Recurrent Gastroesophageal Reflux Research Articles

Laparoscopic treatment of recurrent gastroesophageal reflux disease and hiatal hernia after two failed fundoplications: a clinical case.

Aim: identification of the main causes of failures of previous surgical interventions and methods of their prevention during the primary surgical treatment of hernia of the esophageal orifice of the diaphragm.Material and methods. To address the scientific inquiry, an extensive review was conducted across global scientific literature focused on the treatment of primary and recurrent hernias of the esophageal orifice of the diaphragm (GPOD). Additionally, a clinical observation is provided, detailing a surgical intervention performed on a patient who had undergone correction for hernia and gastroesophageal reflux disease (GERD) on two prior occasions.Results. The scientific literature reports limited instances of successfull correction of the recurrence of gastroesophageal reflux disease (GERD) and gastroesophageal orifice di- aphragmatic hernias (GPOD) in patients after two fundoplications. The term ‘failed fundo- plication’ is introduced, a concept not yet described in domestic literature. Eliminating the incorrectly formed antireflux mechanism, which leads to a programmed recurrence of GPOD, and implementing technically correct antireflux interventions allow for the achievement of a pronounced clinical effect in patients who have undergone one or more fundoplications, provided there is adequate peristalsis of the esophagus and stomach. In the presented clin- ical case, the surgical procedure is based on the principles of mitigating the consequences of the previous intervention through repeated intervention primarily focused on eliminating gastroesophageal reflux.Conclusion. Repeated antireflux surgical interventions pose a significant challenge in surgical treatment, attributable to multiple factors concurrently. Identifying technical errors during ear- ly antireflux surgical interventions, eliminating them, and establishing an adequate antireflux mechanism contribute to the success of repeated interventions. Standardization of antireflux interventions is imperative, as adherence to the technical aspects of primary surgical interven- tions represents the most effective means to diminish the risk of disease relapse and the fre- quency of subsequent revision antireflux operations.

Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient: New surgical proposals

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Cirugía antirreflujo vs cirugía bariátrica como tratamiento anti-RGE y de la hernia de hiato en el obeso. Nuevas propuestas quirúrgicas

The persistence of obesity favors the failure of the fundoplication (FP) in the treatment of gastroesophageal reflux (GER). However, the weight loss obtained with the performance of a gastric bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of post-operative complications. All of this leads us to consider that while FP is the indication in patients with BMI<30, in those patients with BMI>35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI>30. Although sleeve gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of post-operative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms.Likewise, if the existence of an hiatal hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Utilization of Antireflux Mucosectomy and Resection and Plication: A Novel Approach for the Management of Recurrent Gastroesophageal Reflux Disease after Prior Nissen Fundoplication or Transoral Incisionless Fundoplication.

Background: Nissen Fundoplication (NF) and Transoral Incisionless Fundoplication (TIF) are established procedures for the treatment of gastroesophageal reflux disease (GERD). However, the surgically induced plication can loosen over time. This multicenter study aims to evaluate the safety and efficacy of Antireflux Mucosectomy (ARMS) and Resection and Plication (RAP) in symptomatic patients with prior NF or TIF that has become loose. Patients and methods: Eighteen patients were enrolled in the study. Ten had prior TIF, while eight had prior NF. Half of these patients had a Hill Grade 3 Valve while the other half had a Hill Grade 2 valve. Endoscopic submucosal dissection (ESD) was performed in six patients, while endoscopic mucosal resection (EMR) was performed in twelve patients. A follow-up endoscopy was performed at 4-12 weeks. Results: At follow-up, 11 patients had a Hill Grade 1 valve, and seven patients had a Hill Grade 2 valve. All patients had improvement in symptoms for up to 32 months. Conclusions: In this pilot study, ARMS/RAP appears to be an effective option in patients who had prior NF or TIF with recurrent GERD symptoms.

