Outcome Of Antireflux Surgery Research Articles

The Role of High-Resolution Manometry Prior to and Following Antireflux Surgery: The Padova Consensus.

In the last two decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiologic information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision making. A multi-disciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre- and post- ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM prior to ARS and the role of HRM following ARS. This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre- and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.

Recurrence of gastro-esophageal reflux symptoms after anti-reflux surgery

Background: Considering the global impact of Gastro-esophageal reflux disease (GERD) on healthcare and its adverse effects on the quality of life for the world\'s population, this study aimed to assess the outcomes of anti-reflux surgery, mainly the recurrence of symptoms, at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. Methods: This is a retrospective study conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, from May to August 2022. Data were collected from patients\' electronic medical files. A pre-designed checklist was prepared to collect data on patients\' demographics, BMI, smoking and alcohol status, comorbidities, GERD complications, heartburn and regurgitation severity, and gastroscopy findings. Results: In this study, we collected data for 78 patients with a mean age of 42.05 ± 15.06 years. Among the patients, 53.8% were males, and 35.9% were overweight. Concerning health status, 36% of the patients reported a history of reflux surgery, and 88.5% had other comorbidities, with hiatal hernia being the most common. Re-operative treatments were reported in six patients (7.7%). Improvement of symptoms after surgery was reported in 82.1% of the patients. Age was a significant factor affecting the success of the surgery, with older patients reporting improvement (P=0.035). Additionally, asthma and obstructive sleep apnea were associated with significantly worse results after surgery (P=0.013 and 0.031). Conclusion: The recurrence rate was 7.7% in our study. Asthma and sleep apnea were associated with worse surgical outcomes. Milder symptoms were associated with a higher percentage of postoperative improvement.

Comparative Outcomes of Magnetic Sphincter Augmentation and Fundoplication in Revisional Surgery

Background: Outcomes of laparoscopic revisional surgery involving Magnetic Sphincter Augmentation (MSA) have not been clearly delineated, whether MSA was the presenting or the revisional surgery. We compared safety and clinical outcomes of 4 main categories: fundoplication revised to fundoplication (F-F); fundoplication to MSA (F-M), MSA to fundoplication (M-F) and MSA to MSA (M-M). Methods: Analysis of prospective data from 10 U.S. sites participating in the Registry of Outcomes of Anti-Reflux Surgery (ROARS). Patients had undergone at least one prior procedure on the esophagogastric junction with subsequent need for revisional surgery. Results: Between 2/1/2005 and 1/19/23, 742 patients underwent 819 revisional surgeries, of which 645 patients had 722 surgeries in the 4 main categories. Seventy-six percent had their prior operation elsewhere. Indications for reoperation (GERD, hiatal hernia, dysphagia, gas-bloat) were similar across categories. Preoperative and intraoperative findings disclosed disruption of prior hernia repair in 80% and 97% of patients respectively. Hernia size was larger with an antecedent fundoplication (13% >5 cm, 37% 3-5 cm) compared to patients with prior MSA (1.5% >5 cm, 18% 3-5 cm ( P < .0001). Revision of fundoplication resulted in 11% intraoperative complication rate, versus 2% for MSA. Six hundred patients (73.2%) were followed a mean of 2.7 years. Subsequent operation was performed on 77 (12.7%) a mean of 2.5 years; no difference between categories. Kaplan-Meier analysis showed equivalent subsequent reoperation rates at 5 years (20% ± 5%). Similar improvements in GERD-HRQL, bloating, dysphagia scores, ability to belch or vomit were seen. Conclusions: Over 95% of patients had disruption of the hiatus requiring repair, though prior MSA was associated with far fewer >3 cm hernias than prior fundoplication. Patients with an antecedent MSA can be revised with similar safety and outcomes as those having an antecedent fundoplication. MSA has equivalent results to fundoplication when used as a revisional procedure post antecedent fundoplication.

