Recurrent Reflux Research Articles

A Randomized Placebo-Controlled N-of-1 Trial: The Effect of Proton Pump Inhibitor in the Management of Gastroesophageal Reflux Disease.

Background Gastroesophageal reflux disease (GERD) is the most frequent chronic gastrointestinal disorder. It is defined as a condition developed when the reflux of gastric contents causes troublesome symptoms (heartburn and regurgitation). This requires adequate treatment since it can lead to long-term complications including esophagus adenocarcinoma. Proton pump inhibitors (PPI) are generally used to treat GERD due to their high-security profile and efficiency on most patients. However, recurrent reflux despite initial treatment is frequent. N-of-1 trial is a study that allows the identification of the best treatment for each patient. The objective of this study is to compare the efficacy of standard dose with double dosage of esomeprazole, to improve the GERD symptoms in a single patient. Methods A single-patient trial, placebo-controlled, randomized, double-blind, was carried out from September 25th, 2012, to April 26th, 2013. It included one outpatient at the gastroenterology service in a fourth-level hospital, diagnosed with nonerosive reflux disease (NERD). Yet, his symptoms were heartburn and reflux, and his endoscopic results were normal esophageal mucosa, without hiatal hernia, though pathological pH values. A no-obese male without any tobacco or alcohol usage received esomeprazole 40 mg/day and 40 mg/bid for 24 weeks. A standardized gastroesophageal reflux disease questionnaire (GerdQ) was used weekly to evaluate symptom frequency and severity. The consumption of 90% of the capsules was considered as an adequate treatment adherence. D'agostino–Pearson and Wilcoxon test were used to determine normal or nonnormal distribution and compare both treatments, respectively, both with a significant statistical difference of p < 0.05. Results The patient completed the study with 96% of adherence. The double dosage of esomeprazole did not improve the control of symptoms compared with the standard dosage. Mean symptomatic score was 9.5±0.5 and 10.2±0.6 for each treatment, respectively (p > 0.05). Conclusion There was no significant improvement in the patient GERD symptoms increasing the dose of oral esomeprazole during the 6 months of study. N-of-1 trials in chronic pathologies including GERD are recommended due to their potential value as systematic methods that evaluate therapies without strong scientific evidence.

Anti-reflux surgery in infancy: contra

The current management of vesicoureteral reflux (VUR) in infants remains controversial. Parameters such as high spontaneous resolution rates even in high-grade reflux in up to 45 %, associated renal hypo-/dysplasia in boys in up to 30 % and immature bladder function characterise the condition in early life. In this context, the reflux per se has become less important. This makes it all the more surprising that endoscopic treatment is recommended in recent papers to eliminate or downgrade the reflux in infants as an alternative to conservative treatment regimes. Compared with antibiotic prophylaxis, there is no difference in outcomes regarding new episodes of urinary tract infections or renal scarring. On the other hand, the necessity of anaesthesia, considerable reflux recurrence rates and the risk of obstruction in the short and long-term follow-up must be taken into consideration. Minimally-invasive anti-reflux surgery techniques are feasible also in infants. However, in due consideration of the high spontaneous resolution rates of reflux during the first 12 to 15 months of life and the fact that bladder function is still immature at that age, they should not be used as routine interventions.

Long-Term Outcomes After One-Anastomosis Gastric Bypass (OAGB) in Morbidly Obese Patients.

