The Outcomes of Performing Partial Fundoplication Based on Endoflip Versus Manometric Findings

Background The surgical management of gastroesophageal reflux disease (GERD) involves extensive diagnostic studies and sophisticated surgical techniques. The workup should be comprehensive and purposeful. High resolution impedance manometry (HRIM) provides valuable information regarding peristalsis and lower esophageal sphincter relaxation. The disadvantages of HRIM such as intolerance or inability to pass the catheter led to its selective use or even omission especially in laparoscopic hiatal hernia repair with partial fundoplication. This pragmatic approach risks missing motility disorders in patients with secondary reflux symptoms related to achalasia or scleroderma. Endolumenal functional lumen imaging probe (endoFLIP) can fill this void as it evaluates the dynamics of the esophagogastric junction under sedation. This study aims to compare the outcomes of preoperative use of HRIM vs endoFLIP for laparoscopic repair of hiatal hernia with partial fundoplication. Methods This is a retrospective cohort study for consecutive patients who underwent antireflux surgery with partial fundoplication between July 2018 and February 2021. Preoperative and postoperative outcomes were compared between two cohorts of patients: those with preoperative HRIM and those with preoperative endoFLIP. Results A total of 72 patients were evaluated, 41 had preoperative HRIM and 31 had endoFLIP. There was no statistically significant difference in their age, sex, BMI, duration of GERD symptoms, or proton pump inhibitors use. The endoscopic findings of esophagitis, hiatal hernia, and Hill’s grade were comparable. There was no difference in the American Society of Anesthesiology classification or the choice of antireflux surgery. The improvement of postoperative GERD scores and dysphagia subscore was similar between the two groups. Conclusion Performing partial fundoplication based on endoFLIP evaluation of the dynamics of the esophagogastric junction is safe and does not increase postoperative dysphagia compared to preoperative manometric use. Randomized prospective studies are needed to confirm the findings of this study.

766 PROPHYLAXIS OF POST-FUNDOPLICATION SIDE EFFECTS AFTER LAPAROSCOPIC NISSEN EXTRA SOFT FUNDOPLICATION.

Laparoscopic Nissen Fundoplication (LNF) is well-established surgical treatment of GERD with best long-term postoperative outcomes in controlling reflux. Usually it is associated with a high risk of dysphagia, flatulence, inability to belch, bloating, which appear due to total over-tight wrap around esophagus. Partial fundoplication can avoid these effects, but unfortunately does not have the same long-term postoperative reflux control. So, new approach to prophylaxis of post-fundoplication side effects during LNF is needed. Methods Modified extra-soft LNF for GERD during 2016–2020 years were proposed in 75 patients. Prior to the fundoplication wrap formation the operation was performed according to the standard procedure. The proposed surgical techniques were: performing of an extra mobilization of the stomach (mandatory fundus and more ½ part of a large curvature) by crossing the gastro-splenic ligament completely and the gastro-colonic ligament partially and formation of a short extra-soft fundoplication wrap around the esophagus less 1.5 cm in the length with no more than 3 non-absorbable sutures with obligatory fixation to the esophagus. We examined twelve months follow-up. Results Along with the disappearance of GERD symptoms, no post-fundoplication dysphagia, flatulence, inability to belch and bloating were marked in any patient. Routine application of the above-described techniques allowed us to perform a modified LNF in all 75 patients by the extra mobilization of the stomach and formation of an extra-soft total fundoplication wrap with obligatory fixation to the esophagus without mandatory use of a thick (56–60 Fr) gastric fundoplication tube. Conclusion According to our study, in comparison with standard LNF, the proposed surgical techniques is effective in the prevention of post-fundoplication complications (dysphagia, flatulence, inability to belch, bloating) and support routine use of this modified Laparoscopic Nissen Extra Soft Fundoplication in treatment of GERD.

652 LAPAROSCOPIC FUNDOPLICATION IS EFFECTIVE TREATMENT FOR PATIENTS WITH GASTROESOPHAGEAL REFLUX AND ABSENT ESOPHAGEAL CONTRACTILITY

Anti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, particularly in individuals with an aperistaltic esophagus (absent esophageal contractility). Emerging evidence suggests fundoplication is safe and effective in patients with esophageal dysmotility. This study aimed to determine the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility. Methods A case control study was performed, using a prospectively maintained database to identify all (40) patients with absent esophageal contractility on preoperative manometry who subsequently underwent fundoplication (36 anterior partial, 4 Nissen). Cases were propensity matched based on age, gender, and fundoplication type with another 708 patients who all had normal motility. Groups were assessed using prospective symptom assessment questionnaires to assess heartburn, dysphagia for solids and liquids, regurgitation, and satisfaction with surgery. Outcomes were compared at baseline and at 1, 5 and 10 years follow-up. Results Across follow-up to 10 years, no significant differences were found between the two groups for any of the assessed postoperative symptoms. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5 and 10 year follow-up. No differences in overall patient satisfaction were identified across the follow-up period. Conclusion Laparoscopic anterior partial fundoplication in patients with absent esophageal contractility achieves acceptable symptom control without significantly worse dysphagia compared to patients with normal contractility. Patients with medically refractory reflux who have absent contractility should still be considered for surgical intervention.

Esophageal Motility Disorders and Diverticula: Physiologic Implication and Surgical Considerations

Zenker’s diverticula are the most common diverticula of the esophagus and attributed to a hypertensive non-compliant cricopharyngeus muscle with reduced sphincter opening. Cricopharygeus myotomy is the treatment with variable management of the diverticulum. Mid-esophageal diverticula are classically attributed to traction, though many are associated with dysmotility similar to epiphrenic/distal esophageal diverticula. Myotomy is again key for symptomatic presentations. Resection of the diverticula and a partial fundoplication are other components in the surgical management. Although treatment of diverticula has evolved over the decades, it remains a rare condition often associated with significant pre-operative symptomatology and post-operative morbidity.

