Impaired postoperative EGJ relaxation as a determinant of post laparoscopic fundoplication dysphagia: a study with high-resolution manometry before and after surgery

Background

Laparoscopic fundoplication (FP) reduces gastroesophageal reflux (GER) efficiently. Dysphagia is its main complication, but no clear data have been published in literature to evaluate risk factors associated with it. The goal of this retrospective study was to identify factors associated with dysphagia occurring after FP for GER disease, with high-resolution manometry (HRM) performed before and after surgery.

Methods

Twenty patients (11 women; mean age, 49 (range, 19?C68?years) underwent HRM before and 2?C3?months after laparoscopic Nissen?CRossetti FP. Analysis was performed with esophageal pressure topography according to the Chicago Classification.

Results

Before FP, ten patients had a manometric hiatal hernia (none after FP). Esophagogastric junction (EGJ) pressures increased after surgery (p?<?0.01). Bolus pressurization was present in 2?% of all swallows before FP and in 22?% after (p?=?0.01). Postoperative bolus pressurization percentage was significantly correlated with EGJ relaxation as measured with integrated relaxation pressure (IRP) (r?=?0.79, p?<?0.01). Eight patients reported dysphagia after FP. The only pre- or post-operative parameter significantly associated with dysphagia was postoperative IRP (5.1?mmHg without vs. 10.3 with dysphagia, p?<?0.02).

Conclusions

FP establishes an efficient antireflux mechanism by correcting hiatal hernia and increasing EGJ pressures. EGJ relaxation as measured by IRP is significantly altered after surgery, leading to more frequent motility disorders, and bolus pressurization. Postoperative dysphagia was associated with higher values of IRP.     

Laparoscopic antireflux surgery improves esophageal body motility in patients with severe reflux esophagitis

Purpose

This study was designed to clarify whether laparoscopic antireflux surgery (LARS) improves the esophageal body motility (EBM) in patients with reflux esophagitis.

Methods

Thirty-five patients with gastroesophageal reflux disease (GERD) scheduled to undergo LARS were divided into a mild esophagitis group (ME; n = 18, Grade O:A:B = 7:10:1) and a severe esophagitis group (SE; n = 17, Grade C:D = 13:4), according to the Los Angeles classification of reflux esophagitis. The types of fundoplication (Nissen/Toupet) were 6/12 in the ME group and 4/13 in the SE group. Esophageal pH monitoring and manometry were performed before and 1 year after surgery.

Results

The fraction time of a pH below 4 significantly decreased after surgery in both groups. The LES pressures did not change significantly after surgery in the ME group, but significantly increased in the SE group. The peristaltic amplitudes 18 and 13 cm above the LES did not change significantly after surgery in either group. The peristaltic amplitudes 8 and 3 cm above the LES did not change significantly after surgery in the ME group, but significantly increased after surgery in the SE group.

Conclusions

The preoperative EBM was not improved by LARS in patients with GERD and mild mucosal breaks in the esophagus, but the preoperative middle to distal EBM was improved by LARS in patients with GERD and severe mucosal breaks.     

Esophageal Stenting and Radiotherapy: A Multimodal Approach for the Palliation of Symptomatic Malignant Dysphagia

Background

Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia.

Methods

We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement.

Results

We placed stents in 45 patients for esophageal stricture from esophageal cancer (n?=?30; 66.7?%), malignant TEF (n?=?8; 17.7?%), and esophageal compression from airway, mediastinal, or metastatic malignancies (n?=?7; 15.6?%). Twenty patients (44.4?%) had no RT; 25 patients had RT before stent placement (n?=?16; 35.6?%), RT after stent placement (n?=?8; 17.8?%), or both (n?=?1; 2.2?%). Median follow-up was 30?days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9?% of all patients, with no differences noted between groups (p?=?0.99). The 30-day mortality was 15.6?%. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38?days).

Conclusions

Esophageal stent placement with RT is a safe approach for malignant dysphagia.     

Peroral Endoscopic Myotomy (POEM) Is Safe and Effective in the Setting of Prior Endoscopic Intervention

Objective

We aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions.

Patients

This study involves 40 consecutive patients undergoing POEM.

Intervention

POEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm.

Main Outcome Measures

Outcome measures include length of procedure (LOP), intraoperative complications, and dysphagia relief.

