Recurrent GERD Research Articles

Scalp and auricular acupuncture attenuate recurrent gastroesophageal reflux disease and related inflammatory cytokines

BackgroundGastroesophageal reflux disease (GERD) is increasingly common in developed countries. The pathogenesis involved in the symptoms includes gastric acid, esophageal or gastric motility disorders, visceral hypersensitivity, and lower esophageal sphincter (LES) dysfunction. Proton pump inhibitors (PPIs) are the most effective treatment, but long-term use can lead to gastric hypoacidity and nutrient deficiencies. AimsThis study exams the potential of meridian acupoint stimulation to modulate visceral hypersensitivity and LES tone in patients who are dependent or have failed PPIs. calp acupuncture activates the trigemino-parasympathetic reflex, while auricular acupuncture stimulates the vagus nerve, affecting the autonomic nervous system (ANS) of the viscera. This approach may restore LES function and reduce visceral hypersensitivity. However, its effectiveness for recurrent and PPI-dependent GERD remains unclear. MethodsPatients with recurrent GERD dependent on PPIs for at least 6 months were enrolled. The intervention involved four sessions of 2-week treatments with Wen's modern scalp and auricular acupuncture (WMA) versus seed acupressure (SAP). Reflux disease questionnaire (RDQ) scores, serum Gamma-aminobutyric acid (GABA), and serum inflammatory cytokines were evaluated before and after treatment. ResultsWMA significantly reduced total RDQ scores, on-demand PPI use, esophageal epithelial cell-derived cytokines, tight junction-modulating cytokines, and recurrent GERD markers. Patients with increased GABA levels post-WMA showed significant decreases in RDQ scores and PPI use. ConclusionWMA may alleviate recurrent, PPI-dependent GERD symptoms by modulating the ANS, potentially reducing systemic and local inflammatory cytokines within the lower esophageal epithelial barrier.

Redo Nissen Fundoplication with and without Mesh to Re-Inforce Crural Repair: A Cohort Comparative Study

Abstract Background The incidence of hiatal hernias increases with age. Approximately 55%-60% of individuals over the age of 50 have a hiatal hernia. However, only about 9% have symptoms, and it depends on the type and competency of the lower esophageal sphincter. The vast majority of these hernias are type I sliding hiatal hernias. Type II, paraesophageal hernias, only make up about 5% of hiatal hernias where the LES remains stationary, but the stomach protrudes above the diaphragm. There is also an increased prevalence in women, which could be attributed to increased intraabdominal pressure during pregnancy. Hiatal hernias are most common in Western Europe and North America and are rare in rural Africa. Aim of the Work This prospective – retrospective study aims to compare the efficacy of redo laparoscopic Nissen fundoplication with and without mesh repair for treatment of recurrent hiatus hernia after failed primary repair, regarding improvement of recurrent GERD symptoms, sliding hernia recurrence, and postoperative patients’ satisfaction. Patients and Methods In our study, prospective - retrospective randomized study was conducted on 30 patients who underwent redo laparoscopic Nissen fundoplication for the treatment of recurrent hiatus hernia with at least 1-year follow-up. A total of 15 patients underwent redo laparoscopic Nissen fundoplication, whereas 15 patients underwent the same technique with mesh reinforcement. Results Significant differences in postoperative reflux-associated symptoms were observed in both groups than preoperatively, but with a significant higher score for dysphagia noticed in the group in which mesh has been used. Anatomical recurrence occurred in four (26%) patients in the group of repair with out mesh after 12 months with relatively higher regurgitation, heartburn scores. Overall, patient's satisfaction was higher in the mesh group Conclusion Mesh reinforcement is associated with less recurrence rate in comparison with redo laparoscopic Nissen fundoplication alone during the short-term follow-up, but it is associated with more incidence of postoperative dysphagia. Mesh reinforcement is specially recommended for large defects more than 6 cm.