680 ACUTE GASTRIC DILATATION: A LIFE-THREATENING EARLY COMPLICATION FOLLOWING LAPAROSCOPIC HIATUS HERNIA REPAIR

Laparoscopic anti-reflux surgery prevents reflux of gastric fluid into the oesophagus but it may also inhibit belching. Gastric outflow impairment may lead to a closed-loop obstruction and life-threatening acute gastric dilatation. Methods We report a case of a 69-year-old female who underwent a laparoscopic giant hiatus hernia repair and anterior 180° fundoplication. Post operatively, she suffered from gastroparesis that resulted in a closed-loop obstruction. This was managed successfully with nasogastric tube insertion and commencement of prokinetic agents. A review of the literature of acute gastric dilatation and hiatus hernia repair was made. Results In the last 30 years, there have been 7 cases of acute gastric dilatation following hiatus hernia repair. Timing was 7 months to 14 years following a 360 degree fundoplication. In most cases, the ensuing gastric dilatation led to venous congestion, tissue necrosis and perforation, necessitating emergency gastrectomy for control of sepsis. All patients required a prolonged hospital stay and one mortality was reported. Our case is unique, characterized by its early presentation, and occurring after a partial 180° fundoplication. Our patient was successfully managed non-operatively with nasogastric decompression and supportive measures. Conclusion Surgeons should be aware that acute gastric dilatation is a life-threatening complication which may occur following laparoscopic partial fundoplication. Early diagnosis and prompt nasogastric decompression are required to avoid gastric necrosis and significant morbidity.

81 ANTI-REFLUX SURGERY: TOUPET AND DOR TECHNIQUES

Gastroesophageal reflux disease (GERD) is one of the most important digestive disorders, in view of the high incidence, intensity of symptoms and severity of complications. GERD is probably one of the most prevalent diseases in the world that compromises quality of life. It is a common disease that affects between 20–40% of the population of the United States of America at least weekly. In Brazil, the incidence is 12%, corresponding to 20 million individuals. Methods Prospective and retrospective cohort study, which aims to assess the regression of symptoms in patients undergoing surgical technique to correct GERD. The present study was carried out in Natal, Rio Grande do Norte, Brazil, in two hospitals: one in the private network and another study at the State University Hospital, with 130 patients between 2014 and 2020. The study population consisted of patients with GERD confirmed by clinical symptoms, upper gastrointestinal endoscopy, manometry and/or pH monitoring, with the inclusion criteria: patients with GERD refractory to clinical treatment, with hiatus hernia, with atypical symptoms and/or need for surgical intervention. Results We studied 130 patients undergoing GERD correction surgery, 122/130 (93%) Nissen-Toupet, 03/130 (2%) Collis-Dor, 03/130 (2%) Dor and 02/130 (1.5%) Collis-Toupet, with 18/130 (13%) REDO Nissen to Toupet, 13/130 (10%) with mesh reinforcement (TABLE-I) and 01/130 (0.7%) performed Toupet + VSS + gastroenteroanastomosis. In addition, 45/123 (36%) did not have hiatus hernia and 78/123 (63%) did, 40/78 (51%) type 01, 14/78 (17%) type 02 and 18/78 (23%) type 03; 107/130 (82%) performed a manometric study. In short-term complications, 02/130 (1.5%) presented gas bloat syndrome, 01/130 (0.7%) grade 1 dysphagia, fistula 01/130 (0.7%) and mortality 01/130 (0,7%). Conclusion In conclusion, it is observed that the partial fundoplication technique, Toupet and Dor, maintains a competent anti-reflux mechanism with the advantage of reducing postoperative dysphagia, the inability to belch and gas bloat syndrome, in addition to decreasing the rates of postoperative recurrence.

Magnetic sphincter augmentation device removal: surgical technique and results at medium-term follow-up

Background The magnetic sphincter augmentation (MSA) device has become a common option for the treatment of gastroesophageal reflux disease (GERD). Knowledge of MSA-related complications, indications for removal, and techniques are puzzled. With this study, we aimed to evaluate indications, techniques for removal, surgical approach, and outcomes with MSA removal. Methods This is an observational singe-center study. Patients were followed up regularly with endoscopy, pH monitoring, and assessed for specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and generic short-form 36 (SF-36) quality of life. Results Five patients underwent MSA explant. Four patients were males and the median age was 47 years (range 44–55). Heartburn, epigastric/chest pain, and dysphagia were commonly reported. The median implant duration was 46 months (range 31–72). A laparoscopic approach was adopted in all patients. Intraoperative findings included normal anatomy (40%), herniation in the mediastinum (40%), and erosion (20%). The most common anti-reflux procedures were Dor (n = 2), Toupet (n = 2), and anterior partial fundoplication (n = 1). The median operative time was 145 min (range 60–185), and the median hospital length of stay was 4 days (range 3–6). The median postoperative follow-up was 41 months (range 12–51). At the last follow-up, 80% of patients were off PPI; the GERD-HRQL and SF-36 questionnaire were improved with DeMeester score and esophageal acid exposure normalization. Conclusion The MSA device can be safely explanted through a single-stage laparoscopic procedure. Tailoring a fundoplication, according to preoperative patient symptoms and intraoperative findings, seems feasible and safe with a promising trend toward improved symptoms and quality of life.