Recurrent Reflux Research Articles

ЛАПАРОСКОПИЧЕСКАЯ ФУНДОПЛИКАЦИЯ НИССЕНА У НЕДОНОШЕННЫХ ДЕТЕЙ, НАХОДЯЩИХСЯ В УСЛОВИЯХ ПАЛАТЫ ИНТЕНСИВНОЙ ТЕРАПИИ

The present study focuses on registration of early postoperative changes based on a comparison of the clinical parameters of respiratory and nutritional support after laparoscopic Nissen fundoplication in premature infants in an intensive care unit. Materials and methods of research: a retrospective continuous single-center study was carried out. In the course of the study, the medical records of all infants with a body weight of less than 2500 g and gestational age less than 37 weeks, who underwent laparoscopic antireflux procedures, were studied for the period from January 2012 to December 2019. 25 patients met this criteria, 12 (48%) of which were female and 13 (52%) were male. Standard laparoscopic procedure was Nissen fundoplication. At the final stage of the study, perioperative data and complications that occurred in the early and longterm follow-up period were studied. Results: the average weight of patients was 1560.0±450.4 g (median 1600.0 [1200.0; 1950.0] g). Infants with gastroesophageal reflux were on various modes of respiratory therapy: 50% – mechanical ventilation (MV), 50% – oxygen therapy. The average duration of operation was 35.4±8.2 min (median 35.0 [30.0; 40.0] min). The average daily weight gain before and after surgery, measured during the first 28 days after surgery, was 15.3±2.1 g/day, respectively (median 15.0 [14.0; 16.0] g/day) and 24.9±1.8 g/day (median 25.0 [24.0; 26.0] g/day) (p<0.001). The assessment of the severity of lung disease based on the determination of the concentration of O2 in the inhaled mixture (FiO2) before surgery and 7 days after it, a statistically significant (p<0.001) decrease in the child's body oxygen demand for adequate gas exchange from 34.4±3,9% (median 35.0 [30.0; 37.5]%) to 23.1±3.4% (median 21.0 [21.0; 25.0]%). The need for invasive MV significantly decreased from 68 [47; 85]% up to 20 [7; 41]% (p<0.001), in noninvasive MV – from 32 [15; 54]% up to 20 [7; 41]%, but this decrease was statistically insignificant (p=0.084). The ability to breathe spontaneously appeared in 60% of patients (0 [0; 14]% versus 60 [39; 79]%; p=0.002). Postoperative complications included recurrent reflux was in one patient (4 [0; 20]%), which required repeated fundoplication in the long-term follow-up period. Conclusions: thus, laparoscopic antireflux surgery is possible in premature infants. These surgical procedures are well tolerated by infants and can improve their quality of life.

Assessment of the CHIVA and the ASVAL Method.

In this article, the CHIVA and ASVAL methods are assessed from the hemodynamic point of view. The CHIVA method comprises complicated, unusual terminology and new perceptions, such as closed and open shunts, fractionation of the hydrostatic pressure, subdivision of the venous network. The principal part of the CHIVA theory is the drainage of venous blood from the thigh saphenous system into the deep lower leg veins through the preserved saphenous trunk after high ligation at the saphenofemoral junction, which is considered as a beneficial, physiological phenomenon. In reality, this is recurrent reflux producing ambulatory venous hypertension. The main impact of the CHIVA procedure is the elimination of the saphenous reflux by high ligation at the saphenofemoral junction; thus it can be presumed that the CHIVA procedure yields similar results like the crossectomy. The ASVAL procedure is de facto the modification of the old Madelung method that was the prevalent surgical procedure before the Trendelenburg era in the 19th century. The results after ASVAL were not checked by plethysmography; there is a good case to suppose that the results after the ASVAL method would comply with those after sclerotherapy.

Failed fundoplication with delayed gastric emptying: efficacy of subtotal gastrectomy.