A new approach to the treatment and classification of recurrent hiatal hernia and gastroesophageal reflux disease

Background. The incidence of disease relapse after primary antireflux surgical treatment ranges from 4 to 24 %, with up to 9 % of cases requiring revision surgery. Several studies demonstrate that the results of operations for recurrent hiatal hernia are less satisfactory compared to the primary procedure, especially after multiple interventions.Aim. To propose a technique for laparoscopic redo fundoplication using a novel method, to evaluate short-term and long-term results after repeated surgical treatment of patients with recurrent hiatal hernia and GERD, and also to propose a classification of relapses of GERD and hiatal hernia.Material and methods. The prospective study included data from 31 patients diagnosed with recurrent GERD and hiatal hernia. Laparoscopic redo fundoplication was used as a surgical method. Intraoperatively, technical errors of the previous operation were identified. The classification of relapses was conducted using the author’s method. Quality of life indicators using specialised questionnaires before surgery were: GERD-Q — 12.1 ± 2.82, GERD-HRQL — 26.12 ± 8.31, GSRS — 44.26 ± 10.21.Results. There were no access conversions. The average duration of the operation was 141.21 minutes, blood loss was 81.40 ml, intraoperative complications in 4 (9.7 %) patients were eliminated intraoperatively, postoperative complications according to Clavien-Dindo ≥ 3 were diagnosed in one patient (pneumothorax), performed drainage of the pleural cavity. In 18 (58 %) patients, technical errors were identified that were made during the previous antireflux intervention. Quality of life indicators using specialised questionnaires six months after surgery were: GERD-Q — 2.1 ± 1.31, GERD-HRQL — 4.31 ± 2.98, GSRS — 17.02 ± 6.18. During the follow-up examination, 27 (87 %) patients noted complete recovery, as well as the absence of the need for PPI and prokinetic therapy.Conclusion. The results of the study confirm the effectiveness, functionality and safety of laparoscopic redo fundoplication as the main treatment for this disease.

A clinical case: gastric cancer after gastric bypass

Introduction: Gastric cancer is one of the most common oncological diseases in the world, occupying the 5th place of morbidity and the 3rd place in the structure of mortality from oncological diseases. For a long time, issues affecting the risk of developing cancer after bariatric surgery remain relevant. Our observation is devoted to the diagnosis and treatment of a patient with gastric cancer after gastric bypass. Description of the clinical case: A 62‑year‑old patient was operated on 13. 07. 2016 – laparoscopic Roux gastric bypass for morbid obesity, 11. 09. 2019 – laparoscopic installation of the Cardioplant plate on a small stomach due to recurrent weight gain. Since 2020 the patient had the phenomena of anastomositis, dysphagia and gastroesophageal reflux. Courses of conservative therapy, sessions of balloon dilation of gastroenteroanastomosis and anastomosis resection failed to show a significant effect. The patient underwent comprehensive examinations at each treatment, including abdominal MSCT, cancer markers and studies of biopsy material of the gastric mucosa and gastroenteroanastomosis. As a result of histological studies, no signs of cancer were found. After applying to the Avicenna Medical Center in 2022 a molecular genetic analysis was carried out, in which the mRNA panel most corresponded to a malignant neoplasm. 20. 12. 2022 extirpation of the stomach stump with resection of the esophagus was performed. The cancer diagnosis was confirmed by histological and immunohistochemical studies: low‑grade adenocarcinoma of the stomach with a cricoid component with germination into the esophagus and small intestine, with spread beyond the muscle layer. Conclusion: This clinical case highlights the complexity of oncological verification in patients after bariatric surgery. Prolonged dysphagia, anastomositis and recurrent GERD in such patients determine the need for a more detailed examination, including the latest achievements of molecular genetic analysis.

