Pre-emptive active drainage of reflux (PARD) in Ivor-Lewis oesophagectomy with negative pressure and simultaneous enteral nutrition using a double-lumen open-pore film drain (dOFD)

Background Postoperative reflux can compromise anastomotic healing after Ivor-Lewis oesophagectomy (ILE). We report on Pre-emptive Active Reflux Drainage (PARD) using a new double-lumen open-pore film drain (dOFD) with negative pressure to protect the anastomosis. Methods To prepare a dOFD, the gastric channel of a triluminal tube (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over 25 cm. The ventilation channel is blocked. The filmcoated segment is placed in the stomach and the intestinal feeding tube in the duodenum. Negative pressure is applied with an electronic vacuum pump (− 125 mmHg, continuous suction) to the gastric channel. Depending on the findings in the endoscopic control, PARD will either be continued or terminated. Results PARD was used in 24 patients with ILE and started intraoperatively. Healing was observed in all the anastomoses. The median duration of PARD was 8 days (range 4–21). In 10 of 24 patients (40%) there were issues with anastomotic healing which we defined as “at-risk anastomosis”. No additional endoscopic procedures or surgical revisions to the anastomoses were required. Conclusions PARD with dOFD contributes to the protection of anastomosis after ILE. Negative pressure applied to the dOFD (a nasogastric tube) enables enteral nutrition to be delivered simultaneously with permanent evacuation and decompression.

A Novel Method of Piggyback Jejunal Interposition Reconstruction Single-Tract Reconstruction After Proximal Gastrectomy for Siewert II and III Adenocarcinoma of the Esophagogastric Junction with a Diameter <4 cm

Background Digestive tract reconstruction after proximal gastrectomy (PG) has been extensively discussed. Herein, we introduce a novel method of PG with piggyback jejunal interposition reconstruction single-tract reconstruction (PJIRSTR) for Siewert II and III adenocarcinoma of the esophagogastric junction (AEG) with a diameter <4 cm, and investigate its safety, practicability, and short-term and long-term clinical outcomes of this procedure. Method The clinical data of 33 patients with Siewert II or Siewert III AEG who underwent PJIRSTR in Shanxi Cancer Hospital from July 2013 to November 2016 were retrospectively reviewed. Data of clinicopathologic characteristics, postoperative and surgical outcomes, and follow-up findings, especially postoperative reflux esophagitis and postoperative reflux symptoms, were analyzed.Results The mean operation time was 136.7±22.4 (range: 110-180) min, including 32.3 ± 5.0(range: 26-45) min of the digestive tract reconstruction; the mean estimated blood loss was 87.6±18.1 mL; the mean number of dissected lymph nodes was 14.7±5.1; and the mean duration of postoperative hospitalization was 7.5±1.2 days. The early complication rate was 9% (n=3), including one case each of anastomotic bleeding, incision infection, and ileus. The late complication rate was 6% (n=2): both patients had gastroesophageal reflux symptoms (Visick grade II), but only one patient had Los Angeles grade B reflux esophagitis by endoscopy. Conclusion PJIRSTR is a safe, feasible, and innovative reconstruction method after PG for patients with Siewert II and III AEG with a diameter <4 cm. Furthermore, it has excellent efficiency in terms of preventing reflux symptoms and reflux esophagitis after surgery.

178 RANDOMIZED CONTROLLED TRIAL COMPARING ANGLE OF HIS ACCENTUATION WITH TOUPET FUNDOPLICATION IN PATIENTS UNDERGOING LAPAROSCOPIC HELLERS MYOTOMY: INTERIM RESULTS

