Surgery For Gastroesophageal Reflux Disease Research Articles

Efficacy evaluation of pepsin in laparoscopic antireflux surgery for gastroesophageal reflux disease.

The false positive rate of the PPI test for the diagnosis of typical symptoms of gastroesophageal reflux disease (GERD) is extremely high. This study aims to investigate the effect of the pepsin test on GERD and laparoscopy-assisted anti-reflux surgery for GERD. A total of 30 GERD patients were enrolled into this study, and the pre-diagnosis of GERD was determined by symptom evaluation, impedance-pH examination, gastroscopy and pepsin test. All patients underwent surgery. Among the 30 GERD patients, 18 patients were male and 12 were female, and their average age was 58.2 + 12.6years old. The patients were treated with laparoscopic fundoplication and hiatus hernia repair after preoperative assessment. A total of 28 patients were followed up, one patient developed recurrent symptoms, and one patient developed postoperative dysphagia and received non-operative treatment. Furthermore, the symptom scores were significantly lower at postoperative pepsin detection when compared to the scores before the operation (pepsin: preoperative: 148.8 ± 82.6, postoperative: 30.7 ± 24.6; t= 4.848, P= 0.000). Laparoscopic fundoplication and hiatus hernia repair may effectively control the symptoms of GERD. Furthermore, the detection of pepsin is non-invasive and easy to operate.

Reoperation after antireflux surgery: a population-based cohort study.

Antireflux surgery for gastro-oesophageal reflux disease (GORD) and/or hiatal hernia is effective. Between 10 and 20 per cent of patients undergo reoperation for recurrent symptoms. Most studies are undertaken in a single centre and possibly underestimate the rate of reoperation. The aim of this nationwide population-based cohort study was to investigate long-term reoperation rates after antireflux surgery. This study included patients who underwent antireflux surgery between 2000 and 2017 in Denmark, and were registered in the Danish nationwide health registries. Reoperation rates were calculated for 1, 5, 10 and 15 years after the primary antireflux operation for GORD and/or hiatal hernia. Duration of hospital stay, 30- and 90-day mortality and morbidity, and use of endoscopic pneumatic dilatation were assessed. This study included a total of 4258 antireflux procedures performed in 3717 patients. Some 3252 patients had only primary antireflux surgery and 465 patients underwent reoperation. The 1-, 5-, 10- and 15-year rates of repeat antireflux surgery were 3·1, 9·3, 11·7 and 12·8 per cent respectively. Thirty- and 90-day mortality rates were similar for primary surgery (0·4 and 0·6 per cent respectively) and reoperations. The complication rate was higher for repeat antireflux surgery (7·0 and 8·3 per cent at 30 and 90 days respectively) than primary operation (3·4 and 4·8 per cent). A total of 391 patients (10·5 per cent of all patients) underwent endoscopic dilatation after primary antireflux surgery, of whom 95 (24·3 per cent) had repeat antireflux surgery. In this population-based study in Denmark, the reoperation rate 15 years after antireflux surgery was 12·8 per cent. Reoperations were associated with more complications.

Reintervention After Antireflux Surgery for Gastroesophageal Reflux Disease in England.

After antireflux surgery, highly variable rates of recurrent gastroesophageal reflux disease (GERD) have been reported. To identify the occurrence and risk factors of recurrent GERD requiring surgical reintervention or medication. The Hospital Episode Statistics database was used to identify adults in England receiving primary antireflux surgery for GERD in 2000 to 2012 with follow-up through 2014, and the outcome was surgical reintervention. In a subset of participants, the Clinical Practice Research Datalink was additionally used to assess proton pump inhibitor therapy for at least 6 months (medical reintervention). Risk factors were assessed using multivariable Cox regression providing adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). Among 22,377 patients who underwent primary antireflux surgery in the Hospital Episode Statistics dataset, 811 (3.6%) had surgical reintervention, with risk factors being age 41 to 60 years (HR = 1.22, 95% CI 1.03-1.44), female sex (HR = 1.5; 95% CI 1.3-1.74), white ethnicity (HR = 1.71, 95% CI 1.06-2.77), and low hospital annual volume of antireflux surgery (HR = 1.32, 95% CI 1.04-1.67). Among 2005 patients who underwent primary antireflux surgery in the Clinical Practice Research Datalink dataset, 189 (9.4%) had surgical reintervention and 1192 (59.5%) used proton pump inhibitor therapy, with risk factors for the combined outcome being age >60 years (HR = 2.38, 95% CI 1.81-3.13) and preoperative psychiatric morbidity (HR = 1.58, 95% CI 1.25-1.99). At least 3.6% of patients may require surgical reintervention and 59.5% medical therapy following antireflux surgery in England. The influence of patient characteristics and hospital volume highlights the need for patient selection and surgical experience in successful antireflux surgery.

