Successful Antireflux Surgery Research Articles

Reintervention After Antireflux Surgery for Gastroesophageal Reflux Disease in England.

After antireflux surgery, highly variable rates of recurrent gastroesophageal reflux disease (GERD) have been reported. To identify the occurrence and risk factors of recurrent GERD requiring surgical reintervention or medication. The Hospital Episode Statistics database was used to identify adults in England receiving primary antireflux surgery for GERD in 2000 to 2012 with follow-up through 2014, and the outcome was surgical reintervention. In a subset of participants, the Clinical Practice Research Datalink was additionally used to assess proton pump inhibitor therapy for at least 6 months (medical reintervention). Risk factors were assessed using multivariable Cox regression providing adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). Among 22,377 patients who underwent primary antireflux surgery in the Hospital Episode Statistics dataset, 811 (3.6%) had surgical reintervention, with risk factors being age 41 to 60 years (HR = 1.22, 95% CI 1.03-1.44), female sex (HR = 1.5; 95% CI 1.3-1.74), white ethnicity (HR = 1.71, 95% CI 1.06-2.77), and low hospital annual volume of antireflux surgery (HR = 1.32, 95% CI 1.04-1.67). Among 2005 patients who underwent primary antireflux surgery in the Clinical Practice Research Datalink dataset, 189 (9.4%) had surgical reintervention and 1192 (59.5%) used proton pump inhibitor therapy, with risk factors for the combined outcome being age >60 years (HR = 2.38, 95% CI 1.81-3.13) and preoperative psychiatric morbidity (HR = 1.58, 95% CI 1.25-1.99). At least 3.6% of patients may require surgical reintervention and 59.5% medical therapy following antireflux surgery in England. The influence of patient characteristics and hospital volume highlights the need for patient selection and surgical experience in successful antireflux surgery.

Does Treatment of the Hiatus Influence the Outcomes of Magnetic Sphincter Augmentation for Chronic GERD?

BackgroundHiatal dissection, restoration of esophageal intra-abdominal length, and crural closure are key components of successful antireflux surgery. The necessity of addressing these components prior to magnetic sphincter augmentation (MSA) has been questioned. We aimed to compare outcomes of MSA between groups with differing hiatal dissection and closure. MethodsWe retrospectively reviewed 259 patients who underwent MSA from 2009 to 2017. Patients were categorized based on hiatal treatment: minimal dissection (MD), crural closure (CC), formal crural repair (FC), and extensive dissection without closure (ED). The primary outcome was normalization of postoperative DeMeester score (≤ 14.72). Univariable and multivariable logistic regression was used to assess which preoperative predictors achieved normalization. ResultsOf the 197 patients, MD was used in 81 (41%); FC in 42 (22%); CC in 40 (20%); and ED in 34 (17%). Normalization occurred in 104 (53%) patients, with MD achieving normalization in 45/81 (56%); FC in 25/42 (60%); CC in 21/40 (53%); and ED 13/34 (38%). After regression, FC was most likely to normalize acid exposure. The presence of a hiatal hernia, defective LES, and higher preoperative DeMeester score were less likely to achieve normalization. ConclusionsHiatal dissection with restoration of esophageal length and crural closure during MSA increases the likelihood of normalizing acid exposure.

Building a model for day case hiatal surgery - Lessons learnt over a 10 year period in a high volume unit: A case series

BackgroundLaparoscopic anti-reflux surgery has become the standard treatment for symptomatic gastro-oesophageal reflux disease refractory to medical therapy. Successful anti-reflux surgery involves safe, minimally invasive surgery, resulting in symptom resolution with minimal side effects. This study aims to assess the feasibility and safety of day case anti-reflux surgery focussing on peri- and post-operative outcomes as a measure of success. MethodsData was collected from the hospital database from 2003 to 2012. Data collection included demographics, surgeon, mode of admission, length of stay and complications. Electronic records were independently scrutinised for all patients with a length of stay of more than two nights. Results723 patients underwent laparoscopic fundoplication ± small hiatus hernia repair (<5 cm) with a day case rate of 67.1%. The 30 day readmission rate in these patients was 2.9% (21/723 patients). Nine patients had a failure of their initial laparoscopic fundoplication (defined as recurrence of symptoms). Three patients required a re-operation within 12 months of their initial procedure (re-operation rate = 0.41% (3/723 patients)). ConclusionLaparoscopic hiatal surgery can be performed safely as a day case in high volume specialist centres with good outcomes. Raising the national standard for day case fundoplication promotes good practice and should be the model for future commissioning.