Laparoscopic Heller’s Cardiomyotomy (LHCM) is the surgical treatment of choice for achalasia. Addition of an antireflux procedure is recommended to reduce the postoperative reflux. However, there is no consensus regarding the ideal antireflux procedure. In an earlier study we have shown that Angle of His accentuation (AOH) is similar to Dor fundoplication. In this study we present the interim results of an RCT comparing AOH with Toupet fundoplication as an adjunct to LHCM. Methods Patients of Achalasia cardia presenting after October 2017 were randomised to receive either AOH or Toupet following Heller cardiomyotomy based on computer generated random sequence. Primary outcome was incidence of post-operative symptomatic reflux and esophagitis on endoscopy. Secondary outcome was relief of dysphagia and Achalasia specific health related Quality of life assessment (ASHRQoL). Symptom scores for dysphagia, regurgitation and heartburn as well as ASHRQoL were noted pre operatively and at 3 monthly intervals. Objective evaluation was done using timed barium swallow, Upper GI endoscopy and oesophageal manometry. Data was recorded on excel spreadsheet and analysis done using SPSS v5. Results A total of 52 patients (25 Toupet, 27 AOH) were included in the analysis. All patients were successfully operated laparoscopically with no conversions, intraoperative perforations or perioperative mortality. The mean operative duration was 128 min in the AOH group and 146 min in the Toupet group (p &lt; 0.05). There was significant improvement in symptom scores as well as objective parameters in both groups with no difference between the 2 groups at a mean follow-up of 6 months (5-9 months; Table 1). 3 patients in AOH group (11%) and 4(16%) patients had new onset reflux with esophagitis in 2 patients in each group. Conclusion AOH is technically easier and can be performed in a shorter time. The symptom relief is similar in both groups with similar incidence of heartburn and esophagitis in the short term. A longer follow up is recommended in a larger number of patients.

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.

Indications for operation and results from surgical treatment of vesicoureteral reflux

The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR

Optional Management of Achalasia in 2021: Dilatation or Myotomy

Achalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.

A common TMPRSS2 variant protects against severe COVID-19

SummaryInfection with SARS-CoV-2 has a wide range of clinical presentations, from asymptomatic to life-threatening. Old age is the strongest factor associated with increased COVID19-related mortality, followed by sex and pre-existing conditions. The importance of genetic and immunological factors on COVID19 outcome is also starting to emerge, as demonstrated by population studies and the discovery of damaging variants in genes controlling type I IFN immunity and of autoantibodies that neutralize type I IFNs. The human protein transmembrane protease serine type 2 (TMPRSS2) plays a key role in SARS-CoV-2 infection, as it is required to activate the virus’ spike protein, facilitating entry into target cells. We focused on the only common TMPRSS2 non-synonymous variant predicted to be damaging (rs12329760), which has a minor allele frequency of ∼25% in the population. In a large population of SARS-CoV-2 positive patients, we show that this variant is associated with a reduced likelihood of developing severe COVID19 (OR 0.87, 95%CI:0.79-0.97, p=0.01). This association was stronger in homozygous individuals when compared to the general population (OR 0.65, 95%CI:0.50-0.84, p=1.3×10−3). We demonstrate in vitro that this variant, which causes the amino acid substitution valine to methionine, impacts the catalytic activity of TMPRSS2 and is less able to support SARS-CoV-2 spike-mediated entry into cells.TMPRSS2 rs12329760 is a common variant associated with a significantly decreased risk of severe COVID19. Further studies are needed to assess the expression of the TMPRSS2 across different age groups. Moreover, our results identify TMPRSS2 as a promising drug target, with a potential role for camostat mesilate, a drug approved for the treatment of chronic pancreatitis and postoperative reflux esophagitis, in the treatment of COVID19. Clinical trials are needed to confirm this.

Comparative analysis of laparoscopic proximal gastrectomy plus semi-embedded valve anastomosis with laparoscopic total gastrectomy for adenocarcinoma of the esophagogastric junction: a single-center retrospective cohort study