The index of failure of the antireflux function of the cardia (IFAFC), as a criterion for the effectiveness of its videolaparoscopic correction for gastroesophageal reflux disease (gerd) in pthe index of failure of the antireflux function of the cardia after video-laparoscopic correction in gerd patients with hiatal hernia

The purpose of the study was to create an index based on the total results of special research methods that characterizes the antireflux function of the cardia in the long term after its video-laparoscopic correction in GERD patients with hiatal hernia (HH). Long-term results of video-laparoscopic antireflux intervention in 213 patients with GERD and HH were analyzed. Based on the results of a remote survey and instrumental examination, the patients were divided into three groups. The first group consisted of the patients who had symptoms of GERD, but the presence of pathological gastroesophageal reflux was not confirmed by instrumental methods (122 patients, 57.3 %); the second group included the patients with recurrent GERD (19 patients, 8.9 %); the third group (72 patients, 33.8 %) consisted of the patients without GERD symptoms or its recurrence. To assess the antireflux function of the cardia in the long term after its video-laparoscopic correction, the index of failure of the antireflux function of the cardia (IFAFC) was developed based on the generalized results of instrumental research methods. Before surgery in all groups of the patients, the IFAFC did not have a statistically significant difference and indicated a very significant severity of signs of failure of the antireflux function of the cardia (0.70±0.06, 0.74±0.05, and 0.70±0.06, respectively; р>0.05). In the long term after surgery, the patients with false-positive GERD symptoms showed an improvement in the IFAFC by 87.14 % (p<0.001), the patients without symptoms of GERD and its recurrence — by 92.86 % (p<0.001), and the patients with recurrent GERD — by 16.22 % (p<0.05). The IFAFC allows assessing the results of the antireflux surgery. In the absence of recurrent GERD, the IFAFC is 0.05±0.01; in patients with recurrent GERD, it is 0.62±0.07. The IFAFC equal to 0.09±0.07 is typical for patients at risk with false-positive symptoms of GERD without confirmation of its relapse by special studies. These patients require follow-up.

1034 A Rare Case of ROHHAD Syndrome

Abstract Introduction Early diagnosis of pediatric syndromes that are rare and involve multiple systems can be challenging. Rapid onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysregulation characterizes ROHHAD syndrome which, if undiagnosed, can lead to potentially harmful outcomes including deferring radiological workup for a neural crest tumor (which has an over 50% association) and cardiopulmonary arrest. Report of case(s) A 10-year-old female with a history of obesity, precocious puberty, recurrent hypothermia, recurrent sodium derangements, bilateral ptosis, seizure disorder, and GERD initially presented to sleep clinic as a 4-year-old in 2017 when she recently began snoring with excessive daytime sleepiness as a result of rapid onset of weight gain. BMI at that time was 99th percentile and Epworth was 11. An in-lab polysomnography revealed severe OSA with AHI 26.4 events/hour; nocturnal hypoxemia with TS90 27% and O2 nadir 70%; and sleep related hypoventilation based on elevated pCO2 on end-tidal capnometry. Patient underwent adenotonsillectomy, revision adenoidectomy, and was started on CPAP before transitioning to BiPAP over the span of the next several years with serial polysomnographies ultimately showing significant improvement of sleep apnea with AHI 5.4 events/hour. Sleep-related hypoventilation, however, remained persistent with blood gases showing pCO2 as high as 89. PHOX2B gene testing was negative and secondary causes of hypoventilation were ruled out. During this time, she was also followed by Endocrinology for suspected hypothalamic dysfunction resulting in precocious puberty, deceleration of growth rate, sodium derangements. Autonomic dysfunction was also suspected due to recurrent hypothermia including a recent admission for Temperature < 95F and ophthalmologic abnormalities including bilateral ptosis. At a multidisciplinary care conference, a working diagnosis of ROHHAD syndrome was made based on the rapid onset of obesity, hypoventilation on sleep studies and CBGs, hypothalamic dysfunction, and autonomic degeneration. Workup for neural crest tumor with MRI chest and abdomen unremarkable. Outside academic consultation was sought for management which recommended shared decision-making regarding steroids, immunosuppressive therapy (eg rituximab, cyclophosphamide), and IVIG. Conclusion For ROHHAD syndrome, there are very few documented cases in the United States and there is no known laboratory marker; diagnosis remains clinical and takes multidisciplinary collaboration, education, and a high degree of suspicion. Support (if any)

False-positive symptoms of recurrence of gastroesophageal reflux disease (gerd) in patients with hiatal hernia (hh) after anti-reflux videolaparoscopy