Laparoscopic repeat surgery for gastro-oesophageal reflux disease: Results of the analyses of a cohort study of 117 patients from a multicenter experience.

Short and long-term outcomes after repeat anti-reflux surgery (RARS) are still debated and generally not considered as satisfying as after primary anti-reflux surgery (PARS). The aim of this study was to evaluate functional outcomes after RARS and risk factors associated to intra-operative and post-operative complications. This is a multicenter retrospective survey from four European laparoscopic centers. Patients who underwent elective RARS from January 2005 to October 2017 for dysphagia or for persistent reflux disease refractory to medical treatment were analyzed. Data on demographic characteristics, including type and timing of previous operations as well as intra-operative details (surgical technique, type of RARS, conversion to open surgery, prosthetic material placement) were collected. Patients who underwent operations in the emergency setting, interventions mixed with bariatric procedures and PARS performed in other surgical departments were not included in this study. Primary endpoint of this study was to evaluate risk factors associated with intraoperative and postoperative complications. Secondary endpoint was to evaluate clinical outcomes and to identify any possible correlation with clinical and surgical parameters. Among 1662 patients who underwent PARS, failure occurred in 174 (10.5%) patients. Repeat surgery was performed in 117 (7%) patients, after a mean time of 80 months (range 4-315). RARS was carried out laparoscopically in 88% of cases. Prosthetic mesh to reinforce hiatoplasty was used in 22.2% of patients. Intra-operative upper gastro-intestinal tract's injuries occurred in 6 (5.1%) patients. Perioperative mortality was nil and 13 (11.1%) patients experienced postoperative complications. Mean length of hospital stay was 9.6±6.4 days. Based on a multivariable analysis, age >70 years (OR 1.074, C.I.95% 1.018-1.133, p=0.008) and body mass index (BMI)<23 (OR 0.172, C.I.95% 0.052-0.568, p=0.004) were independently associated to postoperative complications. After a mean follow-up time of 36 months (range 6-107), 24 (20.5%) patients presented recurrent symptoms. Based on a multivariable analysis, early onset of dysphagia (OR 3.539, C.I.95% 1.254-9.990, p=0.017), open approach (OR 4.505, C.I.95% 1.314-15.442, p=0.016) and the use of prosthetic material (OR 2.790, C.I.95% 0.930-8.776, p=0.047) were significantly associated to good clinical outcomes. Repeat anti-reflux surgery is a safe and feasible procedure in high-volume centers, with acceptable perioperative outcomes. Long-term results are favorable with a success rate of almost 80%. Advanced age (>70 years) and low BMI (<23kg/m2) were factor predicting perioperative complications. The use of prosthesis for hiatoplasty was associated to better functional outcomes.

Hospital Volume of Antireflux Surgery in Relation to Endoscopic and Surgical Re-interventions.

To test the hypothesis that higher hospital volume decreases endoscopic and surgical re-intervention rates after antireflux surgery. Antireflux surgery for gastro-esophageal reflux disease is followed by varying rates of re-interventions. Whether hospital volume influences re-intervention rates is uncertain. This population-based cohort study used nationwide data from Denmark, Finland, and Sweden for patients having undergone primary antireflux surgery. Hospitals were divided into tertiles based upon annual volume, that is, 3 equal-sized groups. The outcomes were 30-day surgical re-intervention, endoscopic re-intervention, and secondary antireflux surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs) for risk of the first outcome occurrence. Incidence rate ratios were calculated to count all outcome occurrences. All risk estimates were adjusted for age, sex, comorbidity, type of antireflux surgery, year of surgery, and country. Among 33,060 patients and a median follow-up of 12 years after antireflux surgery, the frequencies of 30-day re-intervention, endoscopic re-intervention, and secondary antireflux surgery were 1.2%, 4.6%, and 7.0%, respectively. When comparing the highest with the lowest tertiles, higher hospital volume did not decrease HRs of 30-day re-intervention (adjusted HR = 1.14, 95% CI 0.73-1.77), endoscopic re-intervention (HR = 1.21, 95% CI 0.96-1.51), or secondary antireflux surgery (HR = 1.28, 95% CI 1.05-1.54), but rather increased point estimates. The incidence rate ratios showed similar patterns. Higher hospital volume of primary antireflux surgery may not decrease risk of endoscopic or surgical re-intervention, suggesting that centralization will not decrease rates of postoperative complications or recurrence of gastro-esophageal reflux disease.

