sd 1.4). There were no conversions to the laparoscopic approach. In 5 patients (35.8%) a mesh was placed. Pleural effusion was the only postoperative complication reported (1/14) and it was managed non-operatively. No other complications were recorded and mortality rate was 0. Conclusions To the authors knowledge, this is Spain’s largest Robotic - Revisional Hiatal Hernia Repair (R- RHR) series. The results lead us to conclude that the robotic approach, even the complexity of the surgery, is safe and feasible in trained teams with similar outcomes from the primary surgery that are published.

279. NOVEL REFLUX MICROASPIRATION SCINTIGRAPHY ALLOWS EFFECTIVE PATIENT SELECTION FOR ANTIREFLUX SURGERY IN PROXIMAL REFLUX EVENTS

Abstract Background and Aims There is currently no reference standard test for the detection of the extra-esophageal manifestations of gastroesophageal reflux disease (GORD). The current suite of diagnostic tests principally assess reflux events in the oesophagus have problematic accuracy issues in the pharynx. A new scintigraphic technique has been developed and validated against 24-hour oesophageal monitoring with pH, impedance. It allows direct visualization of refluxate in the laryngopharynx and lungs. This was utilised to evaluate patients having laparoscopic fundoplication for severe proximal reflux resistant to maximal medical therapy. Scanning may allow succesful patient selection for antireflux surgery. Methodology Following Institutional Ethics approval, 50 patients were assessed by scintigraphy before and after laparoscopic fundoplication (LF) at a single nuclear medicine facility. Standardised Reflux Symptom Indices (RSI) were obtained from each patient before and after surgery. Patients were scanned after oral 99m technetium Fyton administration with early dynamic images and delayed SPECT/CT images of the head, neck and lungs. Background corrected time-activity curves were generated for the pharynx and upper oesophagus from which frequency of reflux was estimated by counting events with activities greater than 2 standard deviations above fitted values. Frequencies, Spearman correlation and the student’s t test were utilised for analysis. Results The study population (35F, 15M) had a mean age of 63.9 years (Range 21-86). All patients underwent LF. Mean BMI was 26.8 with 67% being over-weight or obese. All patients had proximal reflux events in the early dynamic study. SPECT/ CT showed LPR events in 45/50 and pulmonary micro-aspiration (PMA) in 45/50 pre-operatively and in 36/50 and 20/50 post-operatively. The RSI, cough and throat clearing indices showed a significant fall post-operatively (p&amp;lt; 0.001). The frequency of scintigraphic pharyngeal reflux events was reduced from a mean of 4.5 in 30 minutes to 2.9 (t=9.1, p=0.004). Conclusion The novel scintigraphic test detects oesophageal and extra-oesophageal reflux events and permits direct visualization of refluxate in the head and neck structures and lungs. Scintigraphy correlates well with symptoms of reflux in the oesophagus and extra-esophageal structures such as the laryngopharynx (chronic cough and throat clearing) and the response to LF albeit partial. PMA was significantly reduced.

420. MESH REINFORCEMENT IN HIATAL HERNIA REPAIR: CLINICAL RESULTS OF OUR EARLY EXPERIENCE

Abstract Background Approximately one-third of the population develops diaphragmatic hernias among which only 10% are symptomatic. Restoration of the normal anatomy, hiatus closure and fundoplication are effective methods in the surgical treatment of diaphragmatic hernia repair. Placement of absorbable meshes to cover the hiatal closure emerges as a new, albeit controversial in the literature, technique for reinforcement. This study aims to assess the quality of life of patients diagnosed with hiatal hernia who underwent Nissen or Toupet fundoplication with absorbable biosynthetic mesh placement covering the suturing of the hiatus as an additional step during the laparoscopic or robotic hiatal hernia repair. Methods Data of all patients who underwent Nissen or Toupet fundoplication with absorbable mesh reinforcement at the hiatus between 2020-2023 at our specialised unit was collected and analysed. Thirteen patients who had completed their 6-month and 1-year postoperative follow-up, were interviewed. GERD score, PPI use and postoperative endoscopy were evaluated. Results Occasional use of PPI was reported by one patient, whereas those who had already undergone endoscopy of the upper gastrointestinal tract presented no signs of esophagitis, recurrence of hernia or Barrett esophagus. One patient reported symptom improvement after the operation with a GERD score of 13, while the rest of the patients had a GERD score of 0 (12/13). Conclusion The treatment of diaphragmatic hernias with Nissen or Toupet fundoplication using absorbable mesh reinforcement of the hiatus after closure with sutures seems to be an effective therapeutic method with a success rate over 90% in our case series provided that the rest of the surgical steps are identical between the cases through a well-established technique by our surgical team. However, further studies with larger number of patients and longer follow-up are mandatory aiming to further investigate the potential benefits when mesh reinforcement is applied.