Secrets for successful antireflux surgery: learning curve

The field of surgery is a complex environment of constant innovation. With persistent advancement in technique and tools, there also comes the need for proper surgical education in order to maximize technical proficiency in a short period of time. In recent times, the concept of a learning curve has been the focus of surgical education. A learning curve is essentially a positive curvilinear relation of performance and experience; this curve is par-ticularly steep in antireflux laparoscopic surgery. There are, however, certain fundamental secrets that allow any individual to efficiently and successfully adapt to such an arduous learning curve. In order to identify these secrets, we conducted a thorough search on PubMed and systematically reviewed relevant literature on the learning curve of laparoscopic surgery, with a focus on antireflux surgery, from 1995 to 2016. The following key words were used in our search: “Learning Curve”, “Anti-Reflux Surgery” and “Surgery Education”. Based on our review of literature, the authors of this perspective manuscript propose three key fundamental secrets to successful adaption of the steep learning curve of laparoscopic surgery.

Secrets for successful laparoscopic antireflux surgery: surgical technique

Laparoscopic Nissen fundoplication is an effective surgical treatment for gastroesophageal reflux disease (GERD). However, as a “creative” operation (rather than, for example, a destructive operation involving excision of an organ), the efficacy of surgery is directly and closely linked to the skill and experience of the surgeon. As a part of the special issue, “Secrets for Successful Laparoscopic Antireflux Surgery”, we detail here technical surgical principles we have found essential for successful completion of this operation in our experience. This text also has an accompanying video that the reader can follow visually.

Secrets for successful laparoscopic antireflux surgery: surgical technique

Secrets for successful laparoscopic antireflux surgery: surgical technique

Secrets for successful laparoscopic antireflux surgery: preoperative workup

Secrets for successful laparoscopic antireflux surgery: preoperative workup

Secrets for successful laparoscopic antireflux surgery: preoperative workup

Gastroesophageal reflux disease (GERD) is a highly-prevalent multifactorial disease, with primary symptoms including heartburn and regurgitation. Despite the widespread pharmacologic treatment of GERD, antireflux surgery is cur-rently the most effective and definitive treatment for the disease. An accurate indication for surgery and the appropriate preoperative workup are the best predictors of surgical success in those patients. Several factors affect the decision of performing anti-reflux surgery, including the patient’s response to anti-acid medication and therapy duration, presence of side-effects, and progression of disease. Other diagnoses, such as esophageal cancer, must also be ruled out. A proper preoperative workup includes esophageal symptom evaluation and esophageal testing. Ambulatory pH testing is the gold standard for GERD diagnosis, and it is crucial for the assessment of the relationship between symptom presen-tation and reflux episodes. High-resolution manometry evaluates esophageal body motility and lower esophageal sphincter function, playing an important role in the definition of the surgical technique to be adopted. Upper GI endoscopy is the exam of choice for the diagnosis of disease progression and presence of other complications. Esophagram provides a detailed anatomy of the esophagus and stomach. In summary, a meticulous preoperative workup done by experts is crucial for improving patient outcomes.

Secrets for successful laparoscopic antireflux surgery: mesh hiatoplasty

Repair of hiatal hernias is associated with an elevated recurrence rate, a fact that has long driven modifications to surgical technique. During the past 20 years, reinforcement of the repair with mesh has formed the basis of many of these modifications. However, despite early success, the use of synthetic and biologic mesh at the hiatus has been found to carry increased complication and high long-term recurrence rates, respectively. In this article, we review available evidence as well as our current practice for mesh-reinforced hiatal hernia repair.

Secrets for successful laparoscopic antireflux surgery: patients with pulmonary diseases

Gastroesophageal reflux disease (GERD) has been associated to a spectrum of respiratory disorders such as idiopathic pulmonary fibrosis (IPF), asthma, and chronic obstructive pulmonary disease (COPD). Several factors including increased trans-diaphragmatic pressure gradient, flattening of the diaphragm, and medication side effects affecting relaxation of the lower esophageal sphincter have linked GERD with pulmonary diseases. While medical therapy alters the pH of the gastric juice, it does not eliminate the occurrence of gastroesophageal reflux episodes, which cause regurgitation and respiratory symptoms. Selected group of patients with pulmonary disease and proven GERD may benefit from antireflux surgery.