Current status of surgery for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is becoming increasingly prevalent worldwide, although with much lower incidence in East Asia compared with Western countries. This review addresses the pathophysiology of gastroesophageal reflux and its surgical therapy. The current status of novel surgical and endoscopic therapies also will be described.

THE HISTORY OF SURGICAL TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE

The most important historical stages of formation of scientific ideas of gastroesophageal reflux and its complications are presented in the article; the main milestones in the development of gastroesophageal reflux disease surgery are reflected.

Management of failure after surgery for gastro-esophageal reflux disease

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.

Nationwide survey of partial fundoplication in Korea: comparison with total fundoplication.

PurposeLaparoscopic total fundoplication is the standard surgery for gastroesophageal reflux disease. However, partial fundoplication may be a viable alternative. Here, we conducted a nationwide survey of partial fundoplication in Korea.MethodsThe Korean Anti-Reflux Surgery study group recorded 32 cases of partial fundoplication at eight hospitals between September 2009 and January 2016. The surgical outcomes and postoperative adverse symptoms in these cases were evaluated and compared with 86 cases of total fundoplication.ResultsAnterior partial fundoplication was performed in 20 cases (62.5%) and posterior in 12 (37.5%). In most cases, partial fundoplication was a secondary procedure after operations for other conditions. Half of patients who underwent partial fundoplication had typical symptoms at the time of initial diagnosis, and most of them showed excellent (68.8%), good (25.0%), or fair (6.3%) symptom resolution at discharge. Compared to total fundoplication, partial fundoplication showed no difference in the resolution rate of typical and atypical symptoms. However, adverse symptoms such as dysphagia, difficult belching, gas bloating and flatulence were less common after partial fundoplication.ConclusionAlthough antireflux surgery is not popular in Korea and total fundoplication is the primary surgical choice for gastroesophageal reflux disease, partial fundoplication may be useful in certain conditions because it has less postoperative adverse symptoms but similar efficacy to total fundoplication.

Antireflux Surgery in the USA: Influence of Surgical Volume on Perioperative Outcomes and Costs-Time for Centralization?

Few studies have analyzed the relationship between surgical volume and outcomes after antireflux procedures. The aim of this study was to determine the effect of surgical volume on postoperative results and costs for patients undergoing surgery for gastroesophageal reflux disease. We analyzed the National Inpatient Sample (period 2000-2013). Adult patients (≥18years old) with gastroesophageal reflux disease who underwent fundoplication were included. Hospital surgical volume was determined using the 30th and 60th percentile cut points using weighted discharges and categorized as low (<10 operations/year), intermediate (10-25operations/year), or high (>25 operations/year). We performed multivariable logistic regression models to assess the effect of surgical volume on patient outcomes. The studied cohort comprised 75,544 patients who had antireflux surgery. When operations performed at low-volume hospitals, postoperative bleeding, cardiac failure, renal failure, respiratory failure, and inpatient mortality were more common. In intermediate-volume hospitals, patients were more likely to have postoperative infection, esophageal perforation, bleeding, cardiac failure, renal failure, and respiratory failure. The length of hospital stay was longer at low- and intermediate-volume hospitals (1.08 and 0.55days longer, respectively). There was an increase in charges of 5120dollars per patient at low-volume centers, and 4010dollars per patient at intermediate-volume centers. When antireflux surgery is performed at high-volume hospitals, morbidity is lower, length of hospital stay is shorter, and costs for the healthcare system are decreased.