OGBN O04 Modern surgery and endoscopic procedures for gastro-oesophageal reflux in lung transplant recipients: a systematic review and meta-analysis

Abstract Background Gastro-Oesophageal Reflux Disease (GORD) is a major cause of morbidity and rejection following lung transplantation. Interventional treatment of GORD is a widely accepted management strategy for GORD in the context of lung transplant surgery. We conducted a systematic review of all modern interventions to treat GORD following lung transplantation to identify the optimum management strategy for these patients. Methods We conducted a literature search of MEDLINE, Embase and the Cochrane library, using a tailored search strategy, from inception until 18/10/2022. Articles reporting outcomes of Anti-Reflux Surgery (ARS) following lung transplantation were included. Two independent reviewers performed screening, full text review and data extraction using the COVIDENCE platform. The study protocol was registered on PROSPERO (CRD42022379748). Results The screen identified 236 studies, with 21 deemed suitable for inclusion. These studies included a total of 1063 patients. The procedures described included fundoplication (n = 19), (Nissen, Toupet, Dor), Stretta (n=1) and LINX (n=1) procedures. Follow up ranged from 50 days to 6.9 years. 6 studies reported FEV1 outcomes which all demonstrated stable or improved lung function following ARS. From identified literature, 9 papers reported survival outcomes with 4 studies demonstrating improved survival following ARS. Conclusions ARS appears to be an effective management strategy for GORD in the context of lung transplantation. However, modern alternatives, such as Stretta and LINX require further clinical evaluation to assess their impact on lung function and survival.

The impact of delayed gastric emptying as measured by gastric emptying scintigraphy on the outcome of magnetic sphincter augmentation.

The impact of delayed gastric emptying (DGE) on the outcome of anti-reflux surgery (ARS) is controversial. There is concern that poor gastric emptying diminishes outcomes. Magnetic sphincter augmentation (MSA) may have a comparatively mild impact on gastric physiology, but the relationship between DGE and MSA outcomes is unknown. This study aims to evaluate the relationship between objective DGE and MSA outcomes over time. Patients who completed gastric emptying scintigraphy (GES) prior to MSA between 2013 and 2021 were included. DGE was defined as a 4 h retention > 10% or half emptying time > 90min on GES. Outcomes were compared between DGE and normal gastric emptying (NGE) groups at 6 months, 1 and 2 years. Sub-analysis of patients with severe (> 35%) DGE and correlation analysis between 4-h retention and symptom and acid-normalization were performed. The study population consisted of 26 (19.8%) patients with DGE and 105 with NGE. DGE was associated with more 90-days readmissions (18.5 vs 2.9%, p = 0.009). At 6 months patients with DGE had higher median (IQR) GERD-HRQL total [17.0(10-29) vs 5.5(3-16), p = 0.0013], heartburn [1(1-3) vs 0(0-1), p = 0.0010) and gas-bloat [4(2-5) vs 2(1-3), p = 0.033] scores. Outcomes at 1 and 2 years follow-up were comparable (p > 0.05). From 6months to 1-year the gas-bloat score decreased from 4(2-5) to 3(1-3), p = 0.041. Total and heartburn scores decreased, but not significantly. Severe DGE (n = 4) patients had lower antiacid medication freedom at 6months (75 vs 87%, p = 0.014) and 1-year (50 vs 92%, p = 0.046). There were non-significant trends for higher GERD-HRQL scores, dissatisfaction, and removal rates in severe DGE at 6months and 1-year. There was a weak correlation between 4-h retention and 6-month GERD-HRQL total score [R = 0.253, 95%CI (0.09-0.41), p = 0.039], but not acid-normalization (p > 0.05). Outcomes after MSA are diminished early on in patients with mild-to-moderate DGE, but comparable by 1 year and durable at 2 years. Severe DGE outcomes may be suboptimal.

Evaluation of the Outcomes of Anti-Reflux Surgery in the Management of Extraoesophageal Symptoms of Gastro-oesophageal Reflux Disease

Evaluation of the Outcomes of Anti-Reflux Surgery in the Management of Extraoesophageal Symptoms of Gastro-oesophageal Reflux Disease

Impact of Objective Colonic and Whole Gut Motility Data as Measured by Wireless Motility Capsule on Outcomes of Antireflux Surgery.