A Case Study of Achalasia Presenting with Chest Pain

&lt;p&gt;胸痛為臨床常見主述，在排除心因性問題後，常因病人合併胃灼熱感，診斷為胃食道逆流。然而本案例為一位36歲女性，因反覆進食後胸痛、胃灼熱及逆流等症狀，依醫囑斷續服用氫離子幫浦抑制劑（Proton Pump Inhibitor, PPI）治療胃食道逆流約一年仍未改善，直至夜間逆流咳嗽加劇，轉至本院消化內科求治，問診後發現合併有吞嚥困難及體重減輕情形，安排上消化道內視鏡排除食道腫瘤後，經食道攝影檢查確診為食道弛緩不能症（achalasia）。個案接受經口內視鏡肌層切開術治療、營養重建及心理諮商後，胸痛、逆流及吞嚥困難等症狀大幅改善，體重也從44 kg回復至50 kg，焦慮程度亦漸緩解。針對反覆出現與胃食道逆流相似症狀，或經藥物治療無效者，應進一步評估有無吞嚥困難，與胃食道逆流作鑑別診斷，避免病人因進食困難，造成營養不良併發症，以及長期睡眠困擾導致負向情緒感受，嚴重影響生活品質。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Chest pain as a relatively common clinical symptom especially when excluding ischemic heart dis&amp;shy;ease, patients are often diagnosed with gastroesophageal reflux disease due to acid regurgitation and a sensation of heartburn. A 36-year-old woman had had been intermittently treated with an oral proton pump inhibitor (PPI) under the impression of gastroesophageal reflux disease for approximately one year due to recurrent chest pain, heartburn, and a sensation of regurgitation. However, the symptoms deteriorated with exacerbation at night, which was an indication of poor response to the oral medi&amp;shy;cation. Thus, she was transferred to the Department of Gastroenterology for further examination and treatment. After detailed inquiry, the patient also suffered from progressive dysphagia with body weight loss, chest pain and regurgitation sensation. Therefore, an upper gastrointestinal panendoscopy was performed to exclude the presence of esophageal tumors. A diagnosis of esophageal achalasia was confirmed after an upper gastrointestinal examination series was conducted. After informing the patient, per-oral-endoscopic myotomy was performed. Nutritional supplementation and psychological consultation were also provided. The patient&amp;rsquo;s symptoms (e.g., chest pain, regurgitation, and dyspha&amp;shy;gia) improved significantly. Body weight increased from 44 kg to 50 kg, and her anxiety level was gradually reduced. For those who diagnosed with recurrent gastroesophageal reflux disease along with a poor response to oral medications, a detailed inquiry and a specific examination should be conduct&amp;shy;ed for other differential diagnoses, (e.g., achalasia) that may have long-term negative impact on the patient&amp;rsquo;s nutritional status, sleep disturbance, negative emotions, and quality of life&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Minimally Invasive Surgical Approach for Esophageal Adenocarcinoma in a Patient with Previous Belsey Mark IV Fundoplication: A Case Report

Background: Historically, the management for recurrent or persistent Gastro-esophageal reflux disease included selective vagotomy and fundoplication. Despite these surgical interventions, the risk of Barrett’s esophagus (BE) and subsequent malignant transformation remains, requiring cancer resection surgery. We present a case of a patient with a gastro-esophageal junction (GEJ) adenocarcinoma, who underwent a pediatric thoracotomy and Belsey Mark IV fundoplication, and was successfully treated by Laparoscopic Ivor-Lewis Esophagectomy (LILE). Case Presentation: This 64-year-old gentleman with BE and GEJ adenocarcinoma was previously deemed unsuitable for curative surgery due to clinical staging indicating a tumor length of 10cm and suspected invasion of the left pleura. Further staging by Endoscopic ultrasound indicated no evidence of pleural invasion with the distal esophageal thickening in keeping with his previous Belsey Mark IV fundoplication. He underwent neo-adjuvant chemotherapy and a subsequent LILE with complete laparoscopic reversion of the gastric fundoplication without injury to the gastroepiploic artery or fundus. There was sufficient preservation of conduit length to enable a tension free hand-sewn anastomosis with an uneventful post-operative recovery. Final histopathology confirmed ypT1 ypN0 moderately differentiated adenocarcinoma with R0 resection margins. The patient has completed 24 months of cancer recurrence free surveillance. Conclusion: We describe the successful management of a patient by LILE on a background of previous hiatal fundoplication surgery, previously refused curative surgery. We highlight the importance of EUS as a staging modality for such cases showing invasive disease to increase the final clinical staging accuracy. We suggest a minimally invasive approach may be utilized for successful re-do hiatal dissection as an alternative to a conventional open surgery.