Laparoscopic revisional antireflux and hiatal hernia surgery results in a higher rate of complications and severity at 90 days than primary surgery

ObjectiveData on graded complications and their frequency after laparoscopic revisional antireflux and hiatal hernia surgery compared with primary surgery are lacking. We describe 30- and 90-day morbidity using the Clavien-Dindo classification. MethodsA total of 298 patients underwent revision surgery between 2003 and 2020 and were propensity matched to primary surgeries (1:2 ratio) based on age, sex, body mass index, American Society of Anesthesiology classification, Los Angeles grade esophagitis, presence of Barrett's, and indication for surgery. Complications were graded using the Clavien-Dindo classification, with the highest grade of complication reported per patient. ResultsAfter matching, both groups had a majority of female patients, with a median age of 60 years and a median body mass index of 29.5 kg/m2. Most were healthy, with nonerosive esophagitis and modest levels of Barrett's esophagus. A laparoscopic Nissen fundoplication was most common; however, a partial fundoplication was more common in revisions. Mesh, relaxing incisions, and Collis were more common in revisional surgery. At 30 days, total complications were similar (23.5% [70/298] vs 20.6% [123/596], P = .373) with 1 death in each group. Minor complications (less than Clavien-Dindo 3A) were comparable. Patients undergoing revisional surgery experienced Clavien-Dindo 3B complications (4.7% [14] vs 0.8% [5], P > .001) more frequently, with esophageal obstruction requiring revision and esophageal/gastric leak being most common. Grade Clavien-Dindo 4 A/B complications were comparable in both groups. At 90 days, patients undergoing revisional surgery experienced overall complications (7.1% [21] vs 2.0% [12], P = .003), and Clavien-Dindo 3B complications (1.0% [3] vs 0, P = .037) more frequently, with intra-abdominal abscess washout being the most common Clavien-Dindo 3B complication. ConclusionsRevisional surgery results in similar total complications at 30 days, but additional complications can occur out to 90 days.

Impact of Toupet fundoplication with bougie on post-operative dysphagia and quality of life.

Numerous studies comment on quality of life outcomes comparing complete and partial fundoplication with or without a bougie. Society guidelines are moving toward recommending partial fundoplication over complete fundoplication due to improved side effect profile with similar outcomes. Retrospective studies and randomized trials have elucidated that use of a bougie during Nissen fundoplication does impact long-term dysphagia. To date there are no retrospective or prospective data that guide practice for partial fundoplications. The purpose of this project is to investigate the clinical implications of using a bougie for Toupet fundoplication with regard to short-term and long-term dysphagia and need for further therapeutic interventions. A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic, pre-operative quality of life outcomes data, perioperative, and post-operative quality of life outcomes data of 373 patients from 2011 to 2022 undergoing Toupet fundoplication without bougie or with a traditional Savary 56Fr or 58Fr bougie were reviewed. The two groups were compared using student's t-test to identify statically significant differences between the groups. Between 2011 and 2022, 373 patients underwent Toupet fundoplication (276 with traditional bougie, 97 without). Median follow-up in the bougie group was 19months, versus 9months in the non bougie group. There was no difference between early (3weeks) and late dysphagia scores (6months). In the bougie group there were two mucosal perforations due to the bougie. There were no statistically significant differences in GERD-HRQL, gas bloat, and dysphagia scores between groups at one year. There is no difference observed in early or late dysphagia scores, GERD-HRQL, gas bloat or need for dilation in patients undergoing Toupet fundoplication with or without a traditional bougie. It is reasonable to discontinue the use of a traditional bougie during Toupet fundoplication, especially due to risk of esophageal perforation.