The management of patients with gastroparesis and recurrent reflux after previous fundoplication is challenging. The aim of this study was to evaluate the safety and efficacy of subtotal gastrectomy with Roux-en-Y reconstruction as a remedial procedure in this select patient population. Retrospective analysis of a prospectively populated database identified all patients that underwent subtotal gastrectomy with Roux-en-Y reconstruction (SGRNY) due to reflux symptoms and delayed gastric emptying (DGE). Demographic, intra-operative and post-operative data including pre and post-operative modified reflux aspiration scintigraphy studies were evaluated. Standardized questionnaires were used to assess symptomatic outcomes. From 2018 SGRNY has been selectively performed in 13 patients. Preoperative workup confirmed DGE and severe symptomatic reflux in all patients. The median number of previous fundoplication and or hiatal hernia operations was two (range 1-3). The mean hospital length of stay was 10± 6 days. Post-operative morbidity was experienced in three patients (23%). Seven patients (64%) had significant improvement or complete resolution of reflux on post-operative scintigraphy. Symptom improvement was reported in 92% of patients. In a select patient cohort with post-fundoplication reflux and DGE symptoms, SGRNY is a moderately safe and effective salvage option.

Treatment of Recurrent Symptomatic Saphenous Trunk Reflux with Catheter Directed Foam Sclerotherapy and Tumescent Anaesthesia

ObjectiveThe aim was to assess short and midterm efficacy and safety of catheter directed foam sclerotherapy (CDFS) with tumescent anaesthesia in patients with recurrent symptomatic saphenous reflux.MethodsThis was a prospective observational study (February 2018 to February 2019) including 21 consecutive patients referred with recurrent symptomatic varicose veins. Standing duplex ultrasound (DUS) with saphenous vein diameter measurement 3 cm from the terminal valve was performed pre-operatively. All the patients were operated on under local anaesthesia. By ultrasound guided puncture a hydrophilic 0.035″ guidewire and 5F Berenstein catheter were inserted through a 5F introducer sheath. Peri-saphenous tumescent anaesthesia (PSTA) was performed under ultrasound guidance. Sclerosant foam was prepared with sodium tetradecyl sulphate 3% or polidocanol 3% using the Tessari method. Concomitant phlebectomies were performed in 52%. Clinical evaluation and DUS were performed pre- and post-operatively at one week, six months, and 12 months.ResultsThere were 11 men and 10 women (median age 52 years; interquartile range [IQR] 43 – 61). The great saphenous vein was treated in 18 patients. The median vein diameter was 6.8 mm (IQR 4.7 – 8.9). Previous procedures were Cure conservatrice et Hemodynamique de l'Insuffisance Veineuse en Ambulatoire (CHIVA), mechanochemical ablation, thermal ablation, and cyanoacrylate closure. The distribution of the clinical class (Clinical Etiology Anatomy Pathophysiology [CEAP] classification) was 16 C2, three C3, and two C4 limbs. Immediate technical success was 100%. There were no complications in the early post-operative period. The median follow up was eight months (IQR 5 – 10). The occlusion rate demonstrated by DUS was 100% (21/21) at one week, 100% (21/21) at six months, and 86% (18/21) at 12 months. The median post-procedural vein diameter at one week, six months, and 12 months was 4.8 mm (IQR 3.9 – 6), 4.3 mm (IQR 3.5 – 5.5), and 4 mm (IQR 3 – 4.9), respectively.ConclusionCombination CDFS with PSTA achieves good short and medium term venous occlusion rates, associated with few complications in patients with recurrent symptomatic saphenous reflux.

LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION.

ABSTRACTBACKGROUND:Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested.AIMS:This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C).METHODS:This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up.RESULTS:Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery.CONCLUSIONS:Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Endoscopic Treatment of GERD in Patients With Obesity

Gastroesophageal reflux disease (GERD) is one of the most common obesity-associated comorbidities. The increasing prevalence of obesity worldwide is expected to cause a concomitant increase in the prevalence of GERD. While laparoscopic Nissen fundoplication (LNF) remains the gold standard for the treatment of GERD, its efficacy in the setting of obesity is limited by a relatively high rate of post-procedural reflux recurrence. Currently, Roux-en-Y gastric bypass (RYGB) is the gold standard treatment for GERD in patients with obesity. However, despite its proven efficacy, it remains underutilized due to its cost, safety concerns, and patient acceptance. During the past 2 decades, endoscopic therapies have emerged as minimally invasive and safe alternatives for the management of GERD. While most studies assessed their outcomes in patients without obesity, recently published case reports offered a potential framework for their use in patients with obesity. In this article, we review the available endoscopic anti-reflux therapies (EART) and endoscopic bariatric therapies (EBT), with emphasis on their potential role in the management of GERD in patients with obesity.