We compared the results of remote survey of 213 patients with HH associated with GERD in the long term after anti-reflux videolaparoscopy, according to the GERD-HRQL, GIQLI, and SF-36 questionnaires (patients’ complaints) and special methods for studying the anti-reflux function of the cardia (X-ray endoscopy of the esophagus and stomach, daily esophageal pH monitoring, esophageal manometry). Based on the results of special studies, a generalized indicator of failure of the anti-reflux function of the cardia (GIFAFC) was developed. It was found that 57.3% of the examined patients had false-positive symptoms of GERD recurrence, which was manifested by pain in the epigastric region (31.2%), belching with air (4.1%), and heartburn (21.3%). There were no symptoms when bent over or lying down. The existing symptoms were mild, easily stopped by conservative treatment. The patients with false-positive GERD symptoms after surgery showed an improvement in GIFAFC by 7.9 times (p <0.001), but it was 5.4 times worse than in patients without recurrent GERD (p <0.001), and 6.3 times better in relation to patients with recurrent GERD (p<0.05). False-positive symptoms of GERD recurrence contributed to a decrease in the generalized indicator of quality of life, which, according to the SF-36 questionnaire, was 76% of the maximum desired result. Due to the absence of reliable clinical manifestations, all patients with HH who have certain symptoms of GERD after fundoplication should undergo an instrumental study of the anti-reflux function of the cardia. Patients with established false-positive symptoms of GERD are subject to dispensary follow-up.

Role of Transoral Incisionless Fundoplication in Salvage Therapy for Recurrent Reflux

Background: Gastroesophageal reflux (GERD) occurs when anatomic barriers fail to prevent retrograde movement of stomach contents into the esophagus. When lifestyle and medications fail to relieve patients’ symptoms, anti-reflux procedures can be safe and effective options for addressing the mechanical deficits (such as reduced lower-esophageal sphincter pressure, hiatal hernia, and/or patulous diaphragmatic hiatus) contributing to GERD. When laparoscopic fundoplication treatment of GERD fails, repeat surgical treatment is an option—but comes with risk of increased morbidity when compared to the primary fundoplication. Transoral incisionless fundoplication (TIF) is an endoscopic anti-reflux procedure that may be an alternative option for salvage therapy in patients with recurrent GERD. Methods: This review will explore fundoplication failure, the theoretical role for TIF in this setting, and the literature to support TIF as endoscopic rescue at this time. Literature review of studies reporting TIF for salvage therapy outcomes was performed, revealing 2 published papers. Results: TIF as salvage therapy has been shown in patients with minimal recurrent hiatal hernia but a loose fundoplication to be feasible, safe, and effective with improvement of GERD symptom scores and acid exposure time. However, this has only been shown in small, retrospective studies at this time. Conclusion: TIF may be a reasonable alternative to repeat laparoscopic fundoplication in patients with a small hiatal hernia.

Removal of the magnetic sphincter augmentation device: an assessment of etiology, clinical presentation, and management

BackgroundMagnetic sphincter augmentation (MSA) erosion, disruption or displacement clearly requires device removal. However, up to 5.5% of patients without anatomical failure require removal for dysphagia or recurrent GERD symptoms. Studies characterizing these patients or their management are limited. We aimed to characterize these patients, compare their outcomes, and determine the necessity for further reflux surgery.MethodsThis is a retrospective review of 777 patients who underwent MSA at our institution between 2013 and 2021. Patients who underwent device removal for persistent dysphagia or recurrent GERD symptoms were included. Demographic, clinical, objective testing, and quality of life data obtained preoperatively, after implantation and following removal were compared between removal for dysphagia and GERD groups. Sub-analyses were performed comparing outcomes with and without an anti-reflux surgery (ARS) at the time of removal.ResultsA total of 40 (5.1%) patients underwent device removal, 31 (77.5%) for dysphagia and 9 (22.5%) for GERD. After implantation, dysphagia patients had less heartburn (12.9-vs-77.7%, p = 0.0005) less regurgitation (16.1-vs-55.5%, p = 0.0286), and more pH-normalization (91.7-vs-33.3%, p = 0.0158). Removal without ARS was performed in 5 (55.6%) GERD and 22 (71.0%) dysphagia patients. Removal for dysphagia patients had more complete symptom resolution (63.6-vs-0.0%, p = 0.0159), freedom from PPIs (81.8-vs-0.0%, p = 0.0016) and pH-normalization (77.8-vs-0.0%, p = 0.0455).Patients who underwent removal for dysphagia had comparable symptom resolution (p = 0.6770, freedom from PPI (p = 0.3841) and pH-normalization (p = 0.2534) with or without ARS. Those who refused ARS with removal for GERD had more heartburn (100.0%-vs-25.0%, p = 0.0476), regurgitation (80.0%-vs-0.0%, p = 0.0476) and PPI use (75.0%-vs-0.0%, p = 0.0476).ConclusionsMSA removal outcomes are dependent on the indication for removal. Removal for dysphagia yields excellent outcomes regardless of anti-reflux surgery. Patients with persistent GERD had worse outcomes on all measures without ARS. We propose a tailored approach to MSA removal-based indication for removal.Graphical abstract