One-anastomosis gastric bypass (OAGB) has gradually gained in popularity. Evidence of the validity of the technique and the quality of life in the longer term is scarce. The aim of this study was to retrospectively evaluate the longitudinal (≥ 5 years) safety, weight-loss efficacy, comorbid disease improvement, and quality of life of patients following OAGB. Data from patients who underwent OAGB from January 2009 to December 2011 were retrospectively reviewed. Preoperative clinical characteristics and data through 8 years were analyzed. A total of 163 patients completed 5 to 8 years of follow-up with a mean age of 41 ± 11.4 years (22-65). Ninety-four patients (57.6%) had undergone prior bariatric surgery (gastric band). Mean body mass index (BMI, kg/m2) at the time of OAGB was 41.2 ± 6.5 (range 30.1-50.6). Twenty-one patients (13.0%) suffered from type 2 diabetes mellitus (T2DM), 59 (36.2%) hypertension, 31 osteoarthritis (19.0%), and 24 had obstructive sleep apnea (14.7%). At 5, 6, 7, and 8 years of follow-up, respective mean BMI reduction was 12.6 (n = 163), 11.8 (n = 100), 10.7 (n = 82), and 8.8 (n = 40). Respective mean excess weight loss was 81.8 ± 23.6%, 75.9 ± 20.8%, 69.1 ± 20.4%, and 62.3 ± 23.4%. All obesity-related comorbidities decreased significantly at follow-up time points. Five patients (3%) underwent laparoscopic reoperation within 90 days after surgery. Incidence of recurrent reflux was 14.0%. At a mean follow-up of 92 months (76-111), improved or greatly improved quality of life was reported by 86.0% of patients. OAGB provided very good weight loss, comorbidity improvement, and quality of life at follow-up of ≥ 5 years.

Comparison of foam sclerotherapy versus radiofrequency ablation in the treatment of primary varicose veins due to incompetent great saphenous vein: Randomized clinical trial

Minimally invasive procedures such as foam sclerotherapy and radiofrequency ablation (RFA) have gained attention for treatment of incompetent great saphenous vein (GSV). The objective of this study was to compare recurrence rate and quality of life between foam sclerotherapy and RFA in patients with incompetent GSV varicose veins. In this parallel single-blinded randomized clinical trial, 60 adult patients with primary varicose veins due to incompetent GSV (CEAP classes C2-4EPAsPr) were included and randomly divided to receive RFA or foam sclerotherapy. Health-related quality of life (HRQOL) was assessed by the Short Form 36, and the Aberdeen Varicose Vein Questionnaire (AVVQ) was applied to assess the impact of varicose veins on quality of life of the patients. In addition, pain severity after the procedures was investigated by a visual analog scale (VAS) (range, 0 to 10). The patients were followed at 1week, 1month, 3months, and 6 months postoperation. GSV reflux and recurrence was assessed by color Doppler ultrasound examination after 6 months. Twenty-eight patients in RFA and 27 patients in foam sclerotherapy remained for the final analyses. The time interval from the procedure and recovery to daily normal activities was 1 day in both groups. Mean (±SD) pain VAS score in RFA group decreased from preintervention score of 7.35 (±3.28) to 1.21 (±0.68); P<.0001. Likewise, this score decreased from 6.64 (±2.04) to 1.29 (±0.91) in foam sclerotherapy group. HRQOL scores increased gradually at 1, 3, and 6months after the intervention. AVVQ scores decreased significantly 1 week postintervention in both groups. After 6 months, 17.9% (5 patients) in RFA group and 14.8% (4 patients) in foam sclerotherapy group had recurrence of GSV reflux (P=.52). Both foam sclerotherapy and RFA were effective in treatment of GSV reflux. Comparable findings were observed between the 2 groups regarding postoperative pain, recovery time, HRQOL, and AVVQ scores.

Percutaneous Minimally Invasive Fetoscopic Surgery: Ramah Ibu dan Janin

Spina bifida is a neural tube defect in which incomplete closing of the spine membrane that occurs in the lumbar and sacral. The defect of spina bifida can be motoric defect or sensoric defect. Clinical manifestation of spina bifida can be appear as limb anaesthesia, total paralysis, incontinensia urine and alvi that can cause recurrent uronary tract infection, renal insufficiency, and nephropathy reflux. Spina bifida can cause hindbrain herniation and hydrocephalus. Diagnosis of spina bifida can use 2D ultrasonography, 3D ultrasonography, and MRI. Procedure surgery of spina bifida can be done with postnatal surgery, prenatal surgery, or percutaneous minimally invasive fetoscopic surgery. Percutaneous minimally invasive fetoscopic surgery is a procedure to close the defect of fetus while intrauterine using minimal access with three or four trocar and using partial amniotic carbon dioxide insufflation (PACI) without laparotomy or hysterectomy. The adventage of percutaneous minimally invasive fetoscopic surgery compare with postnatal surgery and prenatal surgery is improve baby’s motoric function, decrease risk of ventriculoperitoneal (VP) shunt, decrease hindbrain herniation, decrease fluid in hydrocephalus, decrease risk of preterm birth, decrease risk of spontaneous membrane rupture, oligohydramnione, uterine dehiscence, uterine rupture, less pain in two days, and mother can go home from the hospital in a weeks.&#x0D; Keywords: Spina bifida, percutaneous minimally invasive fetoscopic surgery, partial amniotic carbon dioxide insufflation (PACI)