Studies show higher rates of dissatisfaction with antireflux surgery (ARS) outcomes in patients with chronic constipation. This suggests a relationship between colonic dysmotility and suboptimal surgical outcome. However, due to limitations in technology, there is no objective data available examining this relationship. The wireless motility capsule (WMC) is a novel technology consisting of an ingestible capsule equipped with pH, temperature, and pressure sensors, which provide information regarding regional and whole gut transit times, pH and motility. The aim of this study was to assess the impact of objective regional and whole gut motility data on the outcomes of ARS. This was a retrospective review of patients who underwent WMC testing before ARS. Transit times, motility, and pH data obtained from different gastrointestinal tract regions were used in analysis to determine factors that impact surgical outcome. A favorable outcome was defined as complete resolution of the predominant reflux symptom and freedom from antisecretory medications. The final study population consisted of 48 patients (fundoplication [n = 29] and magnetic sphincter augmentation [n = 19]). Of those patients, 87.5% were females and the mean age ± SD was 51.8 ± 14.5 years. At follow-up (mean ± SD, 16.8 ± 13.2 months), 87.5% of all patients achieved favorable outcomes. Patients with unfavorable outcomes had longer mean whole gut transit times (92.0 hours vs 55.7 hours; p = 0.024) and colonic transit times (78.6 hours vs 47.3 hours; p = 0.028), higher mean peak colonic pH (8.8 vs 8.15; p = 0.009), and higher mean antral motility indexes (310 vs 90.1; p = 0.050). This is the first study to demonstrate that objective colonic dysmotility leads to suboptimal outcomes after ARS. WMC testing can assist with preoperative risk assessment and counseling for patients seeking ARS.

Comparative Outcomes of Anti-Reflux Surgery in Obese Patients with Gastroesophageal Reflux Disease1

IntroductionRoux-en-Y gastric bypass (RYGB) has been the preferred operation for obese patients with gastroesophageal reflux disease (GERD); however, some patients are hesitant to undergo bypass. Obese patients have a multifactorial predisposition to GERD, including lower esophageal sphincter (LES) dysfunction and aberrant pressure gradients across their diaphragmatic crura. Among non-obese patients, anti-reflux surgery (ARS) with hiatal hernia (HH) repair and LES augmentation has shown excellent long-term results. We aimed to determine whether patient satisfaction and GERD recurrence differed between obese and non-obese patients who underwent ARS. MethodsReview of patients who underwent ARS between January 2012 and June 2021 was performed. Perioperative and postoperative characteristics were compared across three BMI groups: BMI < 30 kg/m2, 30 kg/m2 ≤ BMI < 35 kg/m2, and BMI ≥ 35 kg/m2. ResultsFour-hundred thirteen patients were identified, of which 294 (71.1%) had BMI < 30 kg/m2, 87 (21.1%) were 30 kg/m2 ≤ BMI < 35 kg/m2, and 32 (7.7%) had a BMI ≥ 35 kg/m2. Patients with BMI ≥ 35 kg/m2 had higher preoperative manometric and EndoFLIP™ intra-balloon pressure at the LES than those with lower BMIs. This value was increased to a similar level throughout ARS across the three cohorts. Post-operative GERD-specific satisfaction was similar across the three cohorts, as were rates of postoperative reflux and hiatal hernia recurrence on barium swallow; rates of reoperation were low. ConclusionsARS with HH repair and LES augmentation may be appropriate for select patients across a range of BMIs, including those with a BMI ≥ 35 kg/m2 who are hesitant to undergo RYGB.

Efficacy of laparoscopic fundoplication in patients with chronic cough and gastro-oesophageal reflux

