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.

634 ROBOTIC-ASSISTED HIATAL HERNIA AND GASTROESOPHAGEAL DISEASE SURGERY: INITIAL RESULTS AND EXPERIENCE IN A SINGLE INSTITUTION

Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common disease that frequently needs a surgical solution. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery but the robotic approach seems to gain widespread acceptance because offers enhanced visualization, dexterity and reach, which may facilitate the hiatal reconstruction and mediastinal dissection. Methods Between June 2019 and February 2021, 23 patients (5 male, 18 female) underwent robotic approach fundoplication (19 sliding hernia, 3 paraesophageal and 2 gastroesophagic reflux) after being pre operative diagnosed. All surgeries were elective. Biosynthetic tissue absorbable mesh was applied in one patient with double time recurrence hernia. Sixteen patients underwent total fundoplication (Nissen), 6 patients had Toupet fundoplication, and one patient had hiatus repair without fundoplication. Results The mean age of the patients was 61 years. Biosynthetic mesh was used in one patient. The mean operative time was 127 minutes (80-240) and no intraoperative complications were described. There were no conversions to open or laparoscopic procedures. Nine of the twenty-three patients underwent redo hiatal hernia repairs and the mean hospital stay was 2 days. Only one patient had a major complication (Clavien Dindo 3b) requiring urgent surgery. The early and 30 day mortality rate was 0%. Conclusion In our experience, robotic approach to paraesophageal repair seems safe and effective with low complication rates even in high-risk patients and those with redo surgery. Subjectively, the robotic approach provides the surgeon better vision and maneuverability during the intervention. We hope to progressively increase the number of robotic cases to analyse long-term clinical outcomes such as hiatal hernia recurrences, need of medical therapy and quality of life.

584 MULTIPLE OBSERVER DETERMINATION OF GASTRO-ESOPHAGEAL JUNCTION CHARACTERISTICS ON VIDEO-FLUOROSCOPY RELATING TO TROUBLESOME DYSPHAGIA POST-FUNDOPLICATION

Dysphagia is a common adverse effect of fundoplication and in some patients, there is no clear identifiable cause despite extensive investigation. Subtle anatomical features of anti-reflux surgery may relate to dysphagia. In this study multiple observers examine gastro-esophageal junction (GEJ) anatomy using objective measures of video-fluoroscopy swallow study (VFSS) to explore possible correlates with post-fundoplication dysphagia. Methods Thirty-one patients underwent structured VFSS 6–12 months after laparoscopic total (TotLF) or partial anterior (PAntLF) fundoplication recording: standing AP, 2x standing oblique (SOb), 2x prone oblique (POb), and prone oblique with continuous drinking (PObCont). Post-operative dysphagia was evaluated (Dakkak & Bennett Score: range 0–45; troublesome ≥12). Three observers (Obs1–3) independently measured: GEJ displacement anteriorly; degree of axis deviation of esophagus & GEJ (E-GEJ); posterior distal esophageal angle (PDEA); and GEJ opening diameter cf. maximal distal esophageal diameter (ME-GEJ). Correlations between measurements and dysphagia by operation type were assessed using linear regression analysis and linear mixed-effects models. Results Post-operatively, 5/18 TotLF and 4/13 PAntLF patients reported troublesome dysphagia. Three observers independently found: patients with troublesome dysphagia after TotLF had greater anterior displacement of the GEJ (SOb, range 0.61 cm–1.18 cm, Obs1 p = 0.04), and larger axis deviation of E-GEJ (POb, range 3.28°-13.07°, Obs2 p = 0.03) compared to patients with no/mild dysphagia. There was a trend for greater PDEA in patients with troublesome dysphagia after TotLF (POb, range 0.46°-2.12° and PObCont, range 3.37°-13.4°), but this trend did not reach statistical significance. Following PAntLF, all observers recorded a reduction in ME-GEJ for each unit of worsening dysphagia (PObCont, range 0.03 cm–0.04 cm, Obs1 p = 0.02, Obs2 p = 0.02). Conclusion Multiple observers concur that anterior GEJ displacement, the angle between the esophagus axis—GEJ axis, and posterior distal esophageal angulation are anatomical factors associated with troublesome dysphagia after total fundoplication. After partial anterior fundoplication, a small reduction in GEJ opening diameter relative to the distal esophagus related to worsening dysphagia. To reduce post-fundoplication dysphagia, attention to operative techniques affecting angulation and luminal diameter at the GEJ by fundoplication and hiatal repair is warranted.

Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus

Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett’s oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.

VS02.06: ROBOTIC RE-DO GIANT HIATAL HERNIA WITH MESH

Description The authors present a video of reoperation of relapsed giant hiatal hérnia (twice). Tactics of static presentation of 2 robotic arms allowing safe dissection with 2 concomitant energy modalities: ultrasonic scalpel and bipolar. The endowrist movments allow intrathoracic safe dissection. The hiatal repair with barbed suture at different angles was followed by a biological U-shape mesh. Total fundoplication with 3 lines of suture and hiatal fixation are highlighted. Disclosure All authors have declared no conflicts of interest.