Sleeve gastrectomy in patients with previous antireflux surgery. Preliminary results of the “no-touch to posterior wrap” technique

BackgroundReported morbidity of Roux-en-Y gastric bypass in patients with previous antireflux surgery warrants caution, and data on sleeve gastrectomy (SG) are unexpectedly scarce. ObjectivesTo evaluate the safety and efficiency of SG in patients who previously underwent an antireflux procedure. A new technique to preserve intact fundoplication is described. SettingPrivate practice, bariatric center of excellence, Turkey. MethodsThe following data were retrieved from our prospective data base: (1) details of previous repair; (2) clinical/endoscopic reflux status, body mass index (kg/m2), and presence of metabolic syndrome (MetS) and type 2 diabetes (T2D) before SG; (3) duration of SG, length of stay, complications; and (4) percent excess weight loss, MetS/T2D resolution, and reflux status at follow-up. ResultsFifteen consecutive SGs were performed without conversion or major complications. The first case is excluded from the analysis because complete wrap unfolding was abandoned in favor of the described technique. Among 14, 10 had MetS, 4 had T2D, and 1 had a proven reflux recurrence before SG. Mean operating time was 118.5 minutes. All were discharged on the third postoperative day. Apart from 1 functional stenosis, no complications occurred. At 12 months, percent excess weight loss rate was 82.2, MetS resolved in 9 of 10, and T2D was in complete (n = 2) or partial remission (n = 1). No de novo reflux became evident, and absence of reflux was proved by pHmeter in 3. ConclusionsSG is feasible in patients who previously had antireflux repair with negligible morbidity and percent excess weight loss rates similar to that with regular sleeves. Results in reflux control needs further confirmation.

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.

Laparoscopic surgery for gastroesophageal reflux disease: Nissen, Toupet or anterior fundoplication

Gastroesophageal reflux disease (GERD) is one of the most frequent upper gastrointestinal disorders worldwide. It is defined as a chronic condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. A review of literature has been performed to evaluate the adequate preoperative diagnostic workup, indications to anti-reflux surgery, and surgical outcomes. To establish a correct indication, objective diagnosis of GERD with endoscopy, 24-hour impedance-pH monitoring and esophageal manometry is needed. A careful preoperative selection of patients is the first critical step to reduce the risk of side effects and failure of laparoscopic anti-reflux surgery (LARS). Laparoscopic 360° fundoplication (LTF) is the gold standard surgical treatment for GERD. Relief of heartburn and regurgitation is achieved by 80–90% of patients at 10 years follow-up. Partial fundoplications (anterior and posterior) guarantee similar outcomes in terms of symptom control with a lower risk of postoperative dysphagia. However, at the long-term follow-up, partial fundoplications are associated with an increased number of recurrent reflux episodes at 24-hour pH monitoring when compared to 360° fundoplication. More studies are needed to compare the different types of fundoplication in the long-term follow-up period.