Laparoscopic ureteral reimplantation in the recurrent vesicoureteral reflux in a 12-year-old child

Introduction. The antireflux reimplantation of the ureter may be performed using different surgical approaches with the known techniques. Despite the high efficiency of these surgical interventions, there are cases of reflux relapses even after several surgical interventions on the ureterovesical junction (UVJ). The range of ways for laparoscopic reconstruction of the upper urinary tract is increasingly expanding what allows toperform a successful correction of the defect even in technically difficult positions. The main purpose of the present clinical demonstration is to illustrate a successful application of laparoscopic access in the correction of recurrent forms of vesicoureteral reflux (VUR).Material and methods. The authors present a clinical case and management of a patient with Grade 4 VUR on the right (classification by P.E. Heikel et K.V. Parkkulainen, 1966). Previously, a 12-year-old boy had four surgical interventions, both open traditional correction and endovesical implantations of volume-forming drugs. The reflux persisted and was accompanied with constant recurrences of pyelonephritis and progressive deterioration of the kidney function on the right.Results. Despite technical difficulties associated with cicatricial changes in UVJ, an antireflux surgery with laparoscopic access was performed. The follow-up control within one year revealed no recurrences of urinary tract infection. Findings of VUR control examination demonstrated that the renal function was stabilized.Conclusions. A rational approach and justified surgical access have given good outcomes in this patient.

Has external banding become a historical technique during venous valve repair?

In deep venous valve repair, transcommissural external valvuloplasty (TEV) is the commonly used technique. In some cases, external banding (EB) is combined with this procedure to improve the patency and durability of the surgical procedure. We retrospectively analyzed patients who underwent deep venous valve repair from 1998 through 2018. Patients were divided according to the surgical procedure: Group A: TEV alone and Group B: TEV+EB. Early postoperative outcomes of the procedure were compared between the groups. There were 265 patients in Group A and 165 patients in Group B. The mean follow-up period was 4.2±3.7. The rate of recurrence of venous reflux, ulcer, and reoperation were 31.9 versus 30.9, 21.2 versus 21.8, and 16.7 versus 13.9 in Group A and Group B, respectively. There were 67 reoperations in the follow-up period. At reoperation, external valvuloplasty was performed in 64% of the reoperations in Group A, while this rate was 13% for Group B. There is no more need for EB during the venous valve repair with the increased experience of valvuloplasty techniques. TEV might be enough with acceptable long-term outcomes during deep venous reconstruction.

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.

Comparative Study of Prophylactic Antibiotic Twice a Week Versus Every Night in Recurrent Urinary Tract Infections in Children

Background and Aim: Urinary tract infection is one of the most common childhood diseases. The results of studies investigating discontinuation or continuation of antibiotics in children with recurrent urinary tract infections and urinary reflux are controversial. Therefore, this study was conducted to compare prophylactic antibiotic treatment twice a week versus every night in the recurrence of urinary tract infections in children. Methods: This clinical trial was conducted using non-random simple sampling. Group A was given a single daily dose of cephalexin 10 mg/kg and group B was given cotrimoxazole at a dose of 5 mg/kg. Both groups were followed for ten months. Recurrences of urinary tract infections were compared between the two groups. Results: The mean age of the participants was 3.53±2.04 years. Most of the subjects were female (n=37, 61.7%). Urinary reflux was unilateral in 65% of the cases (n=39) and bilateral in the rest. There was no significant difference in age distribution, sex, and type of reflux between groups A and B. The frequency of recurrent urinary tract infection was 8.3% in group A and 6.7% in group B indicating no significant difference (p = 0.500). Conclusion: The results of this study showed that the frequency of recurrence of urinary tract infections in children who received prophylactic antibiotic treatment twice a week was not significantly different compared to the group of children who received continuous antibiotic prophylaxis.