Secrets for successful laparoscopic antireflux surgery

Secrets for successful laparoscopic antireflux surgery

Secrets for successful laparoscopic antireflux surgery: patients with collagen diseases

Secrets for successful laparoscopic antireflux surgery: patients with collagen diseases

Secrets for a successful laparoscopic antireflux surgery: patients with extraesophageal symptoms

The outcomes for antireflux surgery in patients with extraesophageal symptoms of gastro esophageal reflux disease (GERD) are usually worse compared with patients with esophageal symptoms. This paper focuses on how to obtain a successful laparoscopic antireflux surgery in patients with extraesophageal symptoms. A successful laparoscopic antireflux surgery in patients with extraesophageal symptoms depends on: (I) an objective diagnosis for GERD. The diagnosis of pathological distal reflux is straightforward; however, the diagnosis of proximal reflux and to the target organs may be hard to be established; (II) the attribution of the symptoms to GERD. Extraesophageal symptoms may have a different cause than GERD even in the presence of GERD. A rational and complete workup is necessary to answer this question. A single test is not able to correlate symptoms to GERD. Judicious clinical decision based on a sum of different pieces of information is needed; and (III) the correct selection of patients based on predictors for good outcomes to show those who would benefit from surgery. Adequate surgical technical principles should be followed.

Secrets for a successful laparoscopic antireflux surgery: patients with extraesophageal symptoms

Secrets for a successful laparoscopic antireflux surgery: patients with extraesophageal symptoms

新生児期に腎不全で発症し,逆流防止術を施行した一側 VUR,他側低形成腎の2例

新生児期に腎不全で発症し,逆流防止術を施行した一側 VUR,他側低形成腎の2例

Laparoscopic Nissen–Rossetti Fundoplication for Gastroesophageal Reflux Disease Patients After 2-Year Follow-Up

Gastroesphageal reflux disease (GERD) is a common condition in the general population, affecting patients' quality of life and predisposing to Barrett's esophagus and its most fearsome complication, esophageal adenocarcinoma. The aim of this study is to compare objective and subjective outcomes of laparoscopic Nissen-Rossetti fundoplication after 2 years of follow-up. Seventy-six GERD patients underwent laparoscopic Nissen-Rossetti fundoplication. Patients were subjected to close follow-up. The DeMeester and Johnson score average decreased from a mean preoperative value of 35.48 (SD±40.24) to 9.83 (SD±6.40) at 6 months; at 12 months it was 11.44 (SD±10.28), and at 24 months it was 10.25 (SD±5.61). GERD Health-Related Quality of Life decreased from a preoperative value of 23.04 (SD±11.59) to 9.84 (SD±8.98) at 6 months, 8.34 (SD±8.98) at 12 months, and 6.8 (SD±6.46) at 24 months. The Short Form-36 measurement showed significant improvement. GERD patients need adequate reflux control. Successful antireflux surgery is more effective than medical therapy in preventing both acid and bile reflux. Surgical therapy is effective in terms of reflux control and improvement in quality of life. Strict and rigorous follow-up with both subjective and objective tests is important in order to identify asymptomatic recurrence of reflux after surgery.

Long-term results of ablation with antireflux surgery for Barrett’s esophagus: a clinical and molecular biologic study

The initial results from ablation therapy for metaplastic/dysplastic Barrett's esophagus (BE) are promising, but the results of extended follow-up evaluation are seldom reported. Neodymium:yttrium-aluminum-garnet laser ablation and successful antireflux surgery for 18 patients with metaplastic BE primarily resulted in the total histologic eradication of BE in 15 patients (83%). After antireflux surgery, the healing of gastroesophageal reflux disease (GERD) was objectively verified in all the patients. At late follow-up evaluation, endoscopy, conventional histology, molecular oxidative stress analyses in comparison with normal control conditions (8-hydroxydeoxyguanosine [8-OHdG], superoxide dismutase [SOD], glutathione [GSH], myeloperoxydase [MP]), and immunohistochemistry (p53, and Cdx2, caudal-related homeobox gene 2, marking intestinal differentiation) of the neosquamous epithelium were performed. At the end of the follow-up period (range, 3-15 years; mean, 8 years), intestinal metaplasia without dysplasia was detected histologically in eight patients (44%). Six patients had macroscopic BE (mean length, 3.5 cm; range 1-10 cm). The neosquamous epithelium was histologically normal, with no underlying columnar tissue. The fundoplication was endoscopically normal in 14 patients (82%). The 8-OHdG level was higher in the neosquamous epithelium than in the control conditions in the distal esophagus (4.3 vs. 0.52; P = 0.0002) and the proximal esophagus (1.8 vs. 0.95; P = 0.006). Likewise, SOD activity was higher in the neosquamous epithelium (0.38 vs. 0.12; P = 0.0005), whereas MP activity and GSH levels remained normal. Three patients showed slight nuclear p53 expression (typical in normal inflammatory reactions), whereas Cdx2 positivity was confined to one case with recurrent intestinal metaplasia. The neosquamous mucosa, generated by the ablation of BE and the treatment of GERD with fundoplication, was stable during long-term follow-up evaluation in two-thirds of the patients with initial eradication. It had normal p53 expression and no Cdx2 protein expression. The oxidative stress of the neosquamous esophagus remained high, although the clinical significance of this is unclear.