Robotic-assisted conversion of Nissen fundoplication to Roux-en-Y gastric bypass (avoiding pitfalls)

Abstract Laparoscopic anti-reflux surgery (LARS) utilizing fundoplication plays a major role in the treatment of gastroesophageal reflux disease (GERD). It is important to consider that long term control of reflux in the patient with obesity has been shown to be worse (failure up to four times more likely) than in normal weight patients following Nissen fundoplication. Recurrence of symptoms after LARS may benefit from medical management in some cases, while in others revisional surgery should be considered. Concomitantly, Roux-en-Y gastric bypass has an excellent track record of alleviating GERD in de novo obese patients. For individuals with obesity with recurrent or persistent reflux symptoms despite previous LARS, conversion to a gastric bypass versus redo LARS should be considered. Conversion of Nissen fundoplication to Roux-en-Y gastric bypass can be technically challenging due to factors present for any re-operation - presence of scar tissue, altered tissue planes, and often times unclear anatomy. Meticulous hiatus and wrap dissection, repair of hiatal hernia if present, complete unwrapping of the fundoplication and clarification of gastric redundancy prior to pouch creation, and preservation of the left gastric artery are keys to improving outcomes and reducing morbidity. Particularly, takedown of the fundoplication can be aided with landmark identification such as prior sutures. Ensuring full mobilization of the wrap from the lower esophagus, stomach, and hiatus prior to gastric pouch creation is paramount. The posterior fundic wrap can often unknowingly be left in situ, leading to thicker tissue to staple across and a larger than intended gastric pouch. This area in particular is where most leaks and stapling misadventures occur. Robotic assistance in this operation provides excellent visualization and surgical dexterity in a re-operative setting. We present a video demonstrating robotic assisted conversion of Nissen fundoplication to Roux-en-Y-gastric bypass, and specifically emphasize technical features of this operation to avoid peri-operative complications.

Delineating the durability outcome differences after saphenous ablation with laser versus radiofrequency

ObjectiveThe mechanism of delivering thermal energy to the vein wall differs between endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). Different mechanisms of ablation may have different effects on the durability of these procedures typically performed for saphenous vein insufficiency. Whether there is a difference in long-term durability outcomes between these two techniques remains uncertain. This study aimed to delineate the durability outcome differences in terms of recurrence rate and pattern. MethodsA retrospective review identified 270 consecutive patients who underwent saphenous ablation using EVLA or RFA between July 2013 and October 2016. The primary end points were clinical symptom recurrence and anatomic recurrence of reflux. ResultsOverall, 343 limbs were included in the study; 246 limbs (183 patients) underwent EVLA and 97 limbs (87 patients) underwent RFA. The mean follow-up time was 112 days for EVLA (range, 2-1153 days) and 106 days for RFA (range, 3-735 days; P = .786). No significant differences were observed between the groups with respect to demographic data, Clinical, Etiological, Anatomical, Pathophysiological classification, or ratio of great saphenous vein to small saphenous vein treated. The mean time to recurrence of symptoms was 219 days longer with EVLA (n = 8; mean, 774 days; range, 187-1042 days) than RFA (n = 4; mean 555 days; range, 341-616 days). Kaplan-Meier estimates for 1- and 3-year freedom from clinical recurrence were 100% and 96% for EVLA and 97% and 93% for RFA, respectively. There was no difference between the two groups (log rank, P = .0666). In cases with recurrent reflux documented on duplex (four in the EVLA group and three in the RFA group), the thigh segment was the most frequently involved site (75% in EVLA, 67% in RFA). Same site recanalization was significantly less frequent in EVLA (0.82% in EVLA vs 2.06% in RFA; P = .0388). New areas of reflux developed at a similar rate between the groups, in 0.82% of EVLA limbs in the anterior accessory saphenous vein and the calf great saphenous vein, and in 1.03% of RFA limbs in the anterior accessory saphenous vein (P = .8436). ConclusionsThe results of our study suggest that the outcomes of EVLA and RFA performed for saphenous vein insufficiency may differ in the long term. The clinical recurrence rates are similar, but the anatomic recurrence patterns may differ, with more frequent treated site recurrence in the RFA group.