23 GASTRIC BYPASS AS REVISION SURGERY FOR FAILED FUNDOPLICATIONS

Abstract Laparoscopic fundoplication as anti-reflux technique has emerged and widely expanded as a cost effective alternative to life-long medical treatment in patients with gastroesophageal reflux disease (GERD). Long-term success rate ranges from 80–90% with this procedure, but side effects still exist even with experienced surgeons. Patients with a failed anti-reflux procedure are becoming a more common problem nowadays. Although most of these patients can be managed medically, still some of them will require revisional surgery. Methods We presented our experience from January 2015 to June 2019 facing cases of failed fundoplications. 59 cases with failed fundoplication requiring revision were included in the study. Redo fundoplications were decided preoperatively or intraoperatively to be difficult or unsafe to be done for these cases. Revision surgery for these cases was done using either distal gastrectomy and RY gastro-jejunostomy (22 cases) when the hiatal dissection was not feasible or unsafe due to obscure anatomy or Truncal vagotomy and RY gastro-jejunostomy (37 cases) when the hiatal dissection was easy and feasible. Results Laparoscopy was used in 49 cases and was successfully completed in 42cases (%) and 7conversion (%). Improvement of symptoms: Recurrent reflux or dysphagia was noted in 19 cases (32%) and complete disappeared in 26 cases (44%). One case had leak from the GJ and another one got hematemesis. Both cases were managed conservatively. Nine patient (15%) had bile gastritis with abdominal pain. Five patients (8.5%) complained of dumping symptoms. No mortality was recorded. Conclusion RY gastro-jejunostomy for failed fundoplications is a valid, feasible surgical option when redo fundoplication is difficult to be done or if associated with possible or expected complications.

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 < 0.0001), dysphagia (p < 0.0001) and retrosternal chest pain (p < 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 < 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.

378 REDO LAPAROSCOPIC FUNDOPLICATON IN A PATIENT WITH WRAP MIGRATION FOLLOWING TWICE FAILED NISSEN FUNDOPLICATION

Abstract Re-operation for wrap failure is a complex procedure required in 3–6% of patients. This video demonstrates a successful laparoscopic redo fundoplication in a patient who had previously undergone laparoscopic Nissen's fundoplication twice for GERD in another institution, first for GERD in 2014 and then for recurrence of reflux. Patient presented to us with dysphagia and regurgitation. The work-up revealed wrap migration into the right pleural cavity. A successful redo laparoscopic Toupet fundoplication was performed. Methods The video describes the procedure of laparoscopic re do fundoplication. Results Patient is doing well at a follow up of 16 months. Conclusion Re-do laparoscopic fundoplication can be successfully accomplished through laparoscopic approach. Video https://drive.google.com/file/d/1Perelnr0fwGIk1kiAexYvXnJY01cO98C/view?usp=sharing.

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.

Partial Fundoplications (270° Toupet, 90° Dor)

Partial fundoplication such as the Toupet posterior 270° and the Dor anterior 90° to 180° wraps were developed with the aim of providing long-term GERD control as with the successful Nissen fundoplication, but with reduced post-operative side effects such as dysphagia and gas bloat. Randomized controlled trials with long-term follow-up show this to be the case. Failure of a fundoplication occurs along a predictable anatomical course with posterior herniation almost universal. This informs our method of dissection, hiatal repair, and wrap construction using fundopexy to the diaphragm. We present the indications and our techniques for partial fundoplication, including tips on how to reduce the incidence of fundoplication failure and recurrent reflux.