633 CONVERSION TO TOUPET FUNDOPLICATION WITH DISTAL GASTRECTOMY AND ROUX-EN-Y GASTROJEJUNOSTOMY AFTER FAILED NISSEN FUNDOPLICATION

Abstract Laparoscopic Nissen Fundoplication fails in almost 15% of patients and most of them must be re-operated in order to improve reflux symptoms, esophagitis, or hiatal hernia. Surgical options are to redo LNF, distal gastrectomy alone or combination of both procedures. Redoing LNF, is associated with high rate of postoperative complications and re-failure. Purpose To present the early and medium-term postoperative outcomes of patients submitted to Laparoscopic Toupet Fundoplication combined with Distal Gastrectomy with Roux-en-Y gastrojejunostomy. Methods prospective study including 23 patients submitted to Laparoscopic Nissen Fundoplication who presented recurrence of gastroesophageal reflux after the operation. They were studied with endoscopy, barium swallow, manometry and 24 h pH monitoring in order to determine presence of esophagitis, anatomical deformities, defective Lower Esophageal Sphincter and pathologic acid reflux. Surgical process consisted on re-establishing the anatomy of the esophago-gastric junction, and then perform laparoscopic Toupet fundoplication combined with distal gastrecvtomy and Roux Y gastrojejunostomy. Results After surgery statistically significant improvement regarding heartburn (p &amp;lt; 0.0001), dysphagia (p &amp;lt; 0.0001) and retrosternal chest pain (p &amp;lt; 0.0001) as well as in the endoscopic esophagitis was observed. No significant LES pressure increase after the operation was observed. (from 7.88 + 2.7 to 10.5 + 3.36) (p = 0.15), but the abnormal acid reflux improved significantly after the reoperation, %time pH &amp;lt; 4 decreases from 12.00 + 6.62 to 4.3 + 4.04 (0.0004) and DeMeester score from 44.82 + 21.8 to 11.95 + 5.14 (0.0008) respectively. Conclusion The proposed procedure is safe option to treat successfully patients after failed Nissen fundoplication. Reflux symptoms, esophagitis, presence oh hiatal hernia and reflux score improved after the procedure.

Risk factors for recurrent gastroesophageal reflux disease after Thal fundoplication

PurposeThe recurrence rate of gastroesophageal reflux disease (GERD) after fundoplication has been reported to be 7–25%. We investigated the risk factors for recurrence of GERD after Thal fundoplication (TF) in our department with the aim of further reducing the recurrence rate of GERD.MethodsWe retrospectively analyzed 276 patients who underwent TF for GERD at our hospital between 2000 and 2019. Retrospectively considered variables were obtained from the medical records of patients. The variables included patient characteristics, GERD severity, surgery-related factors and postoperative course.ResultsThe postoperative GERD recurrence rate was 5.8%. In the univariate analysis, the presence of convulsive seizures (12/4 vs. 110/150, p = 0.046) and the absence of a tracheostomy (0/16 vs. 53/207, p = 0.048) at the time of TF were significantly associated with recurrence. In the multivariate analysis, the presence of convulsive seizures at the time of TF was the only factor significantly associated with recurrence.ConclusionThe presence of convulsive seizures and the absence of a tracheostomy at the time of TF were significantly associated with GERD recurrence after TF. Active control of seizures and consideration of surgical indications, including assessment of respiratory status, are important in preventing the recurrence of GERD after TF.

Short and long-term outcomes after pediatric redo fundoplication

BackgroundRedo fundoplication (RF) is the most common surgical treatment for recurrent gastroesophageal reflux disease (GERD) in children, but outcomes after RF are rarely reported. The aim of this study was to assess short- and long-term outcomes after RF in childhood. MethodsThe study is a follow-up study of patients undergoing RF from 2002 to 2020 at a teriary care center. Patients/parents were sent questionnaires recording symptoms of recurrent GERD, troublesome side-effects and satisfaction. Retrospective chart review was also performed. Results24/28 (86%) patients were included median 9 (1.6 months–17.7 years) years after RF. 16 (67%) had neurologic impairment. Indications for RF was recurrence of GERD (n = 18), discomfort or dysphagia from a herniated wrap (n = 5) and dysphagia from a slipped fundoplication (n = 1). Median operating time was 128 (95–250) min. Six (25%) patients experienced early major complications, of which two were gastrostomy related.Five (21%) patients experienced recurrence after RF. Three of these were symptom free at follow-up with medical treatment or re-RF. The most common symptom at follow-up was stomach pain (37%) and excessive flatulence (38%). 18/22 (95%) patients/parents would choose RF again, and 21/22 would recommend RF to someone in a similar situation. ConclusionsRF is successful in treating recurrent GERD after primary fundoplication, and patient/parental satisfaction is high.