BackgroundThe outcome of anti-reflux surgery in patients with suspected gastro-oesophageal reflux-induced cough is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication for controlling cough in patients with chronic cough without asthma, who have pathologic gastro-oesophageal reflux, and to identify predictors of response.MethodsFrom a prospective database of 1598 patients who have undergone laparoscopic fundoplication, 66 (4%) with proven gastro-oesophageal reflux disease (GORD) and chronic cough without asthma were studied. All patients underwent gastroscopy and 24-h pH monitoring before operation. Heartburn and regurgitation were assessed using a modified DeMeester score. Severity of cough before and after surgery was self-assessed by the patient using a visual analog scale at a minimum of 12 months post-operatively (median 43 mo; range: 14–104 mo). Patients were considered to have responded to fundoplication if they had no cough or the cough had improved by 50% or more after operation.ResultsCough and heartburn/regurgitation were relieved in 61% (40/66) and 90% (44/49) of the patients, respectively. The presence of typical GORD symptoms or oesophagitis, and pH study variables did not predict the response of the cough to fundoplication.ConclusionRefinement in the aetiological diagnosis of chronic cough due to GORD is necessary for improved outcome. Patients diagnosed with GORD-related chronic cough need to be counseled regarding their expectations from anti-reflux surgery.

S427 Risk Factors for Dysphagia and Need for Upper Endoscopy in Patients With a Hiatal Hernia Who Undergo Anti-Reflux Surgery

S427 Risk Factors for Dysphagia and Need for Upper Endoscopy in Patients With a Hiatal Hernia Who Undergo Anti-Reflux Surgery

320. EFFICACY OF LAPAROSCOPIC FUNDOPLICATION IN PATIENTS WITH CHRONIC COUGH AND GASTRO-OESOPHAGEAL REFLUX

Abstract The outcome of anti-reflux surgery in patients with cough suspected to be induced by gastro-oesophageal reflux disease is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication (LF) for controlling cough in a patient population suffering chronic cough when alternative aetiologies (e.g. asthma) had been excluded and pathologic gastro-oesophageal reflux had been confirmed on ambulatory pH monitoring, and to identify predictors of response. From a prospective database of 1,598 patients who had undergone laparoscopic fundoplication, 66 (4%) had a principal presenting symptom of chronic cough as well as objective evidence of gastro-oesophageal reflux disease (GORD). Patients completed questionnaires for GORD symptoms (modified DeMeester score) and severity of cough (visual analog scale) both before and after LF, and had pre-operative gastroscopy and 24-hour pH monitoring before operation. Patients were considered to have responded to LF if they had no cough or the cough had improved by 50% or more after operation. Follow-up data was available for 66/66 patients (100%), with a median follow-up time of 43 months (range 14–104 months) after operation. Cough was relieved in 40/66 (61%), while typical GORD symptoms (heartburn, regurgitation) was relieved in 44/49 (90%). The presence of typical GORD symptoms, oesophagitis, or pH study variables did not predict the response of the cough to LF. At 1 year, 67% of patients were satisfied with the results of their surgery, 20% were not and 13% were unsure. For comparison, the 1430/1598 patients in the database with no laryngopharyngeal symptoms had a satisfaction rate of 94%. Based on our study and available literature, it appears there are no reliable pre-operative clinical predictors of a satisfactory response of cough to LF. This probably reflects a current inability to obtain an accurate aetiological diagnosis of chronic cough, even in the presence of known abnormal gastro-oesophageal reflux disease. Regardless, in a well-chosen cohort of patients with chronic cough, LF can yield good patient satisfaction rates, albeit less than for patients with typical GORD symptoms.

P-BN04 Evaluation of Outcomes of Anti-reflux Surgery in a District General Hospital

Abstract Background Gastro-oesophageal reflux disease (GORD) affects up to 20% of the Western population, and is usually associated with presence of hiatus hernia (HH). Proton pump inhibitors (PPI) are the mainstay treatment, but half of PPI users have persistent symptoms. Anti-reflux surgery in the form of fundoplication surgery with HH repair can be considered in patients unable to tolerate or unwilling to persevere with long term medical therapy and those with severe sequalae of reflux, such as those with Barrett esophagus or non-healing erosive esophagitis. We aim to evaluate the outcomes and factors relating to surgical success of anti-reflux surgery. Methods We identified patients who had HH repair and fundoplication surgery from our prospectively maintained theatre database over a eight year period. Retrospective data collection was performed, inclusive of patients’ pre-operative investigations, intraoperative findings and postoperative patient outcomes. Chi Square and Mann Whitney U test were used to calculate the statistical significance. 187 cases were analyzed, involving only 167 unique patients as 14 patients had 1 redo surgery and 2 patients had 2 redo surgeries. Results Male to female ratio was 2:3. Median age was 59 years and median BMI was 29.1. 85% of cases were performed laparoscopically, which had the shorter median length of stay at 2 days. Pre-operative assessment of HH size with barium swallow had the highest sensitivity (82%) and specificity (75%). Large to moderate HH are more prevalent in female patients. Rolling HH are more associated with dysphagia and vomiting whereas sliding HH with reflux symptoms. Rolling HH are more likely to be repaired with an open approach and more likely to require hiatal mesh repair compared to sliding HH. Conclusions In the 96% of patients followed up, we successfully achieved symptom control in 94% of them. Although we were unable to find specific patient or surgical factors contributing to symptom recurrence or redo surgeries, we were able to identify certain pre-operative tests which can predict the difficulty of surgery. Larger scale case series would allow us to predict patient cohort at a higher risk of unsuccessful anti-reflux surgery.