Laparoscopic Anterior 180° Partial Fundoplication - Indian Perspective

Aim: To evaluate Laparoscopic anterior 180° partial fundoplication for its good long-term relief forsymptoms of gastroesophageal reflux disease and association with adverse effects. Methods:Study design: Prospectively evaluated case series. Settings: Tertiary care centers Patients: Theclinical outcomes were determined for all patients who had undergone a laparoscopic anterior partialfundoplication by us between January 1, 2013 to March 31, 2021. Interventions: Clinical outcome,complications, and follow-up after laparoscopic anterior 180° partial fundoplication was obtainedusing a structured questionnaire. Results and Discussion: 228 procedures were performed. Theoutcome at 0 to 8 years (mean, 4 years) follow-up was determined for 195 patients. 1 death waslinked to the laparoscopic procedure and 2 patients died during follow-up due to unrelated causes.For 186 patients (95%) with clinical outcome data at late follow-up, gastroesophageal refluxsymptoms were significantly improved following surgery and were well controlled in 9 patients(4.5%). In a subset of 85 patients with more than 5 years of follow-up, relief of heartburn was foundin 59 patients (69%). Incidence and severity of heartburn were reduced after surgery in 22 patients(26%), decreased dyspepsia in 80 patients (94%). Normal belching was preserved in 84 patients(99%) and almost all patients were able to eat normally. Conclusion: Laparoscopic anterior 180°partial fundoplication is an effective procedure for the surgical treatment of gastroesophageal refluxand is associated with a high rate of patient satisfaction at late follow-up. Compared to Nissen'sfundoplication it is as good as control of recurrent reflux as well as reduced adverse effects. Thepatient goes home in 3-4 days. Hence we recommend it as the procedure of choice for refluxsymptoms.

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.

Large congenital bladder diverticula in children.

Large congenital bladder diverticula (LCBD), congenital bladder diverticula (CBD) larger than 2 cm diameter, is a rare anomaly. The aim of this study was to report long-term surgical and clinical outcomes of children with LCBD. Medical charts of all children who were diagnosed with LCBD at our institution between April 2005 and December 2017, with at least 2 year follow-up were retrospectively reviewed. Patients' demographics, symptoms, operative technique, diverticulum size and localization, surgical outcomes and complications were recorded. Fourteen patients with 18 LCBD, all male and age between 7 and 240 months (mean age: 53.5 months) were included in the study. Urinary tract infection was the main complaint in 10. Vesicoureteral reflux was detected in eight patients. Diverticula were 2-5.5 cm (mean 3.3 cm) in size. All diverticulectomies were performed transvesically and ureteroneocystostomy was added in 12 patients, 5 of whom were bilateral. No postoperative infection or recurrent reflux were observed. The median follow-up period was 4.5 years (2-12 years). Treatment of LCBD is mostly surgical and transvesical approach for diverticulectomy was found to be a safe and effective surgical procedure in long term follow-up.

Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter?

BackgroundPostoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia. MethodsA prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected. ResultsThe study included 902 consecutive patients, 71.3% females, with a mean age of 57.8±14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation.Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit. ConclusionOne attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.

Functional constipation induces bladder overactivity associated with upregulations of Htr2 and Trpv2 pathways

Bladder and bowel dysfunction (BBD) is a common yet underdiagnosed paediatric entity that describes lower urinary tract symptoms (LUTS) accompanied by abnormal bowel patterns manifested as constipation and/or encopresis. LUTS usually manifest as urgency, urinary frequency, incontinence, and urinary tract infections (UTI). Despite increasing recognition of BBD as a risk factor for long-term urinary tract problems including recurrent UTI, vesicoureteral reflux, and renal scarring, the mechanisms underlying BBD have been unclear, and treatment remains empirical. We investigated how constipation affects the lower urinary tract function using a juvenile murine model of functional constipation. Following four days of functional constipation, animals developed LUTS including urinary frequency and detrusor overactivity evaluated by awake cystometry. Physiological examination of detrusor function in vitro using isolated bladder strips, demonstrated a significant increase in spontaneous contractions without affecting contractile force in response to electrical field stimulation, carbachol, and KCl. A significant upregulation of serotonin receptors, Htr2a and Htr2c, was observed in the bladders from mice with constipation, paralleled with augmented spontaneous contractions after pre-incubation of the bladder strips with 0.5 µM of serotonin. These results suggest that constipation induced detrusor overactivity and increased excitatory serotonin receptor activation in the urinary bladder, which contributes to the development of BBD.