Results

Forty patients, with a mean age of 54?±?19 years, underwent POEM. The pre-POEM intervention group consisted of 12 patients (nine achalasia, two nutcracker with nonrelaxing LES, and one diffuse esophageal spasm) who also had previous endoscopic treatment, while the pre-POEM non-intervention group consisted of 28 patients (22 achalasia, 3 hypertensive LES, 2 nutcracker with nonrelaxing LES, and 1 diffuse esophageal spasm). Ten patients had botox injections and two patients had large caliber balloon dilations prior to POEM. The median preoperative Eckardt score was 5 in the pre-POEM intervention group vs 6 in the pre-POEM non-intervention group (p value?=?0.4). There was no statistical difference in the mean LOP (134?±?43 vs 131?±?41, p?=?0.8) or the incidence of intraoperative complications (17 vs 3 %, p?=?0.2) between the two groups. There was also no difference in the 6-month postoperative median Eckardt scores between the two groups (1 vs 1, p?=?0.4).

Conclusion

POEM is safe and effective even following preoperative endoscopic large caliber balloon dilations or botox injection. These interventions do not seem to contribute to increased adverse intraoperative or postoperative clinical outcomes.     

High-Resolution Manometry Classifications for Idiopathic Achalasia in Patients with Chagas' Disease Esophagopathy

Background

Idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) share several similarities. The comparison between IA and CDE is important to evaluate whether treatment options and their results can be accepted universally. High-resolution manometry (HRM) has proved a better diagnostic tool compared to conventional manometry. This study aims to evaluate HRM classifications for idiopathic achalasia in patients with CDE.

Methods

We studied 98 patients: 52 patients with CDE (52 % females, mean age, 57?±?14 years) and 46 patients with IA (54 % females; mean age 48?±?19 years). All patients underwent a HRM and barium esophagogram.

Results

The Chicago classification was distributed in IA as Chicago I, 35 %; Chicago II, 63 %; and Chicago III, 2 %, and in CDE as Chicago I, 52 %; Chicago II, 48 %; and Chicago III, 0 % (p?=?0.1, 0.1, and 0.5, respectively). All patients had the classic Rochester type. CDE patients had more pronounced degrees of esophageal dilatation (p?<?0.002). The degree of esophageal dilatation did not correlate with Chicago classification (p?=?0.08). In nine (9 %) patients, the HRM pattern changed during the test from Chicago I to II.

Conclusion

Our results show that (a) HRM classifications for IA can be applied in patients with CDE and (b) HRM classifications did not correlate with the degree of esophageal dilatation. HRM classifications may reflect esophageal repletion and pressurization instead of muscular contraction. The correlation between manometric findings and treatment outcomes for CDE needs to be answered in the near future.     

Mechanisms of Bolus Clearance in Patients with Laparoscopic Adjustable Gastric Bands

Background

The components of esophageal function important to success with laparoscopic adjustable gastric banding (LAGB) are not well understood. A pattern of delayed, however, successful bolus transit across the LAGB is observed.

Methods

Successful LAGB patients underwent a high-resolution video manometry study in which bolus clearance, flow, and intraluminal pressures were recorded. Liquid and semi-solid swallows and stress barium (a combination of semi-solid swallows and liquid barium) were performed. A new measurement, the lower esophageal contractile segment (LECS), was defined and evaluated.

Results

Twenty patients participated (mean age 48.3?±?12.0 years, four men, %excess weight loss 65.6?±?18.0). During semi-solid swallows, two patterns of esophageal clearance were observed: firstly, a native pattern (n?=?10) similar to that which is expected in non-LAGB patients; secondly, a lower esophageal sphincter-dependent pattern (n?=?7), where flow only occurred when the intrabolus pressure increased during the lower esophageal sphincter (LES) aftercontraction. In both patterns, if there was incomplete bolus clearance, reflux was observed and was usually followed by another swallow. A mean of 4.5?±?2.9 contractions were required to clear the semi-solid bolus. Contractions with an intact LECS demonstrated longer flow duration: 7.1?±?3.8 vs.1.6?±?3.2 s, p?<?0.005. During the stress barium, an intrabolus pressure of 44.5?±?16.0 mm Hg leads to cessation of intake.

Conclusions

In LAGB patients, normal esophageal peristaltic contractions transition to a LES aftercontraction, producing trans-LAGB flow. Repeated contractions are required to clear a semi-solid bolus. Incorporating measurements of the LECS into assessments of esophageal motility in LAGB patients may improve the usefulness of this investigation.     

Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial

Background

The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy.

Methods

A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0?C4, five-point Likert scale questionnaire) and 24-h pH testing at 6?C12?months after surgery. Data are mean?±?SD. Statistical analysis was by Mann?CWhitney U test, Wilcoxon signed rank test, and Freidman??s test.

Results

Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7?years) and gender (52.8 vs. 62.5% male). pH studies at 6?C12?months in 43 patients (72%: Dor n?=?24 and Toupet n?=?19) showed total DeMeester scores and % time pH?p?=?0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups).

Conclusion

Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.     

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis

Background

Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia.

Methods

37 patients underwent placement of a SEMS during a 3?year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures.