373. FLIPPING THE SCRIPT: ENDOFLIPPING THROUGH ESOPHAGEAL CHALLENGES WITH A TWIST!

Abstract Background High-resolution esophageal manometry (HRM) is the gold standard for studying esophageal motility disorders but isn't universally available, and it's also reported as invasive and uncomfortable. The EndoFLIP system offers a dynamic evaluation of the esophagogastric junction (EGJ), crucial for patients with inconclusive HRM or undergoing endoscopic or surgical therapy such as myotomy or fundoplication. EndoFLIP is a practical tool in patients with dysphagia with normal upper endoscopy, allowing diagnostic assessment during the same procedure, and better selecting patients for subsequent HRM. Methods We conducted a retrospective study where we analyzed EndoFLIP procedures performed at a tertiary center from January 2022 to February 2024, for multiple indications, including characterization of findings on HRM, primary investigation of patients with dysphagia undergoing diagnostic upper endoscopy, motility study in patients intolerant to HRM, and post-therapeutic endoscopic/surgical assessment. Results Sixty-nine patients submitted to EndoFLIP procedures were included (39.1% male; 60.9% female) with a median age of 62 years. The primary indication was dysphagia, with 17.3% of patients being intolerant or referred with inconclusive HRM. EndoFLIP enabled diagnosis in all patients, even with an inconclusive HRM. Endoflip was performed on patients with treated achalasia with recurrence of dysphagia (16%), of which 55% exhibited reduced distensibility of EGJ. The evidence of reduced distensibility allowed patient selection for further treatment. Seven patients underwent EndoFLIP to characterize EGJOO. Comparing paired data from HRM and EndoFLIP, overall concordance was only 47,1%. Endoflip showed a large discordance for the EGJOO group, with 50% having normal findings and 20% confirming EGJOO. 43,8% of patients diagnosed with EGJOO confirmed by EndoFLIP underwent endoscopic therapy during the same procedure, allowing the diagnosis and treatment at the same time. Four patients with gastroesophageal reflux disease, intolerant to HRM and proposed for Nissen fundoplication, underwent EndoFLIP for EGJ and esophageal motility evaluation. Currently, they are proposed for surgery due to the normal findings on EndoFLIP. Conclusion The use of EndoFLIP in evaluating esophageal motility disorders presents a paradigm shift, overcoming the limitations of traditional methods like HRM. Our retrospective study demonstrates its pivotal role in diagnosing and managing patients with dysphagia submitted to diagnostic endoscopy, especially post-interventions like achalasia or Nissen fundoplication. With its ability to provide comprehensive assessments and guide tailored treatments, EndoFLIP emerges as a valuable tool in clinical practice. Its impact on patient management, evidenced by alterations in treatment strategies in over 80% of cases, underscores its significance.

811. POOLED 1-YEAR SAFETY AND QUALITY-OF-LIFE DATA AFTER REFLUXSTOP SURGERY AT TWO LARGE HOSPITALS IN SWITZERLAND: A RETROSPECTIVE CHART ANALYSIS

Abstract Background The standards of care in reflux disease management are proton pump inhibitor (PPI) therapy and conventional antireflux surgery, however, both options carry the caveats of medication irresponsiveness and troublesome postoperative sequelae, respectively. More specifically, PPIs respond inadequately in up to 40% of cases and Nissen fundoplication is associated with postoperative dysphagia in a significant proportion of patients. RefluxStop is an innovative technology that was adopted at our two respective institutions following promising safety and effectiveness data from its CE mark trial. We present the pooled safety and quality-of-life data of our 1-year experience with RefluxStop surgery. Methods Between September 2018 and August 2023, RefluxStop surgery was performed on 121 patients as part of routine clinical care at two hospitals, both of which are high-volume centers for antireflux surgery. The procedure involves crural repair with hiatal hernia reduction, reconstruction of the flap valve and angle of His, narrow esophagogastric (90-110°) plication, and device implantation in an external pouch on the gastric fundus (Figure 1). A retrospective chart analysis was conducted to document perioperative adverse events (AEs) and quality-of-life improvements via Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) score. Higher GERD-HRQL scores are indicative of more severe disease. Results Baseline patient characteristics included mean age 54.7 years, female sex (52.9%), body mass index 27.2±4.1 kg/m2, large hiatal hernia &amp;gt;3 cm (46.3%) of median (IQR) size 3 (2-5) cm, abnormal esophageal motility (60.3%), and Barrett’s esophagus (27.3%). At 1-year follow-up, patients experienced a median (IQR) reduction of 90.5% (81.4-100%) in total GERD-HRQL score. Intraoperative AEs included conversion to laparotomy for adhesiolysis with bleeding (n=1), bleeding short gastric arteries leading to return to the operating room the next day (n=1), and esophageal perforation repaired intraoperatively (n=1). Postoperative AEs are summarized in Table 1. Conclusion The results of this pooled retrospective chart analysis support the promising early data of the RefluxStop CE mark trial. Few and predictable AEs occurred during the study period while significant improvements in quality of life were observed, as evidenced by 90.5% (81.4-100%) reductions in GERD-HRQL score. Notably, this pooled cohort of patients was comprised of substantial proportions of difficult-to-treat patients (i.e., abnormal esophageal motility in 60.3%, large hiatal hernia &amp;gt;3 cm in 46.3%), providing evidence for wider implementation of RefluxStop surgery in real-world settings. Additional evaluation is required to further delineate the role of this promising innovative antireflux surgery.