Long-Term Outcomes of Chronic Cough Reduction after Laparoscopic Nissen Fundoplication—A Single-Center Study

Background and Objectives: Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases. It affects 20% of the adult population and is the third most common cause of chronic cough in adults. This study describes the results of LNF for the relief of GERD-related cough. Materials and Methods: The prospectively collected data on 135 laparoscopic LNF in our department from 2014 to 2018 were reviewed. During consultations, patients were asked about the frequency of symptoms using the GERD Impact Scale (GERD-IS), their satisfaction and recommendation to others, and their general condition after the procedure. Results: We analyzed 23 of 111 patients (20.7%) reporting chronic cough. The mean age was 47 years (range 27–76 years, ±13.9 years) and the mean follow-up time was 48.3 months (range 22.6–76.3 ± 18.05 months). Most patients reported relief from cough after the surgery (78.3%, p < 0.001). Five patients (22%) reported the recurrence of symptoms after a mean of 10.8 months (6–18 months). Seventeen patients (74%) would undergo the surgery again and 18 patients (78%) would recommend the surgery to their relatives. There was a statistically significant improvement in all symptoms from the GERD-IS (p < 0.05). Conclusions: LNF may play an important role in the management of GERD patients with extraesophageal symptoms. After LNF, most of the operated patients reported complete resolution of chronic cough and would recommend the procedure to their relatives.

Patient Satisfaction after Laparoscopic Nissen Fundoplication—Long-Term Outcomes of Single-Center Study

Up to 33% of the population suffers from gastroesophageal reflux disease (GERD). Given its high prevalence, the negative impact on quality of life, and the possible progression to esophageal cancer, the definitive treatment of GERD should be used more frequently. This study aims to assess long-term patient satisfaction after laparoscopic Nissen fundoplication (LNF). We reviewed the prospectively collected data of patients who underwent LNF for GERD in our department in 2014–2018. Each patient completed a preoperative questionnaire according to GERD Impact Scale (GERD-IS). Postoperative survey consisted of GERD-IS, the need for PPIs, and two “yes or no” questions to assess satisfaction with the outcome. The mean follow-up time was 50 months (21.2–76.3 ± 16.6 months). There was a statistically significant improvement in each GERD-IS question (p < 0.001). A total of 87 patients (78.4%) would recommend the surgery to their relatives. Patients without symptom recurrence and without the need for chronic PPI use after surgery were significantly more likely to recommend surgery and to undergo the procedure again (p < 001). The age of patients did not influence patients’ recommendations (p = 0.75). A total of 17 patients (15.3%) would not undergo LNF again. There was no significant correlation between the answer and patient’s complications or age (p > 0.05). LNF is a good treatment for GERD with a satisfaction rate of 78.4%.

Experience with a Hybrid Procedure Involving Laparoscopic Fundoplication with Percutaneous Endoscopic Gastrostomy in Chronically Ill Children

Gastrostomy with concurrent laparoscopic Nissen fundoplication (LNF) is often performed as a laparoscopic gastrostomy (LG) by surgeons. Since 2014, we started performing percutaneous endoscopic gastrostomy (PEG) as gastrostomy with LNF. This study aims to compare the outcomes of LG and PEG with LNF. Patients were recruited into two groups: LNF with LG (historical control) or PEG. Demographic data, operation time, time to start feeding, time to full feeding, length of hospital stay (LOS), and complications were compared between the groups. Fourteen patients underwent LNF with LG and 49 underwent LNF with PEG. The median age and body weight of patients were 4.25 years and 14.15 kg in the LG group and 2.58 years and 10.60 kg in the PEG group, respectively. Operation times were significantly shorter in the PEG group (1.81 vs. 2.61 h). The times to start feeding and full feeding as well as LOS were shorter in the PEG group. Nevertheless, complications were similar in both groups. In conclusion, PEG with LNF was associated with significantly shorter operation times, times to start feeding and reach full feeding, and LOS. PEG is a suitable method for LNF in chronically ill children.