The Value of High-Resolution Manometry in Measurement of EGJ Competency and Manometric Outcomes of Antireflux Surgery

The esophagogastric junction (EGJ) barrier plays an integral role in the prevention of gastroesophageal reflux; however, not much attention has been paid to competency parameters, especially in the era of high-resolution manometry (HRM). HRM provides a unique spatiotemporal pressure profile and measurements of the EGJ. Herein, we discuss the evidence for objective measures of EGJ competency, which should guide the clinical management of gastroesophageal reflux disease. Additionally, we will briefly discuss expected normal values after antireflux surgery.

Surgical treatment of GERD: systematic review and meta-analysis.

Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients. PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale. From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference = - 0.51, 95%CI - 0.63, - 0.40, I2 = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I2 = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I2 = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I2 = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I2 = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67). The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.

S0354 Outcomes of Anti-Reflux Surgery in Patients With PPI Refractory Erosive and Non-Erosive Gastro-Esophageal Reflux Disease: A Meta-Analysis

INTRODUCTION: The evidence has suggested that anti-reflux surgery is beneficial in patients with proton-pump inhibitor (PPI) refractory erosive gastroesophageal reflux disease (ERD). The outcomes of surgical intervention in patients with PPI refractory non-erosive reflux disease (NERD) compared to ERD remains unclear. METHODS: 5 prospective observational studies investigating the outcomes of anti-reflux surgery in PPI refractory-NERD and -ERD were selected using PubMed, EMBASE and MEDLINE databases (inception April 2020). The primary endpoint was post-surgical GERD symptom resolution. The secondary endpoints were short-term (≤1-year) and long-term (>1-year) mean improvement in quality of life (QOL). The outcomes were measured as relative risk (RR) and standardized mean difference (SMD) with a 95% confidence interval (CI) using the fixed effect model. RESULTS: In analysis comprising of 670 patients with a mean age of 47.6 ± 3.1 years and 60.5% males, the anti-reflux surgery led to significantly higher GERD symptom resolution in the ERD group as compared to the NERD group as shown in Figure 1 (RR: 1.15, 95% Cl 1.01–1.31, P = 0.04, I2 = 0). There was significant improvement in short-term QOL in both NERD (SMD: 0.28, 95% Cl 0.13-0.44, P < 0.001, I2 = 0) and ERD groups (SDM: 0.34, 95% Cl 0.18–0.50, P < 0.001, I2 = 0). Similarly, long-term QOL significantly improved after surgery in both NERD (SDM: 0.30, 95% Cl 0.14–0.45, P < 0.001, I2 = 13) and ERD groups (SDM: 0.23, 95% Cl 0.07–0.39, P = 0.005, I2 = 0). CONCLUSION: Anti-reflux surgery achieved greater GERD symptom resolution in patients with PPI-refractory ERD as compared to NERD, however, improved short- and long-term QOL in PPI refractory GERD irrespective of mucosal changes evidenced on endoscopy. Randomized controlled trials are required to further validate this data.Figure 1.: Forest Plot demonstrating GERD symptom resolution after anti-reflux surgery in PPI refractory non-erosive gastroesophageal reflux disease (NERD) and erosive esophageal reflux disease (ERD).