Minimally-invasive procedure for pelvic leak points in women

Pelvic leak points (PLP) may be responsible for vulvar, perineal and lower limb varicose veins, in women during and/or after pregnancy. The accurate anatomical and hemodynamic assessment of these points, the perineal (PP), inguinal (IP) and clitoral points (CP) and their surgical treatment under local anesthetics as defined by Claude Franceschi is a new therapeutic option. The aim of this study was to assess the reliability and durability of the PLP reflux ablation using a minimally-invasive surgical disconnection at the PLP level in women with varicose veins of the lower limbs fed by the PLP. In this open-label trial 273 pelvic leak points free of pelvic congestion syndrome, with at least a 12-month follow- up, were assessed. 273 PLP treated: PP (n=177), IP (n =91) and CP (n=5). Followup: Period =12 to 92 months (mean =30.51 months). Age from 29 to 77 years (mean=45). The only 3 patients over 70 years (71, 74, 77) showed a high-speed reflux from a I point that fed symptomatic varicose veins of the lower limb. Exclusion criteria: pelvic congestion syndrome, BMI&gt;24, venous malformations, a post thrombotic varicose vein. Diagnosis was performed using echo duplex and PLPs selected for treatment when refluxing at Valsalva + Paraná + squeezing maneuvers. A surgical skin marking of the PLP had been performed using echo duplex before surgery. Surgery consisted of minimally invasive dissection and selective division and ligation with non-absorbable suture of the refluxing veins and fascias at the PP, IP and CP pelvic escape points, under local anesthesia in a single center. The follow-up consisted of an echo duplex ultrasound, searching for reflux at the PLP treated thanks to the Valsalva maneuver, within 2 weeks, after 6 and 12 months and then yearly. The main endpoint of the study was the immediate elimination of the reflux at the PLP treated. The second endpoint was the long-term durability of the reflux ablation at the PLP treated. 267 (97.8%) without PLP reflux redo. 6 (2.2%) PLP reflux recurrences (PP=4, IP=1, CP 1). 3 patients with PLP reflux recurrence undergo a redo surgery (1.1%) where PP=2 (0.7%) and IP=1 (0.3%). This study shows the feasibility and durability of reflux ablation at the PLP level thanks to a minimally-invasive surgical treatment of the PLP and it demonstrates that there is no need for pelvic varicose embolization in patients without clinical signs of pelvic congestion syndrome. The accurate ultrasound assessment of each specific pelvic leak as well as a special surgical technique (vein division, non-absorbable suture of veins and fascias) seems to be the key for satisfactory outcomes.

Intraluminal mesh erosion after prosthetic hiatoplasty: incidence, management, and outcomes.

The purpose of the present study was to analyze the incidence, presentation, and treatment of mesh erosion into the esophagus or stomach after mesh hiatoplasty for primary or recurrent hiatal hernia. The study is a single-institution, retrospective cohort study. From November 2005 to December 2016, 122 patients consecutively underwent mesh hiatoplasty in our department, 91 during a primary surgery and 31 for a surgical revision. Follow-up was complete for 74%. Six patients of this series were evaluated for mesh erosion. In all cases, the mesh employed was a dual-type circular one. The mean time from surgery to erosion diagnosis was 42 months (median time 46 months, interquartile range 64 months). Three patients were asymptomatic, 1 had dysphagia, 1 had reflux recurrence, and 1 presented with mediastinal perforation. The absolute erosion rate was 4.9%. For patients under surveillance, the erosion rate was 6.6%, or 1 case every 48 patient-years of follow-up. The erosion rate after primary surgery was 3% or 1/86 patient-years of follow-up, and after surgery for recurrent hernia recurrence was 16% or 1/29 patient-years of follow-up. The mesh was left in place in 2 asymptomatic cases and endoscopically removed in 2 cases. Two patients submitted to surgical removal of the mesh, and only one needed a limited gastroesophageal junction resection for a conversion to a Roux-en-Y gastric bypass. The patient with esophageal perforation submitted to mesh removal, drainage, and an anterior partial fundoplication. There was no mortality. Mesh erosion after hiatoplasty presents with a high rate, especially when hiatoplasty is performed during revisional antireflux surgery. Most patients can be managed conservatively, and endoscopic removal should be considered a first-line therapy.