Is There a Role for Elective Early Upper Gastrointestinal Contrast Study in Neurologically Impaired Children following Laparoscopic Nissen Fundoplication?

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11–18.41) years. Mean body weight was 16.22 (3.3–62.5) kg. Mean duration of follow up was 4.15 (0.01–16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention.

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.

633 CONVERSION TO TOUPET FUNDOPLICATION WITH DISTAL GASTRECTOMY AND ROUX-EN-Y GASTROJEJUNOSTOMY AFTER FAILED NISSEN FUNDOPLICATION

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 &lt; 0.0001), dysphagia (p &lt; 0.0001) and retrosternal chest pain (p &lt; 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 &lt; 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.

Unusual case of hyperemesis in a pregnant patient with prior antireflux surgery

A 33-year-old, 8 weeks pregnant, presented with severe upper abdominal pain with vomiting on a background of a previous laparoscopic Nissen fundoplication for reflux disease. An urgent MRI had shown herniation of the fundoplication wrap through the diaphragmatic hiatus. The cause of her symptoms was attributed to hyperemesis gravidarum. The plan was to manage this patient conservatively until the conclusion of her pregnancy. This plan was revised when she presented for the second time and developed worsening pain and haematemesis. An emergency gastroscopy showed ischaemic changes in most of the stomach requiring the patient to undergo an emergency laparotomy. In pregnant patients, presenting with abdominal pain, vomiting as well as haematemesis, having had previous antireflux surgery, incarceration of the stomach must be considered as a differential. Prompt assessment and early senior decision-making is extremely important in avoiding a potentially catastrophic outcome for such patients.

LINX: How I Do It and Why

The LINX device consists of a “bracelet” of magnetic beads in titanium cases, connected by individual wires placed noncompressively around the distal esophagus during laparoscopic surgery. This augments the native lower esophageal sphincter’s (LES) ability to resist reflux by increasing yield pressure and resisting shortening of the LES. Magnetic sphincter augmentation (MSA) was conceived as a safe, stomach sparing, minimally invasive, reversible implantable device for patients seeking an alternative to laparoscopic Nissen fundoplication. Though initially studied in patients with limited hiatal hernias, its use has expanded to include patients with large and even giant or paraesophageal hernias with excellent results. The author’s techniques of complete esophageal dissection, precise hiatal repair, current concepts on noncompressive sizing and placement of the MSA device are reviewed in this article. MSA can be considered first-line surgical therapy for GERD patients with adequate peristalsis regardless of hernia size.

REVIEW OF 5 YEARS RESULTS AFTER SURGERY FOR GASTRO-OESOPHAGEAL REFLUX DISEASE: NISSEN VS TOUPET

INTRODUCTION Multiple studies attempt to demonstrate the superiority of Toupet fundoplication over the classic Nissen technique in the treatment of gastro- oesophageal reflux disease (GERD). In our study we compared the results of both techniques. MATERIAL AND METHODS A retrospective descriptive study of patients operated because of GERD using laparoscopic Nissen and Toupet fundoplication in our centre between January 1, 2015 and December 31, 2019. RESULTS 80 patients were operated, 56 Nissen (70%) versus 24 Toupet (30%). Both groups are comparable in terms of mean age, distribution by sex, obesity, toxic habits, the prevalence of typical symptoms, DeMeester, and presurgical lower oesophagal sphincter pressure; although there are differences regarding the presence of associated hiatal hernia and within them the type. A similar surgical time (136.59 vs 132.71 minutes) and mean stay (4.02 vs 5 days) were observed. In the Nissen group, 12 patients (21.42%) presented initial postoperative dysphagia, requiring 2 endoscopic dilations and 5 reoperations, compared to 5 patients (20.83%) in the Toupet group, that did not require dilation and with 1 reoperation. The conversion and mortality rate was 0% in both groups, with a variable follow-up of 22.08 versus 14.45 months. CONCLUSIONS Both techniques present similar results, including the rate of postoperative dysphagia, which is one of the most feared complications. However, it would be necessary to increase the size and longer follow-up to establish long-term results.