S2801 Mucosal Ablation Salvage Therapy After Prior TIF for Recurrent GERD

Introduction: Gastroesophageal reflux disease (GERD) is a major cause of upper GI complaints and affects approximately a quarter of Americans. If medical therapy with proton pump inhibitors or histamine antagonists fails, there are endoscopic interventions that can be offered to decrease symptoms. One such endoscopic procedure is called anti-reflux mucosal ablation or ARMA. ARMA is a minimally invasive option available to the general endoscopist even in low resource settings and can be an effective treatment even after other techniques have been attempted such as transoral incisionless fundoplication (TIF). Case Description/Methods: A 66-year-old female with severe GERD, confirmed with pH impedance testing, presented with recurrent heartburn two years after successful treatment with TIF. High dose PPI improved the pain but did not resolve it. She continued to have daily severe symptoms. She could not identify any dietary triggers or exacerbating factors other than laying down or bending over. She had no hematemesis, dysphagia or abdominal pain. There was no family history of esophageal or gastric cancer. After discussion of her therapeutic options, she chose to pursue endoscopy with anti-reflux mucosal ablation (ARMA). The patient’s GERD quality of life questionnaire was obtained at 0, 3 and 6-month follow-up from ARMA. The questionnaire consists of 10 questions on a scale of 1-5 with highest numbers being the most severe symptoms related to GERD. Her scoring improved from an initial score of 33 (max 50) down to 13 then 7 at 0, 3, and 6-month follow-up, respectively. (Figure) Discussion: ARMA consists of ablation of the gastric mucosa in a horseshoe shape around the lower esophageal sphincter to induce scar tissue formation. As it contracts, it creates a tighter junction and decreases the risk of reflux. (See picture below). Circumferential ablation is avoided to decrease the risk for strictures. ARMA is an accessible anti-reflux endoscopic intervention because it utilizes argon plasma coagulation (APC) which is readily available to general endoscopists and has promising results for symptomatic relief for patients. It is less invasive than other anti-reflux surgeries and can be performed after other interventions if patients have recurrent symptoms of reflux and has the advantage of being repeatable. Importantly, this procedure is accessible to patients in low-resource environments, such as our county health system.Figure 1.: Example of Endoscopic View: a Pre-ARMA. Endoscopy in retroflexion demonstrated significant hernia but no sliding component. b Immediately post-ARMA. Endoscopy in retroflexion showed horseshoe-shaped artificial ulcer. c Appearance at 1 month post-ARMA. Mucosal flap valve was re-shaped. Inoue H et al. Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors: a pilot study. Endosc Int Open. 2020 Feb;8.

Novel "starburst" mesh configuration for paraesophageal and recurrent hiatal hernia repair: comparison with keyhole mesh configuration.