Invited commentary

Carlie Chaplin once said that simplicity is not a simple thing. We seem to forget this when treating patients with varicose veins. Population studies showed that only one-third of these patients has saphenous reflux, yet elimination of saphenous reflux when it is present is believed to be curative, and removal of the saphenous vein from the circulation remains the mainstream intervention. Excellent short-term results of high ligation with or without stripping of the saphenous vein convinced many surgeons that recurrences result from the errors in surgical technique. Over time, however, it became clear that other factors play an important, if not the major, role in development of recurrent varicose veins and recurrent saphenous reflux. Surgical trauma induces inflammation and angiogenesis. Along with hemodynamic forces, these processes lead to reconnection of remaining distal saphenous vein and other superficial veins to the deep venous system. It is especially demonstrative in cases of high ligation without stripping, when neoveins form large collaterals around the ligated segment, sometimes indistinguishable in appearance from the saphenous vein itself. Histopathologic differences in the endovenous laser ablation between jacketed and radial fibers, in an ex vivo dominant extrafascial tributary of the great saphenous vein in an in vitro model, using histology and immunohistochemistryJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 7Issue 2PreviewThe study aimed to investigate the biologic effects of the 1470-nm endovenous laser (EVL), with a jacketed fiber and a radial fiber, during EVL ablation of an ex vivo dominant extrafascial tributary of the great saphenous vein in our in vitro model by histology and immunohistochemistry. Full-Text PDF

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.

Redo surgery after laparoscopic fundoplication

To analyze the results of redo surgeries after previous laparoscopic fundoplication. A retrospective analysis included 37 repeated anti-reflux surgeries. Control group consisted of 38 patients after the first anti-reflux surgery performed on the same clinical base. The causes of unsatisfactory results of the first operations were studied. Intraoperative data, immediate and long-term results of surgical treatment were compared in both groups. Quality of life in both groups was studied before surgery and in long-term period using GIQLI questionnaire. The most common cause of recurrent reflux was a hernia recurrence combined with slipping or destruction of the fundoplication cuff. Dysphagia was usually a result of compression of the esophagus by tightly sutured diaphragmatic crura and recurrent paraesophageal hernia. The main group was characterized by significantly greater surgery time, hospital-stay, incidence of intraoperative and postoperative complications. However, a more significant improvement of quality of life (∆GIQLI) was observed in the main group due to the low QOL index before redo surgery. Redo surgeries are effective and safe procedures. These operations significantly improve QOL in long-term period despite certain technical difficulties. Repeated surgeries for dysphagia accounted for 2%, for recurrent reflux - 6%. Persistent postoperative dysphagia is usually associated with diaphragm repair rather fundoplication cuff. Reflux recurrence is often caused by cuff slippage and recurrent hernia.

Strategies for surgical remediation of the multi-fundoplication failure patient.

Outcomes are not well studied in patients undergoing remediation for multi-fundoplication failure, that is, two or more prior failed fundoplications. Re-operation must balance reflux control and restoration of the ability to eat with the challenge of reconstructing a distorted hiatus and GE junction. The purpose of this study is to present our experience with surgical remediation for multi-fundoplication failure. Medical records were retrospectively reviewed of 91 patients who underwent third time or more esophagogastric operation for fundoplication failure at a single institution from 2007 to 2016. Dysphagia was present in 56% and heartburn in 51%. Median number of prior operations was 2 with range up to 6. Anatomic failure consisted of slipped wrap in 26 cases, wrap herniation in 23, hiatal stenosis in 24, hiatal mesh complication in 8, and wrap dehiscence in 10. Operative approaches generally followed an institutional algorithm and consisted of hiatal hernia repair with: re-do fundoplication in 55%, takedown of fundoplication alone in 24%, Roux-en-Y gastrojejunostomy in 14%, and GE junction resection in 7%. Laparoscopic approach was successful in 81%. Mean duration of operations was 217min and median length of stay was 3days. The complication rate was 13%, with 7% undergoing unplanned early re-operation. Patients were followed for mean 11months, and recurrent hiatal hernia was detected in 13%. Late re-operation was performed in 6% for recurrent hiatal hernia. Recurrent reflux symptomatology resolved in 93%. Dysphagia resolved in 84%. There were no significant differences in outcomes with regard to number of prior operations, operative approach, BMI, or age. There is no single best approach to remediation in the multi-fundoplication failure patient. Re-do fundoplication is appropriate in over half of patients. Reoperation for multi-fundoplication failure can be performed via minimally invasive approach with excellent remediation of symptoms, low morbidity, and low recurrence rates.