Outcome for Patients With Pathological Esophageal Acid Exposure After Laparoscopic Fundoplication.

The aim of the current study was to assess symptomatic outcome and need for surgical reintervention for patients identified with pathological esophageal acid exposure by routine postoperative 24-hour pH-monitoring. Although laparoscopic fundoplication is associated with excellent short- and midterm results, recurrent symptoms pose an important challenge. Postoperative pH-monitoring is considered the "gold standard" for diagnosing recurrent GERD and frequently used for routine postoperative follow up. Analysis of prospectively collected data from patients who underwent laparoscopic fundoplication between April 1994 and June 2015 and underwent routine postoperative 24-hour pH-monitoring was performed. Symptomatic outcome and need for surgical reintervention up to 5 years was compared between patients with pathological and physiological postoperative esophageal acid exposure. Primary endpoints were heartburn score and need for surgical reintervention for recurrent reflux. A total of 309 patients in whom routine postoperative 24-hour pH-monitoring was performed were included. Pathological acid exposure was present in 33 patients (11%) compared with 276 patients (89%) with physiological acid exposure. During 5-year follow up, there were no differences in heartburn, dysphagia, or satisfaction scores. Eighteen percent of all patients with abnormal postoperative pH-studies underwent redo fundoplication during 5-year follow up. Pathological acid exposure demonstrated by routine postoperative pH-monitoring was not associated with worse symptomatic outcome in terms of reflux control and satisfaction. A possible explanation for this finding is that laparoscopic fundoplication reduces the patients' ability to perceive reflux. This underlines the importance of assessing the association between symptomatic outcome and esophageal function tests in determining outcome of antireflux surgery.

Variation in laparoscopic anti-reflux surgery across England: a 5-year review

BackgroundLaparoscopic anti-reflux surgery (LARS) remains central to the management of gastro-oesophageal reflux disease but the scale and variation in provision in England is unknown. The aims of this study were firstly to examine the processes and outcomes of anti-reflux surgery in England and compare them to national guidelines and secondly to explore potential variations in practice nationally and establish peer benchmarks.MethodsAll adult patients who underwent LARSin England during the Financial years FY 2011/2012–FY 2016/2017 were identified in the Surgeon’s Workload Outcomes and Research Database (SWORD), which is based on the Hospital Episode Statistics (HES) data warehouse. Outcomes included activity volume, day-case rate, short-stay rate, 2- and 30-day readmission rates and 30-day re-operation rates. Funnel plots were used to identify national variation in practice.ResultsIn total, 12,086 patients underwent LARS in England during the study period. The operation rate decreased slightly over the study period from 5.2 to 4.6 per 100,000 people. Most outcomes were in line with national guidelines including the conversion rate (0.76%), 30-day re-operation rate (1.43%) and 2- and 30-day readmission rates (1.65 and 8.54%, respectively). The day-case rate was low but increased from 7.4 to 15.1% during the 5-year period. Significant variation was found, particularly in terms of hospital volume, and day-case, short-stay and conversion rates.ConclusionAlthough overall outcomes are comparable to studies from other countries, there is significant variation in anti-reflux surgery activity and outcomes in England. We recommend that units use these data to drive local quality improvement efforts.

Hypopharyngeal multichannel intraluminal impedance leads to the promising outcome of antireflux surgery in Japanese population with laryngopharyngeal reflux symptoms.