Pain and internalizing symptoms in youth with gastrointestinal conditions including recurrent abdominal pain, eosinophilic esophagitis, and gastroesophageal reflux disease

ABSTRACT Pain intensity, pain interference, internalizing symptoms, and quality of life (HRQOL) were explored in three symptomatically similar gastrointestinal disorders: Recurrent Abdominal Pain, Eosinophilic Esophagitis, and Gastroesophageal Reflux Disease. Caregiver-proxy report was gathered for 133 pediatric patients at the time of endoscopy. There was a significant difference in pain intensity and interference between diagnostic groups. Within the full sample there was a significant difference on the combined daytime functioning variable (pain interference and HRQOL) between participants with and without elevated internalizing symptoms. Assessment of internalizing symptoms should help guide intervention efforts for patients treated by gastroenterology specialists to improve functioning.

Long-term outcomes of Roux-en-Y gastric diversion after failed surgical fundoplication in a large cohort and a systematic review

Roux-en-Y gastric diversion (RNYG) is an alternative approach for patients with persistent or recurrent gastroesophageal reflux disease (GERD) after surgical fundoplication, especially in patients with esophageal dysmotility or morbid obesity, because redo fundoplication could offer unfavorable outcomes. To evaluate long-term outcomes of RNYG for failed fundoplication and its impact on esophageal function. A retrospective cohort study and a systematic review. Patients who underwent RNYG after failed fundoplication between 1995 and 2019 were identified. Surgical-related complications, GERD, dysphagia, and endoscopic and esophageal manometric findings were reviewed. A literature search for relevant studies was performed from several databases from database inception to September2019. A total of 101 patients (mean age, 52.1 yr; 86.1% female; mean body mass index, 35.8kg/m2) were included. Overall complication rates within and more than 30 days after surgery were 36.3% and 53.5%. GERD symptoms were resolved in 70.1% after RNYG. However, 39.7% had a recurrence during a median follow-up of 56.2 months. In patients with no baseline dysphagia (n = 36), 16 (44%) developed new-onset dysphagia after surgery. In patients with severe baseline dysphagia (n = 9), 5 patients (56%) had persistent dysphagia after surgery. Seven studies involving 381 patients were included in our systematic review. High rates of GERD improvement have been reported across studies; however, long-term GERD, dysphagia, and objective outcomes were infrequently reported. RNYG is an effective alternative surgery in a subset of patients with intractable symptoms who failed fundoplication. However, patients should be informed of the risks of postoperative GERD symptoms and dysphagia. Referral for a careful evaluation by a multidisciplinary foregut team is warranted.

Proton Pump Inhibitor Use After Hiatal Hernia Repair: Inhibitor of Recurrent Symptoms and Potential Revisional Surgery

BackgroundHiatal hernia recurrence after hiatal hernia repair (HHR) is often underdiagnosed and underreported but may present with recurrent gastroesophageal reflux disease (GERD) symptoms. Because of their availability, proton pump inhibitor (PPI) use is common and may mask patients who would benefit from revisional surgery, which has been shown to improve symptoms and quality of life. MethodsA retrospective analysis was performed to evaluate recurrence patterns of patients who underwent HHR, specifically for the indication of GERD, from 2007 to 2015 at a single Veterans Administration Medical Center. Clinicopathologic parameters were reviewed for association with hiatal hernia recurrence, including postoperative PPI use. ResultsSixty-four patients were identified with a median follow-up time of 57.8 mo. Thirty-eight patients developed an anatomic recurrence, which did not demonstrate any associated factors on univariate analysis. Seventy percent of patients remained or were restarted on PPI after their initial surgery. For patients with a documented recurrence, the median time to start a PPI was 224 d, but the time to identify recurrence on imaging or endoscopy was 712.5 d. Eleven (39.3%) patients had a reintervention for anatomic recurrence, of which all had developed recurrent symptoms of GERD. ConclusionsMost patients who developed recurrent hiatal hernia were restarted on PPI without workup for their symptoms. The time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia. The use of PPIs in patients whom have undergone HHR may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms.