Evaluation of resection of the gastroesophageal junction and jejunal interposition (Merendino procedure) as a rescue procedure in patients with a failed redo antireflux procedure. A single-center experience

BackgroundPrimary antireflux surgery has high success rates but 5 to 20% of patients undergoing antireflux operations can experience recurrent reflux and dysphagia, requiring reoperation. Different surgical approaches after failed fundoplication have been described in the literature. The aim of this study was to evaluate resection of the gastroesophageal junction with jejunal interposition (Merendino procedure) as a rescue procedure after failed fundoplication.MethodsAll patients who underwent a Merendino procedure at the Karolinska University Hospital between 2004 and 2012 after a failed antireflux fundoplication were identified. Data regarding previous surgical history, preoperative workup, postoperative complications, subsequent investigations and re-interventions were collected retrospectively. The follow-up also included questionnaires regarding quality of life, gastrointestinal function and the dumping syndrome.ResultsTwelve patients had a Merendino reconstruction. Ten patients had undergone at least two previous fundoplications, of which one patient had four such procedures. The main indication for surgery was epigastric and radiating back pain, with or without dysphagia. Postoperative complications occurred in 8/12 patients (67%). During a median follow-up of 35 months (range 20–61), four (25%) patients had an additional redo procedure with conversion to a Roux-en-Y esophagojejunostomy within 12 months, mainly due to obstructive symptoms that could not be managed conservatively or with endoscopic techniques. Questionnaires scores were generally poor in all dimensions.ConclusionsIn our experience, the Merendino procedure seems to be an unsuitable surgical option for patients who require an alternative surgical reconstruction due to a failed fundoplication. However, the small number of patients included in this study as well as the small number of participants who completed the postoperative workout limits this study.

Comparing treatment modalities for transplant kidney vesicoureteral reflux in the pediatric population

Non-refluxing ureteral reimplantation is favored in pediatric renal transplantation to prevent complications, such as vesicoureteral reflux (VUR) in the transplant ureter. VUR resulting in febrile urinary tract infections remains a problem in this population, leading to repeated hospitalizations and increased morbidity. Revision of the vesicoureteral anastomosis can be a surgical challenge due to scar tissue and tenuous vascularity of the transplant ureter. Therefore, alternative options such as endoscopic injection of Deflux at the neo-orifice and surveillance with prophylactic antibiotics have emerged as potential treatment modalities for transplant ureter VUR. The authors reviewed their experience of the management of VUR in the transplant ureter, comparing outcomes of various modalities. With Institutional Review Board approval, a retrospective chart review of all renal transplant patients from January 2002 to January 2017 was conducted. All patients with VUR on voiding cystourethrogram (VCUG) after surgery were identified. Indications for end-stage renal disease, urologic comorbidities, pretransplant VCUG, and operative details were recorded. After transplantation, febrile urinary tract infections, ultrasound findings, and any further interventions-surveillance, subureteral endoscopic injection of Deflux, or ureteral reimplantation-were documented along with their outcomes. Overall, VUR was identified in 35/285 (12.3%) transplant patients aftera non-refluxing ureteroneocystostomy. VUR was managed with surveillance in 17/35 (49%), intravesical Deflux injection in 11/35 (31%), and immediate redo ureteral reimplantation in 7/35 (20%). Ten out of 11 patients undergoing Deflux injection had a postoperative VCUG. All patients developed VUR recurrence; the majority showed immediate failure and only 1/10 showed late recurrence. Of the immediate failures, 3/9 patients were maintained on prophylactic antibiotics, and 6/9 patients underwent ureteral reimplantation. In these six patients undergoing reimplantation after failed Deflux, 3/6 (50%) patients required additional surgeries: One patient developed recurrence of reflux and two patients developed ureterovesical junction obstruction. In contrast, no complications were seen in patients undergoing primary ureteral reimplantation. The study is limited by low numbers and a retrospective design. However, the results of this study differ significantly from the published Deflux series showing a success rate of more than 50% in the treatment of transplant kidney VUR. In fact, post-Deflux redo ureteral reimplantation was associated with an increased risk of postoperative complication. The use of Deflux in the post-transplant setting has poor results. In the study series, 11/11 patients demonstrated clinical and radiographic failure. Therefore, as an institution the authors do not recommend Deflux as first-line treatment of VUR in the transplant patient.