Necessity for hiatal plasty as part of antireflux surgery for gastroesophageal reflux disease in patients with axial hiatal hernias

Necessity for hiatal plasty as part of antireflux surgery for gastroesophageal reflux disease in patients with axial hiatal hernias

A long-term evaluation of the quality of life after laparoscopic Nissen-Rossetti anti-reflux surgery.

BACKGROUND:The quality of life (QoL) has been suggested to be the most relevant parameter to assess and monitor the long-term outcome in patients who underwent surgery for gastroesophageal reflux disease (GERD).PATIENTS AND METHODS:A retrospective evaluation was conducted on patients who underwent Laparoscopic Nissen-Rossetti Fundoplication for GERD between January 1998 and December 2010. To evaluate the long-term results a telephone interview was made using the VISICK score and the GERD-health-related QoL (HRQL) questionnaire at 1, 3, 5 years and at the end of the study. If the questionnaires resulted unsatisfactory, a complete diagnostic revaluation was performed.RESULTS:A total of 168 patients underwent laparoscopic surgery for GERD. When evaluated at the end of the study, the number of unsatisfied patients according to the VISICK score was significantly higher than the one obtained with the GERD-HRQL questionnaire.CONCLUSIONS:Many data suggest a possible recurrence of the symptoms after surgery in a long follow-up period. Our data seem to demonstrate a slight but significant trend in symptoms relapse after surgery. Considering the non-specific and specific nature of the two scores, VISICK and GERD HRQL, our result showed a significantly more relevant trend of symptoms relapse only for the non-specific ones. Such QoL scores seem to be important in selecting patients who need to be instrumentally examined. Consequently, our work proves that only a few patients out of the total number of followed up patients, are to be recalled to undergo instrumental examination.

Laparoscopic reoperation for recurred antireflux surgery of gastroesophageal reflux disease

To investigate the safety and effectiveness of laparoscopic reoperation for patients with gastroesophageal reflux disease (GERD) recurred form previous anti-reflux surgery. Totally 19 patients received laparoscopic reoperation for symptomatic and anatomic recurred GERD in Department of Gastroesophageal Reflux Disease, Rocket Force General Hospital from January 2008 to September 2015 were retrospectively analyzed. There were 12 male and 7 female patients. The average reoperation age was (48±14) years, the average duration of reoperation from original ones was (43±38) months. The patients underwent preoperative barium, endoscopy, manometry and 24-hour pH studies. Laparoscopic hiatal hernia repair plus fundoplication was carried out for reoperation. Gastroesophageal reflux related symptoms (reflux, heartburn, chest pain, chough, wheezing, chest tightness and globus sensation) before and after surgery were compared by a questionnaire. The patients' medication consumption, complications and satisfaction of the reoperation were investigated as well. The repeated measures analysis of variance was used for statistical comparison of data preoperatively and postoperatively. No major complication and death occurred. Six cases (32%) had complications such as diarrhea, increased passing wind, flatulence, dysphagia and abdominal pain. The GERD related symptom score of reflux, heartburn, chest pain, chough, wheezing, chest tightness and globus sensation all significantly decreased (F: 25.0 to 56.7; P: 0.000 to 0.001) after the reoperation, with 68% good outcome of all the patients. After a follow-up of (33±22) months after reoperation, 1 case had partial recurrence at the 3(rd) month after reoperation. For all the patients, 12 cases felt very satisfied or satisfied with the reoperation. Laparoscopic reoperation is generally effective with acceptable morbidity rates for patients with esophageal and extraesophageal symptoms recurred form previous hiatal repair and (or) fundoplication.

Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study.

Surgery for refractory gastroesophageal reflux disease (GERD) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients. Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality. This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery, with the objective to detect possible advantages for the robot-assisted approach. A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study. Baseline characteristics, symptoms, medical history, procedural data, hospital stay, complications and outcome were prospectively gathered. The main indications for redo surgery were dysphagia, pyrosis or a combination of both in combination with a proven anatomic abnormality. The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups, respectively. The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy (1/45 vs. 5/30, p = 0.035) despite a higher proportion of patients with previous surgery by laparotomy (9/45 vs. 1/30, p = 0.038). Median hospital stay was reduced by 1 day (3 vs. 4, p = 0.042). There were no differences in mortality, complications or outcome. Robotic support, when available, can be regarded beneficial in redo surgery for GERD and hiatal hernia. Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery, a reduced number of conversions and shorter hospital stay.