Robot-Assisted Repeated Fundoplication in Children and Adolescents

Recurrent gastroesophageal reflux symptoms in adolescents and young adults who underwent fundoplication in childhood present a technical challenge for the surgeon. The distal oesophagus and hiatus are difficult to access by laparotomy, the anatomy is modified by the primary procedure, and there are often dense adhesions between important structures. Robot-assisted surgery may be advantageous, because of the three dimensional (3D) view and the multiaxial freedom of movement afforded by the system. To describe our experience with robot-assisted Nissen re-fundoplication in adolescents who underwent primary fundoplication in childhood. The video shows the individual steps in robotic repeated fundoplication using the robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Three patients were operated with fundoplication at the age of 15 ± 2 years due to gastroesophageal reflux disease. After an average of 11,8 years after the primary procedure, they showed pathological reflux symptoms, which indicated repeated Nissen fundoplication. The 3D vision of the robotic system provided the surgeon with a good overview of the operative field. In addition, it allowed accurate dissection of the predictable adhesions around the hiatus. Mean operating time from incision to closure in the robot-assisted re-fundoplication was 174 min. Neither intra- nor postoperative complications occurred. As in conventional laparoscopic technique, there is a learning curve for the robotic surgery that can be appreciated from our data. Shorter dissection times and simplified dissection are potential benefits that need to be balanced with the higher cost of the robotic technique. Robot-assisted re-fundoplication is an excellent alternative to the conventional laparoscopic procedure in young adults with recurrent gastroesophageal symptoms, who had a fundoplication in early childhood. The 3D-vision and the multi-axial free mobility of the instruments facilitate precise dissection that consider anatomic structures and adhesions.

Total Oesophagogastric Dissociation in Neurologically Impaired Children: 18 Years' Experience and Long-term Follow-up.

Total oesophagogastric dissociation (TOGD) is an alternative antireflux surgery for neurologically impaired children because of a 16% to 38% fundoplication failure rate. This study evaluates TOGD's feasibility and its long-term efficacy both as a Primary and as a "Rescue" procedure after failed fundoplication. Thirty patients (18 boys) who underwent TOGD between 2000 and 2018 in 2 Italian Centres were retrospectively reviewed. Twenty-three were Primary procedures and 7 were "Rescue" ones. Inclusion criteria were severe neurodisability, intractable gastroesophageal reflux, and dysphagia. Preoperatively, all children had regurgitation, vomiting or retching, and 93% had unsafe swallowing and aspiration, with recurrent chest infections/aspiration pneumonia. Median relative weight was 77% (48%--118%). All patients were taking antireflux medication before surgery. Median age at TOGD was 6.48 years (0.69--22.18). Median follow-up was 3.5 years (0.6-17.7). No recurrence of gastroesophageal reflux (GER) and vomiting was recorded. The number of chest infections and length of hospital stay showed a significative decrease (P value <0.0001 for both), whereas median relative weight reached 101% (P value 0.002). Parents'/caregivers' perception of outcome showed a significative improvement. Six patients (20%) experienced early complications and 3 required surgical intervention. Three late complications (10%) also required surgery. There was no surgery-related mortality. TOGD is an effective procedure with an acceptably low complication rate for children with severe neurological impairment and is followed by a major improvement in general health and quality of life for children and families. There was no substantial difference in outcome between Primary and "Rescue" procedures.

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 surgical treatment for recurrent gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is common, and the outcomes of primary laparoscopic antireflux surgery are excellent. A minority of individuals will present with recurrent symptoms, typically of GERD or dysphagia, and seek revisional surgery. Herein is a discussion of the most common presentations and etiologies of failed antireflux surgery. In addition, the preoperative assessment and diagnostic tests utilized in the workup of this population are reviewed. Finally, the operative approach and outcomes related to performing revision laparoscopic antireflux surgery are examined including the use of Roux-en-Y gastric bypass in this patient population.

Redo laparoscopic surgery for recurrent gastroesophageal reflux disease and hiatal hernia

To assess mechanisms of recurrent gastroesophageal reflux disease and the ability to perform adequate surgical correction after previous surgery. The authors from various surgical centers have operated 2678 patients with gastroesophageal reflux disease and hiatal hernia for the period 1993-2018. 127 (4.74%) patients underwent redo surgery for recurrent disease, 46 of them were previously operated in other clinics. Median follow-up after redo surgery was 63 months (12-139). Satisfactory functional result was achieved in 76.4% of patients.

Indications for total esophagogastric dissociation in children with gastroesophageal reflux disease.

Total esophagogastric dissociation (TED) is used to treat gastroesophageal reflux (GER) after failed fundoplication in neurologically impaired patients. It is now performed for some otherwise healthy patients with severe GER. In this procedure, the gastrointestinal tract is reconstructed in a non-physiological way with a Roux-en-Y esophagojejunal anastomosis and jejuno-jejunostomy. Although TED eliminates almost all GER, some patients experience late complications. In this review, we investigated the long-term outcomes after TED to determine the best indications. In total, 147 neurologically impaired patients and 28 neurologically normal patients were identified. The total rate of complications requiring re-operation was 17.2% in neurologically impaired patients and 32.1% in normal patients, both higher than the rates associated with fundoplication. Although most authors added pyloroplasty when there was a concern of gastric emptying, this sometimes caused bile reflux. Nutritional and metabolic complications, including dumping syndrome and chronic digestive malabsorption, were also reported to occur after TED. TED is an option for the treatment of neurologically impaired patients with recurrent GER after fundoplication or who are at a high risk of recurrence of GER with fundoplication. However, neurologically normal patients who have the ability to obtain nutrition orally should consider options other than TED, as postoperative complications are frequent.