Controversy exists over the use of mesh, its type and configuration in repair of hiatal hernia. We have used biological mesh for large or recurrent hiatal hernias. We have developed a mesh configuration to better enhance the tensile strength of the hiatus by folding the mesh over the edge of the hiatus-entitled the "starburst" configuration. We report our experience with the starburst configuration, comparing it to our results with the keyhole configuration. Medical records of all patients undergoing either the keyhole or starburst mesh configuration hiatal hernia repair were reviewed between 2017 and 2021. Data gathered included age, sex, type of hernia (sliding, paraesophageal, or recurrent), fundoplication type (none, Nissen, Toupet, Dor, Collis-Nissen, Collis-Toupet, or magnetic sphincter augmentation [MSA]), 30-day complications, and long-term outcomes (hiatal hernia recurrence, reflux-symptom recurrence, dysphagia, dilations, reoperations). From 7/2017 to 8/2019, 51 cases using the keyhole mesh were completed. Sliding hiatal hernia comprised 4%, paraesophageal hernia (PEH) 64% and recurrent hiatal hernia (RHH) 34% of cases. Distribution of fundoplication type: 2% none, 41% Nissen, 41% Toupet, 8% Dor, 2% Collis-Nissen, and 6% Collis-Toupet. 30-day complication rate 31%. Long-term outcomes: recurrent hiatal hernia 16%, dysphagia 12%, dysphagia requiring dilation(s) 10%, recurrent GERD symptoms 4%, and reoperation 14%. From 10/2020 to 8/2021, 58 cases using the starburst configuration were completed. PEH comprised 60% and RHH 40%. Distribution of fundoplication type: 10% none, 40% Nissen, 43% Toupet, 5% MSA, 2% Collis-Toupet. 30-day complication rate 16%. Long-term outcomes: recurrent hiatal hernia 19%, dysphagia 14%, dilations 5%, recurrent GERD symptoms 9%, and reoperations 3%. The starburst mesh configuration compares favorably with the keyhole configuration with respect to postoperative dysphagia, need for esophageal dilation, and GERD symptom recurrence, with similar recurrence rates. We are continuing to further refine this technique and study the long-term outcomes.

Anti-reflux surgery in neonates and infants: analysis of indications, outcomes, and link to mortality among primary and secondary gastroesophageal reflux patients

BackgroundThe indications and benefits of anti-reflux surgery (ARS) in neonates and infants are uncertain. Prematurity, operation before 1 year of age, neurological impairment (NI), and chronic lung disease (CLD) are risk factors for surgical failure. We aim to document the indications, management, and outcomes of ARS in this age group and compare them among primary and secondary gastroesophageal reflux (GERD).ResultsBetween January 2008 and December 2019, 24 males and 22 females had ARS; 13 (28.3%) for primary while 33 (71.7%) for secondary GERD. The mean gestational age was 34.6 weeks (range 24–41) and mean birth weight was 2000 gm (range 600–3300). The weight at time of referral ranged from 1.4 kg to 4 kg (mean 2.2 kg). There were no significant differences between the two groups regarding the previous data. The group of primary GERD presented mainly with recurrent aspiration (n = 8), recurrent apnea (n = 5), and recurrent desaturations with or shortly after feeds (n = 4). The group of secondary GERD were referred for poor sucking with failure to thrive (FTT) (n = 25), recurrent aspiration (n = 20), and gastrostomy request (n = 14). The risk factors for secondary GERD were neurologically impaired (n = 22), post-esophageal atresia (EA) repair (n = 9), hiatus hernia (n = 4), thoracic stomach (n = 2), N-type tracheoesophageal fistula (TEF, n = 4), and congenital esophageal stenosis (CES, n = 4). The operations included open Nissen’s fundoplication (ONF) (n = 4) and modified open Thal’s fundoplication (MOTF) (n = 42). There were 8 mortalities in the secondary group, unrelated to surgery. Morbidities after Nissen’s fundoplication included wrap migration, gas bloat, and reoperation in one, laparotomy for intestinal obstruction (IO) in one. Following MOTF, there were two cases of transient recurrent GERD which improved with time and laparotomy in one for IO.ConclusionsDiagnostic tests remain a challenge. Isolated TEF and CES may require fundoplication for staged management. Cases of the primary group did better with MTFO. Prematurity, CLD and age < 2 months were not significant risk factors for fundoplication failure or mortality. Neurological impairment was a risk factor for mortality.