Could a poor outcome of gastro-oesophageal reflux surgery be related to lactase deficiency?

Complications of surgery for gastro-oesophageal reflux disease can provoke severe symptoms that condemn the patient to a very poor quality of life. A similar clinical picture is presented among patients with lactase deficiency, which is highly prevalent today. In view of these considerations, we consider to what extent lactase deficiency may influence the symptoms observed following gastro-oesophageal reflux disease intervention, and to what extent these could be avoided by the prior identification and treatment of this type of patient.

Measurement of Esophagogastric Junction Distensibility May Assist in Selecting Patients for Endoluminal Gastroesophageal Reflux Disease Surgery: Author's Reply.

TO THE EDITOR: We thank the author for his interest in our manuscript.1,2 During the transoral incisionless fundoplication (TIF) procedure, a retractor is anchored at the esophagogastric junction (EGJ) after which tension is applied to advance the EGJ caudally.3,4 Therefore, we agree that lengthening of the EGJ is a substantial mode of action of the TIF procedure. In addition, transmural placement of polypropylene fasteners creates an endoluminal fundoplication through permanent serosa-to-serosa or serosa-to-muscularis fusion with tightening of the distal esophagus, which decreases EGJ diameter and distensibility. 5,6 Therefore, we believe that EGJ distensibility can be an important parameter for evaluation of endoluminal gastroesophageal reflux disease (GERD) surgery like the TIF procedure, although we agree that the immediate decrease in EGJ distensibility after the TIF procedure might be the consequence of postoperative edema.7 It is important to note that consensus is lacking with regard to analysis of parameters obtained from EndoFLIP measurements. According to the most widely accepted approach, EGJ distensibility is assessed based on the narrowest cross sectional area and corresponding intra-bag pressure. Standardized methods to evaluate the change in EGJ length with the EndoFLIP technique are still to be defined. Therefore, we anticipate that development of more extensive biomechanical measures will result in more accurate interpretation of EndoFLIP data. In the present study, we used the EndoFLIP technique in the preoperative diagnostic work-up to predict postoperative outcome. Recent studies highlight that the EndoFLIP technique could be used as an intra-operative quality tool during either anti-reflux or achalasia surgery.8,9 Teitelbaum et al10 described that the EndoFLIP technique is able to guide laparoscopic Heller myotomy and peroral esophageal myotomy to obtain an ideal postoperative EGJ distensibility with regard to both postoperative achalasia and reflux symptoms. In addition, Perretta et al8 provided observational data about the change in EGJ distensibility and diameter during different stages of laparoscopic Nissen fundoplication. In the future, the EndoFLIP method could potentially be used during laparoscopic fundoplication to prevent creation of a hypercompetent valve with associated postoperative symptoms (eg, dysphagia or gas bloating).8 It therefore appears that the EndoFLIP technique has considerable potential as an intra-operative tool. On the other hand, currently available methodologies limit its role with regards to the assessment of EGJ distensibility in the preoperative diagnostic work-up or in post-procedure evaluation of patients undergoing endoluminal GERD surgery like TIF. Additional research is necessary to define the role of the EndoFLIP technique for both the preoperative work-up and tool for intraoperative calibration.

Measurement of Esophagogastric Junction Distensibility May Assist in Selecting Patients for Endoluminal Gastroesophageal Reflux Disease Surgery.