Association Between Laparoscopic Antireflux Surgery and Recurrence of Gastroesophageal Reflux

Cohort studies, mainly based on questionnaires and interviews, have reported high rates of reflux recurrence after antireflux surgery, which may have contributed to a decline in its use. Reflux recurrence after laparoscopic antireflux surgery has not been assessed in a long-term population-based study of unselected patients. To determine the risk of reflux recurrence after laparoscopic antireflux surgery and to identify risk factors for recurrence. Nationwide population-based retrospective cohort study in Sweden between January 1, 2005, and December 31, 2014, based on all Swedish health care and including 2655 patients who underwent laparoscopic antireflux surgery according to the Swedish Patient Registry. Their records were linked to the Swedish Causes of Death Registry and Prescribed Drug Registry. Primary laparoscopic antireflux surgery due to gastroesophageal reflux disease in adults (>18 years). The outcome was recurrence of reflux, defined as use of antireflux medication (proton pump inhibitors or histamine2 receptor antagonists for >6 months) or secondary antireflux surgery. Multivariable Cox regression was used to assess risk factors for reflux recurrence. Among all 2655 patients who underwent antireflux surgery (median age, 51.0 years; interquartile range, 40.0-61.0 years; 1354 men [51.0%]) and were followed up for a median of 5.6 years, 470 patients (17.7%) had reflux recurrence; 393 (83.6%) received long-term antireflux medication and 77 (16.4%) underwent secondary antireflux surgery. Risk factors for reflux recurrence included female sex (hazard ratio [HR], 1.57 [95% CI, 1.29-1.90]; 286 of 1301 women [22.0%] and 184 of 1354 men [13.6%] had recurrence of reflux), older age (HR, 1.41 [95% CI, 1.10-1.81] for age ≥61 years compared with ≤45 years; recurrence among 156 of 715 patients and 133 of 989 patients, respectively), and comorbidity (HR, 1.36 [95% CI, 1.13-1.65] for Charlson comorbidity index score ≥1 compared with 0; recurrence among 180 of 804 patients and 290 of 1851 patients, respectively). Hospital volume of antireflux surgery was not associated with risk of reflux recurrence (HR, 1.09 [95% CI, 0.77-1.53] for hospital volume ≤24 surgeries compared with ≥76 surgeries; recurrence among 38 of 266 patients [14.3%] and 271 of 1526 patients [17.8%], respectively). Among patients who underwent primary laparoscopic antireflux surgery, 17.7% experienced recurrent gastroesophageal reflux requiring long-term medication use or secondary antireflux surgery. Risk factors for recurrence were older age, female sex, and comorbidity. Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring treatment, diminishing some of the benefits of the operation.

Parents reported reduced symptoms and improved satisfaction after fundoplication and their perceptions were an important outcome measure.

Fundoplication is required for children with chronic recurrent gastro-oesophageal reflux disease (GERD). The aim of this study was to report parental perceptions of symptoms and overall satisfaction with the long-term course following fundoplication with special reference to patients with GERD risk factors. We studied 34 patients, with a median age of 6.5 ± 4.9 years, who received fundoplication between 2001 and 2005. Clinical information and surgical complications were recorded. Parents were interviewed to evaluate post-operative symptoms, mode of nutrition and satisfaction. The median follow-up time was 7.3 years. Comorbidities were neurological impairment in 15 patients, other gastrointestinal disorders in seven patients and isolated GERD in 12 patients. The parents reported that fundoplication effectively treated initial reflux symptoms in 60% and improved symptoms in 37%. Vomiting and reflux-associated pain were treated most effectively. Pulmonary symptoms often remained unchanged in neurologically impaired children. Redo fundoplication was necessary in seven patients. Only two parents regretted consenting to surgery. A high percentage of parents reported improved gastrointestinal reflux-related symptoms and a high level of satisfaction following fundoplication. Parental perceptions of GERD symptoms should be an important outcome measure when assessing the efficacy of antireflux surgery in children in routine clinical follow-up.