Collis gastroplasty in surgical treatment of hiatal hernia

To analyze the early and long-term postoperative outcomes after Collis gastroplasty in the treatment of patients with hiatal hernia complicated by gastroesophageal reflux disease and shortening of the esophagus. Postoperative outcomes after Collis gastroplasty were analyzed in 22 patients with hiatal hernia and shortening of the esophagus. The control group consisted of 166 patients after simple repair of hiatal hernia without Collis procedure. In case of Collis gastroplasty, surgery time was 185 (160-250) min. Intraoperative complications were observed in 3 (13.6%) patients, incidence of postoperative complications - 18.2%. There were no lethal outcomes in this group of patients. Mild functional dysphagia was observed in 2 (9.1%) patients. Length of hospital stay was 7.8±2.4 days. Mean follow-up was 34 (6-52) months. There were no anatomical recurrences. A relapse of gastroesophageal reflux was noted in 1 (4.6%) case. GERD-HRQL score was 4.8±2.2 points. Additional Collis gastroplasty did not affect the immediate and long-term results of surgical treatment in comparison with simple cruroraphy and fundoplication. Unreduced shortening of the esophagus may be followed by high incidence of recurrent hiatal hernia and GERD in long-term period. In case of shortening of the esophagus, surgery should include Collis gastroplasty. This effective and safe procedure does not impair treatment outcomes. Indications and optimal technique of Collis gastroplasty require clarification and further research.

Gastroesophageal reflux after laparoscopic hiatal hernia repair in patients with axial hiatal hernia

To find out significance of the main locking mechanisms of lower esophageal sphincter in the relapse of GERD in patients with axial hiatal hernia after previous antireflux laparoscopic surgery. There were 103 patients with GERD and axial hiatal hernia who underwent original circular laparoscopic esophagofundoplication with correction of hiatal opening dimensions by crural and hiatal repair. Depending on generalized DeMeester index (within the normal range or its excess), all patients were divided into two groups - without relapse (group 1, n=88) and with recurrent GERD (group 2, n=15). Both groups were comparable by the main characteristics and postoperative follow-up period (mean - 6 years). Antireflux function was investigated by X-ray examination and endoscopy, manometry of the esophageal-gastric passage, intra-esophageal 24-hour pH-monitoring. Processing and graphical presentation of data was carried out using Statistica v.10.0 Rus software (StatSoft, USA) and Microsoft Office Excel 2013 (USA). Abnormal gastroesophageal reflux was detected in 14.56±3.48% of patients after laparoscopic anti-reflux surgery. Recurrent hiatal hernia occurred in 20±10.33% of these patients, malfunction of lower esophageal sphincter - in 80±10.33%. Failure of cardia was caused by shortening of its length by 30.43% and decrease of tone by 6.78% with significantly (61.09%) increased tone of the stomach. Failure of cardia was manifested by increase of generalized DeMeester index in the lower third of the esophagus by 3.2 times, acidic gastroesophageal refluxes, reflux index and index reflux values. Preserved esophageal motility combined with shortening of time of esophageal clearance in patient's lying position was associated with reduced incidence of reflux-esophagitis by 77.26% even in case of recurrent GERD. Abnormal reflux after antireflux laparoscopic surgery due to GERD with axial hiatal hernia is caused by recurrent hiatal hernia in every fifth patient while the main reason is failure of LES cuff with increased intragastric pressure.

Removing the magnetic sphincter augmentation device: operative management and outcomes.