Therapeutic efficacy of endoscopic management of ureterocele with 1470 nm diode laser

Objective To evaluate the therapeutic efficacy of endoscopic management of ureterocele with 1470 nm diode laser. Methods Form May 2014 to May 2017, 9 patients diagnosed as ureterocele underwent endoscopic management of ureterocele with 1470 nm diode laser in our hospital. Ultrasonography, IVU and cystoscopy were done in all cases before operation. The age of 9 cases was form 6 years to 63 years old(mean 37.3 years old), which male 4 cases and female 5 cases. Unilateral ureterocele was presented in 7 cases(left 3 and right 4), and 2 cases had bilateral ureterocele. One case had unilateral duplex? kidney and one had bilateral duplex kidney. Results The operation in all cases was successfully completed in one time. The mean operative time and hospital stay was 32 minutes and 7 days, respectively. The average postoperative catheter time was 5 days. Follow-up ranged from 3 months to 3 years, postoperative regularly ultrasound and intravenous urography(IVU) revealed no uronephrosis or ureterectasis in all patients, free of symptom, ureteral reflux and clinical recurrence. Conclusions The endoscopic management of ureterocele with 1470 nm diode laser is effective and safe. Key words: Ureteral Diseases; Cysts; Urethra; Lasers, Semiconductor

PO-172 Role of lithocholic acid-induced cell signalling in oesophageal cancer progression model

IntroductionA p53-checkpoint operates in the development of oesophageal adenocarcinoma (OAC) defined by prevalent TP53 gene mutations in patients with Barrett’s and high-grade dysplasia (HGD). The molecular genetic relationship between OAC and its precursor lesion, Barrett’s oesophagus, is poorly understood. The effective therapeutic targets should focus on early mutations of the disease, which become clonal in the later stage. Mutational context of some specific single nucleotide variants are common throughout the progression of the disease, suggesting exposure to common mutagens throughout the progression course.Material and methodsTP53 null or truncated cell lines were generated by targeting exon 4 of TP53 gene using CRISPR/Cas9 technology. Cell cycle analysis and Annexin V5 stained cells were analysed by FACS after treatment with lithocholic acid (LCA) to recapitulate the reflux of bile acids in OAC. Changes in proteins levels and signalling pathways upon LCA exposure were identified using mass spectrometry and validated with western blotting. Immunohistochemistry (IHC) analysis of OAC and normal tissues was performed to check the expression of identified bile acid-induced genes in tumours.Results and discussionsOesophageal Barrett’s wt-p53 cell line CPA was used to define the effects of TP53 gene ablation on stress responses, cell survival, and mutation rates. FACS analysis revealed TP53 null cells sensitivity towards LCA via apoptotic pathway. Mass spectrometry analysis identified disrupted NDRG1 and TGFβ pathways. SMAD4 driver mutations have previously been reported exclusively to OAC, which provide a clear genetic boundary between OAC and HGD. Western blot analysis after LCA exposure showed increased levels of SMAD4-independent of p53 pathway. SMAD4 depletion in TP53 null cells stimulates cell-migration in the presence of inhibitory levels of LCA, corroborates the role of SMAD4 loss in metastasis. Loss of p53 also upregulates NDRG1 which increases migration in presence of LCA and was found to be a pro-invasive factor. IHC staining of OAC, lymph node and normal tissues showed heterogeneous expression of NDRG1 in tumour, mostly in membrane, suggesting its dynamic expansion on LCA exposure in vivo.ConclusionThe recurrent reflux of bile acids in Barrett’s cells, especially LCA, could sensitise cells to harbour further mutations. LCA induces p53-independent upregulation of SMAD4. Depletion of NDRG1 and SMAD4 in p53 null cells stimulates cell-migration in the presence of LCA, corroborating their role in metastasis.