Incidence of Urinary Tract Infections in Children After Successful Ureteral Reimplantation Versus Endoscopic Dextranomer/Hyaluronic Acid Implantation

Endoscopic implantation of dextranomer/hyaluronic acid has proved to be an effective minimally invasive technique for correcting vesicoureteral reflux in children. There is some evidence suggesting that in addition to being less invasive, successful dextranomer/hyaluronic acid implantation compared to successful antireflux surgery is associated with fewer febrile and nonfebrile urinary tract infections. We review the clinical outcomes of 2 groups of children cured of reflux with open surgery and dextranomer/hyaluronic acid implantation to determine if a difference in clinical outcomes exists. We reviewed the charts of 43 patients who underwent dextranomer/hyaluronic acid implantation and 33 who underwent open surgery for vesicoureteral reflux. Data collected included age, gender, preoperative and postoperative grades of reflux, and urinalysis and urine culture results. Urinary tract infection was defined as any culture that grew more than 10(5) colonies of a single organism, with symptoms typical of cystitis (urgency, frequency, dysuria). A febrile urinary tract infection was defined as an infection accompanied by a temperature greater than 101.5F. Any hospitalizations for febrile episodes were also recorded. The incidence of urinary tract infection after successful open surgery (38%) was significantly higher than that observed following successful dextranomer/hyaluronic acid treatment (15%, p = 0.03). Febrile urinary tract infections occurred in 24% of the children who underwent open surgery and in 5% of those who underwent dextranomer/hyaluronic acid implantation (p = 0.02). Hospital readmissions occurred only in the group undergoing open surgery. Children successfully cured of vesicoureteral reflux with dextranomer/hyaluronic acid implantation have a lower incidence of febrile and nonfebrile urinary tract infections compared to those cured with open surgery. These findings suggest that dextranomer/hyaluronic acid implantation, when successful, may result in more favorable clinical outcomes.

The Impact of Antireflux Surgery on Oxidative Stress of Esophageal Mucosa Caused by Gastroesophageal Reflux Disease: 4-yr Follow-Up Study

Oxidative stress to esophageal mucosa plays a key role in the pathogenesis of gastroesophageal reflux disease (GERD), Barrett's esophagus, and adenocarcinoma. We investigated whether successful antireflux surgery eliminates oxidative stress. Oxidative stress of esophageal mucosa was measured in 20 GERD patients, before antireflux surgery and 6 and 48 months after it, and compared with normal controls' mucosa (N = 9). Preoperatively, 12 of the 20 had erosive esophagitis or Barrett's metaplasia. Postoperatively, healing of GERD was verified with endoscopy and 24-h pH monitoring. We measured oxidative stress by myeloperoxidase activity (MPA), superoxide dismutase activity, and glutathione content (GSH) in distal esophagus samples from endoscopy. No patient had reflux symptoms after surgery, and pH measurements had normalized. MPA in the distal esophagus decreased (p < 0.05) after successful antireflux surgery, but remained higher than that of controls both 6 months and 4 yr postoperatively (p < 0.05). At all time-points, MPA was higher in patients with preoperatively detected erosive reflux disease (ERD) as compared to non-erosive reflux disease (NERD) (p < 0.01, p < 0.05, and p < 0.05, respectively). GSH values decreased with time only in NERD. At all time-points, GSH levels in distal esophagus were lower than control levels. Antireflux surgery can heal macroscopic esophagitis but cannot fully reverse the oxidative stress (as reflected by MPA and GSH) upon the distal esophageal mucosa.

Barrett’s Esophagus: Pathologic Considerations and Implications for Treatment

Barrett's esophagus (BE) is a complication of chronic reflux that results in the replacement of esophageal squamous epithelium with columnar epithelium. BE is endoscopically recognized and pathologically confirmed. The presence of goblet cells is diagnostic. The pathologist must also determine if dysplasia or invasive cancer is present. Acceptable terms for dysplasia are no dysplasia, indefinite for dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). It can be difficult to differentiate HGD from intramucosal cancer (IMC) in an endoscopic biopsy specimen. Treatment based on this differentiation is problematic. Indications for treatment of BE are similar to those of patients without BE. Treatment will not cause clinically significant regression of BE or prevent progression to cancer. Cancer development following successful antireflux surgery is uncommon.