Recurrent or persistent symptoms of reflux, dysphagia, or device erosion can lead to removal of the magnetic sphincter augmentation (MSA aka Linx) device. Device removal has been previously reported, and outcomes of various surgical management strategies at the time of removal have not been well described. This is a retrospective review of patients undergoing MSA removal from March 2009 to September 2017 in a single institution. Reason for removal, operative management, and short-term outcomes are reported. During the study, 435 MSA devices were implanted, 24 of which required removal (5.5%). Removal was due to refractory dysphagia in 1.8% (8/435), for recurrent or persistent GERD in 2.9% (13/435), and secondary to erosion in 0.5% (2/435). Mean time from implant to removal was 863days (range 119-1762 days). The most common reasons for removal were recurrent GERD (54%), dysphagia (38%), or erosion (8%). Significant operative findings included recurrent or progressive hiatal hernia (38%), erosion (8%), and normal anatomy (46%). Hiatal hernia was found and repaired at the time of device removal in 38% of patients (9/24). The MSA device was removed through laparotomy (4%), laparoscopically (88%), or through a combination of endoscopy and laparoscopy (8%). After removal patients underwent repeat MSA (33%), fundoplication (21%), gastrectomy (4%), or no additional procedure (42%). Symptoms prompting removal of the MSA device had resolved in 52% of patients and improved in an additional 35% at last contact. Of the 10 patients having no anti-reflux procedure after removal, 9 were available for follow-up at a mean of 97 (106) days of whom 22.2% (2/9) had symptoms of GERD or required any anti-reflux medication. No major complications occurred after removal. MSA removal when necessary can be accomplished through minimally invasive means. Repeat Linx or fundoplication can be performed after removal, however may not be necessary in patients with removal for dysphagia.

A202 - Roux-en-Y Gastric Bypass after Failed Lower Esophageal Sphincter Magnetic Augmentation Procedure

Background: Management of GERD in patients with obesity presents unique challenges. There are different schools of thought as to the type of procedure (anti-reflux vs. bariatric surgery) that should be offered to the patient with reflux. We present a video of a 49y/o female with a failed lower esophageal sphincter magnetic augmentation (LESM). The patient presented after referral to the bariatric practice after developing recurrent GERD (HRQL=13, on PPI), intermittent dysphagia, regurgitation and weight gain <24 months after LESM procedure. BMI at the time of the LESM procedure was 31.9 kg/m2 (down from 35.4 at consultation). At the time of bariatric consultation, her BMI was 38.6 kg/m2. Preoperative evaluation demonstrated the LESM beads approximately 1-2cm below the GE Junction with a small hiatal hernia.

Minimal versus obligatory dissection of the diaphragmatic hiatus during magnetic sphincter augmentation surgery.

The magnetic sphincter augmentation (MSA) device was initially implanted with minimal hiatal dissection (MHD) at the diaphragmatic hiatus. Due to concern of possible MSA device dysfunction if herniated into an occult or small hiatal hernia, and increased understanding to the role of defective crura in reflux disease, the operative procedure was changed to planned obligatory dissection (OD) of the hiatus at the time of all implantations. Between December 2012 and September 2016, 182 patients underwent MSA implant at a single medical center and have complete records available for review through September 2017. The MHD dissection period extended from December 2012 to September 2015, from September 2015 to 2016 all patients underwent OD. MHD occurred 53% (96/182) versus OD in 47% (86/182), mean follow-up time in days for MHD and OD was 554 (SD 427) versus 374 (298)days. Intraoperative measurement of hernia size for the MHD versus OD was 0.77 (1.1) versus 3.95 (2.4)cm, p < 0.001. At first visit follow-up, there was no difference in any dysphagia (p = 0.11). Recurrent GERD (defined as resumption of PPI after successful initial post-operative wean) was less frequent after OD than after MHD, 3.6 versus 16.3%, p = 0.006. Delayed onset dysphagia was 1.2% in the OD group versus 8.6% in the MHD group, p = 0.04. Recurrent hiatal hernia of 2cm or greater occurred in 0.0% of the OD and 11.5% of the MHD, p = 0.03. Repeat surgery for hiatal hernia repair has occurred in 0% of the OD and 6.6% of the MHD, p = 0.02. OD of the hiatus with crural closure resulted in less recurrence of reflux symptoms and hiatal hernia, despite an increased proportion of patients with larger hiatal hernia and more complex anatomic disease at the time of operation.

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.

V-003 重症心身障害児の再発性胃食道逆流症に対する食道胃分離術(第44回日本小児外科学会学術集会)

V-003 重症心身障害児の再発性胃食道逆流症に対する食道胃分離術(第44回日本小児外科学会学術集会)

Hill procedure for recurrent GERD post-Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB. After placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance. No peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism. The Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population.