TO THE EDITOR: I read with interest the study by Smeets et al,1 who evaluated the association between pre-operative distensibility measurements and objective and clinical outcomes after transoral incisionless fundoplication (TIF) surgery. The study concluded that distensibility measurements have no added value in the pre-operative diagnostic work-up or in the post-procedure evaluation of endoluminal anti-reflux therapy. This study adds to a growing body of literature,2–9 which in general suggests that there is little benefit in the use of any of the standard gastrodiagnostic methods to predict post-surgical outcomes in gastroesophageal reflux disease (GERD) surgery. The outcomes of such functional surgery are operator and technique dependent, producing highly variable gastroesophageal junction (GEJ) constructs.10 It is therefore questionable whether the geometry of the GEJ pre-surgery alone could be reasonably expected to predict how the GEJ will perform post-surgically. However the authors, in my view, have made an important contribution in addressing a question of significant clinical importance, namely as to whether a pre-operative measurement can help stratify patients who might reasonably benefit from a lower risk transoral GERD procedure versus, for example, a laparoscopic fundoplication. Using criteria of a distensibility cut-off value of 2.3 mm2/mmHg (measured at 30 mL distension volume) combined with acid exposure time < 11%, they noted that 94% of the patients meeting these combined pre-operative criteria had normalized acid exposure time at 6 months after TIF surgery. On a technical note, I would question whether distensibility is a measurement best suited for the evaluation of TIF procedure itself. Distensibility is calculated by dividing the minimum cross sectional area of the GEJ by balloon distending pressure. Observational experience of the TIF procedure would suggest that the mode of action of the EsophyX device serves to lengthen the high pressure zone as distinct from tightening it. This mode of action is somewhat different from the clear barrier to distension of the GEJ created during cruroplasty, or with an external wrap. I would alternatively hypothesize that the immediate post-operative tightening presented in Table 4 may be due to intra-procedural edema which has resolved by the time the 6-month measurement was taken. In conclusion, I would disagree that distensibility measurements have no added value in the pre-operative diagnostic work-up, but believe that they may offer an important adjunctive measurement to assist a surgeon decide whether a more minimally invasive approach to GERD surgery should be offered to a patient.

A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age

AimsThe surgery of gastroesophageal reflux disease (GERD) is common in modern pediatric surgical practice. Any differences in perioperative and long-term clinical outcomes following laparoscopic (LN) or open Nissen (ON) fundoplication have not been comprehensively described in young children. This randomized, prospective study examines outcomes following LN versus ON in children <2years of age. MethodsFour surgeons at a single institution enrolled patients under 2years of age that required surgical management of GERD, who were then randomized to LN or ON between 2005 and 2012. A universal surgical dressing was employed for blinding. Analgesia and enteral feeding pathways were standardized. The primary outcome was postoperative length of stay. Perioperative outcomes and long-term follow up were collected as secondary outcomes and used to compare groups. ResultsOf 39 enrolled patients, 21 were randomized to ON and 18 to LN. Length of postoperative hospital stay, time of advancement to full enteral feeds, and analgesic requirements were not significantly different between treatment cohorts. The LN group experienced longer median operating times (173 vs 91min, P<0.001) and higher surgical charges ($4450 vs $2722, P=0.002). The incidence of post-discharge complications did not differ significantly between the groups at last follow-up (median 42months). ConclusionsThis randomized trial comparing postoperative outcomes following LN vs ON did not detect statistically significant differences in short- or long-term clinical outcomes between these approaches. LN was associated with longer surgical time and higher operating room costs. The benefits, risks, and costs of laparoscopy should be carefully considered in clinical pediatric surgical practice.

Prognostic factors of gastroesophageal reflux disease in congenital diaphragmatic hernia: a multicenter study

Gastroesophageal reflux disease (GERD) is one of the concomitant problems in infants with congenital diaphragmatic hernia (CDH). We assessed risk factors of GERD in CDH patients. The retrospective observational study for CDH infants was conducted. Cases of CDH who were born between January 2006 and December 2010, were operated in the 9 participating institutions, and survived to discharge were included. Completion of medical therapy for GERD and incidence of surgery were primary outcomes. Kaplan-Meier survival analysis and Cox proportional hazards regression were used. In 182 cases of CDH, the medical therapies for GERD were performed in 23.8% (40/168), and were completed in 60.0% (24/40). Prenatal detection of CDH (HR 5.87, CI 1.6-18.8, p = 0.012) and tube feeding at discharge (HR 5.04, 95% CI 1.3-33.1, p = 0.016) were significantly correlated with unsuccessful weaning from medical therapy. Surgery for GERD was performed in 10.7% (18/169). Gestational age (HR 4.78, 95% CI 1.5-21.1, p = 0.006) and diaphragmatic defect of more than 75% (HR 4.3, 95% CI 1.6-12.9, p = 0.005) were significantly correlated with need for antireflux surgery. Diaphragmatic defect of more than 75% was risk factor of future need for antireflux surgery.

The Mexican consensus on gastroesophageal reflux disease. Part II

AimsTo update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002. MethodsPart I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher. ResultsTwenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%. ConclusionsCurrently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.