Clinical characteristics of laryngopharyngeal reflux (LPR) in Japanese population remain unclear, and its treatment outcome is suboptimal. The objectives of this study were to evaluate Japanese patients with LPR symptoms using hypopharyngeal multichannel intraluminal impedance (HMII) and to assess the outcome of antireflux surgery (ARS). Subjects included patients who had LPR symptoms for > 12 weeks or laryngoscopic findings suggestive of LPR and underwent laryngoscopy and esophageal testing including HMII. Abnormal proximal exposure (APE) was defined as LPR ≥ 1/day and/or full column reflux (FCR) (reflux 2cm distal to the upper esophageal sphincter) ≥ 5/day on HMII. Patients with APE were offered ARS and the outcome of ARS was objectively assessed using Reflux Symptom Index (RSI). From July 2015 to September 2016, 52 patients with LPR symptoms (28 men, 24 women, median BMI 22.3) underwent HMII, and 38 patients (73%) had APE. Of them, 29 (76%) patients were not obese (BMI < 25) and 19 (50%) patients had a negative DeMeester score. Approximately one-third of LPR and FCR events were non-acid in the distal esophagus. A positive symptom-association probability was seen only in 18 patients (35%). Mild esophagitis and hiatal hernia were found in 5 (10%) and 23 (48%) patients, respectively. All 12 patients (100%) who had undergone ARS were able to discontinue PPI and had a significant improvement in the RSI scores postoperatively (22.9 ± 10.0 vs. 6.8 ± 6.8, p <.001). APE was frequently observed in Japanese patients with LPR symptoms. Obesity and esophagitis were uncommon in this population. Since a large number of patients with APE had negative DeMeester score and proximal reflux events were often non-acid, a conventional pH monitoring is insufficient. HMII is crucial to evaluate patients with LPR symptoms as the documentation of APE is a key for successful outcome of ARS.

Safety and effectiveness of antireflux surgery in obese patients.

Introduction The incidence of gastro-oesophageal reflux disease and obesity has increased significantly in recent years. The number of antireflux procedures being carried out on people with a higher body mass index (BMI) has been rising. Evidence is conflicting for outcomes of antireflux surgery in obese patients in terms of its safety and efficacy. Given the contradictory reports, this meta-analysis was undertaken to establish the outcomes of antireflux surgery (ARS) in obese patients and its associated safety. Methods A systematic electronic search was conducted using the PubMed, MEDLINE®, Ovid®, Cochrane Library and Google Scholar™ databases to identify studies that analysed the effect of BMI on the outcomes of ARS. A meta-analysis was performed using the random effects model. The intraoperative and postoperative outcomes that were examined included operative time, conversion to an open procedure, mean length of hospital stay, recurrence of acid reflux requiring reoperation and wrap migration. Results A total of 3,772 patients were included in 13 studies. There was no significant difference in procedure conversion rate, recurrence of reflux requiring reoperation or wrap migration between obese and non-obese patients. However, both the mean operative time and mean length of stay were longer for obese patients. Conclusions ARS in obese patients with gastro-oesophageal reflux disease is safe and outcomes are comparable with those in patients with a BMI in the normal range. A high BMI should therefore not be a deterrent to considering ARS for appropriate patients.

Antireflux surgery is equally beneficial in nonerosive and erosive gastroesophageal reflux disease.

PurposeAlthough nonerosive and erosive gastroesophageal reflux disease (GERD) have similar symptom severity, nonerosive reflux disease (NERD) is considered a milder type of GERD and gastroenterologists have hesitated to refer these patients for antireflux surgery. The aim of this study was to compare surgical outcomes of antireflux surgery between patients with NERD and erosive reflux disease (ERD).MethodsSeventy patients met the inclusion criteria of this study among a total of 117 patients who underwent antireflux surgery from November 2012 to October 2017. According to preoperative endoscopy, patients were classified into NERD group (minimal changes or no esophagitis) and ERD group. Clinical characteristics and surgical outcomes were compared between NERD and ERD.ResultsThere were 26 patients in NERD group and 44 patients in ERD group. The male:female ratio was higher in the ERD group than in the NERD group (P = 0.044). Preoperative symptoms, response to acid suppressive medication, acid exposure on pH monitoring study, and esophageal manometry results were similar in the 2 groups. Reflux on barium esophagography was more frequently observed in ERD (77.3%) than in NERD (50.0%, P = 0.019). At 6 months after surgery, complete resolution and partial improvement of GERD symptoms were similar in the 2 groups (80.8% and 15.4%, respectively, in NERD vs. 88.6% and 2.3%, respectively, in ERD; P = 0.363).ConclusionLaparoscopic Nissen fundoplication is equally beneficial to patients with NERD and ERD. Antireflux surgery should not be avoided for GERD patients without mucosal breaks on endoscopy as the evidence of erosive esophagitis.