Background We invented a new antireflux anastomosis method for use in proximal gastrectomy for adenocarcinoma of the esophagogastric junction (AEG) and named it semi-embedded valve anastomosis (SEV). This study was conducted to compare and analyze the short-term efficacy and long-term prognosis of this anastomosis reconstruction method versus laparoscopic total gastrectomy (LTG). Methods We retrospectively analyzed the general data and surgical outcomes of patients with AEG who underwent three united laparoscopic proximal gastrectomy plus semi-embedded valve anastomosis (TULPG-SEV, N = 20) and LTG (N = 20) at our hospital from January 2015 to September 2017 and investigated the incidence of postoperative reflux esophagitis and postoperative nutritional status between the two groups. Survival analysis was also performed. Results The operative time (178.25 ± 15.41 vs 196.5 ± 21.16 min) and the gastrointestinal reconstruction time (19.3 ± 2.53 vs 34.65 ± 4.88 min) of the TULPG-SEV group were significantly less than that of the LTG group. There was no difference in intraoperative blood loss, length of hospital stay, and postoperative complications. There was no difference in the scores on the postoperative reflux disease questionnaires (RDQs) conducted 1 month (P = 0.501), 3 months (P = 0.238), and 6 months (P = 0.655) after surgery between the TULPG-SEV group and LTG group. Gastroscopy revealed 2 cases of reflux esophagitis (grade B or higher) in each group. The postoperative hemoglobin level was better in the TULPG-SEV group than in the LTG group, and the difference was most noticeable at 1 month after surgery (P = 0.024) and 3 months after surgery (P = 0.029). The levels of albumin and total protein were not significantly different between the groups. There were more patients with weight loss over 5 kg after surgery in the LTG group than in the TULPG-SEV group (P = 0.043). There was no significant difference in the 3-year overall survival rate between the two groups (P = 0.356). Conclusion SEV has a certain antireflux effect and can reduce the anastomosis time. Proximal gastrectomy may be better than total gastrectomy for maintaining postoperative hemoglobin levels and reducing weight loss.

Comparison Between Dunking (Invagination) Pancreaticojejunoanastomosis and Double Layer Duct to Mucosa Anastomosis After Cephalic Duodenopancreatectomy-Whipple Procedure for Pancreatic Cephalic Carcinoma

Introduction: Pancreatic cancer is malignancy with poor prognosis for quality of life and overall survival. The incidence is variant, 7.7/100,000 in Europe, 7.6/100,000 in the USA, 2.2/100.000 in Africa. The only real benefit for cure is surgery, duodenopancreatectomy. The key points for this procedure are radicality, low morbidity and low mortality, the follow up and the expected overall survival. The benchmark of the procedure is the pancreaticojejunoanastomosis, with its main pitfall, postoperative pancreatic fistula B or C. Subsequently, the manner of creation of pancreaticojejunoanastomosis defines the safety, thus the postoperative morbidity and mortality. Finally, this issue remarkably depends on the surgeon and the surgical technique creating the anastomosis. We used 2 techniques with interrupted sutures, dunking anastomosis and duct-to-mucosa double layer technique. The objective of the study was to compare these 2 suturing techniques we applied, and the aim was to reveal the risk benefit rationale for dunking either duct to mucosa anastomosis.Material and method: In our last series of 25 patients suffering pancreatic head carcinoma we performed a standard dodenopancreatectomy. After the preoperative diagnosis and staging with US, CICT, tumor markers, they underwent surgery. Invagination-dunking anastomosis was performed in 15, whereas, duct-to-mucosa, double layer anastomosis was performed in 10. In the first group with dunking anastomosis, we had 6 patients with soft pancreas and 8 with narrow main pancreatic duct, less than 3 mm. In the duct-to-mucosa group there were 5 patients with soft pancreas and 4 with narrow main pancreatic duct. All other stages of surgery were unified, so the only difference in the procedure remained on the pancreatojejunoanastomosis. The onset of the postoperative pancreatic fistula was estimated with revelation of 3 fold serum level of alfa amylases from the third postoperative day in the drain liquid.Results: In the duct to mucosa group there wasn’t a clinically relevant postoperative pancreatic fistula, while in the dunking anastomosis group we had 4 postoperative pancreatic fistula B, 26 %. One of these 4 patients experienced intraabdominal collection – abscess, conservatively managed with lavation through the drain. Comparing the groups, there was no significant difference between the groups concerning the appearance of postoperative pancreatic fistula: p>0.05, p=0.125. From all 25 patients, in 21 patients biliary stent was installed preoperatively to resolve the preoperative jaundice. All 21 suffered preoperative and postoperative reflux cholangitis, extending the intra-hospital stay.Conclusion: So far, there have been many trials referring to opposite results while comparing these 2 techniques in creation of the pancreticojejunoanastomosis. In our study, the duct to mucosa anastomosis prevailed as a technique, proving its risk benefit rationale. However, further large randomized clinical studies have to be conducted to clarify which of these procedures would be the prime objective in the choice of the surgeon while creating pancreatojejunoanastomosis.