Results

SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n?=?6), severe heartburn (n?=?1), and upper gastrointestinal bleeding requiring SEMS revision (n?=?1). Dysphagia scores improved significantly from 3.2?±?0.4 before stent placement to 1.4?±?1.0 at 1?month (P?P?P?=?0.0018) at 6?months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n?=?3), stent malfunction (n?=?5), and stent migration (n?=?3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3?±?143.6 (range, 13–680) days.

Conclusions

Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.     

Preoperative high-resolution esophageal manometry and postoperative symptoms in patients undergoing bariatric surgery: a retrospective cohort study

BackgroundThe increasing incidence of obesity has led to a rise in bariatric surgeries. Obesity can be associated with various gastrointestinal symptoms as well as abnormal findings on high-resolution esophageal manometry (HRM). Bariatric procedures have variable effects on esophageal function and may contribute to postoperative symptoms. Preoperative HRM is not performed routinely on patients undergoing bariatric surgery but may identify patients likely to experience postoperative esophageal symptoms via delineation of structural or functional abnormalities.ObjectivesTo evaluate whether prebariatric surgery HRM could predict persistent or de novo postoperative esophageal symptoms.SettingAcademic tertiary care hospital, United States.MethodsRetrospective data were collected for 20 patients undergoing HRM and 100 controls 18 years and older from May 2012 to May 2015. Propensity score matching was performed to adjust for baseline differences between the 2 groups. Preoperative and postoperative esophageal symptoms (reflux, dysphagia, nausea/vomiting, bloating, fullness, early satiety, pain, and intolerance) were compared between HRM and control patients, and associations among HRM findings, Chicago Classification, and symptoms were analyzed. All included patients had follow-up beyond 3 months postoperatively. Data were analyzed with 2-tailed Fisher’s exact test, Wilcoxon rank-sum test, and odds ratio.ResultsCompared to controls, patients undergoing preoperative HRM had a higher rate of postoperative chronic intolerance (25% versus 8%, P = .041). This difference was not observed in propensity score matching analysis. Identification of elevated integrated relaxation pressure and esophagogastric junction outflow obstruction predicted chronic intolerance (odds ratio = 21.0; 95% confidence interval: 1.40–314; P = .027 for each).ConclusionsPreoperative HRM abnormalities were associated with postoperative symptoms in patients undergoing bariatric surgery. HRM can identify patients who are more likely to experience postoperative esophageal symptoms and may aid in discussion of suitability for surgery and selection of bariatric intervention.     

Esophageal acid-clearance physiology is altered after Nissen-Collis gastroplasty

Background

Nissen-Collis gastroplasty (NCG) is an effective treatment for short esophagus, but it sometimes is associated with abnormal postoperative esophageal acid exposure. This study was designed to test the hypothesis that NCG prevents gastric reflux and that pathologic distal esophagus acid exposure is due to prolonged acid clearance in the “neoesophagus.”

Methods

The study enrolled 11 normal healthy subjects (ten patients status post—laparoscopic Nissen fundoplication and nine patients status post-NCG). All the participants were age and gender matched, and all were studied via manometry, acid-clearance test, and 24-h pH analysis. The clearance test was performed according to an established protocol. A 15-ml acid bolus (pH 1.2) was rapidly infused (×4) using a nasogastric tube 15 cm proximal to the lower esophageal sphincter, followed by dry swallows every 30 s until the esophageal pH rose above 4.

Results

All the subjects had normal esophageal peristalsis and distal amplitudes. The acid-clearance time was significantly higher with NCG (P < 0.001 vs Nissen and normal subjects). Pathologic esophageal acid exposure occurred in one of ten Nissen patients (10 %) and in two of nine NCG patients (22 %) (nonsignificant difference [NS]). The median distal esophageal acid exposure time during the 24-h pH study was similar in the two groups (NCG, 1.2 %; Nissen, 2.5 %; NS).

Conclusions

The findings showed that NCG is an adequate antireflux procedure but that it is characterized by a delayed esophageal acid clearance.     

Endoscopic Management of Early Esophageal Neoplasia: an Emerging Standard

Introduction

Endoscopic mucosal resection (EMR) and ablation technologies have markedly changed the treatment of early esophageal neoplasia. We analyzed treatment and outcomes of patients undergoing multimodal endoscopic treatment of early esophageal neoplasia at our institution.

Methods

Records of patients undergoing endoscopic treatment for esophageal low-grade intraepithelial neoplasia (LGIN, n?=?11), high-grade intraepithelial neoplasia (HGIN, n?=?24), or T1N0M0 neoplasia (n?=?10), presenting between 2007 and 2009, were reviewed. Outcomes included eradication of neoplasia/intestinal metaplasia, development of metachronous neoplasia, and progression to surgical resection.

Results

There were 45 patients, 96% male, with a mean age 67?years. The degree of neoplasia prior to intervention was intramucosal (8) or submucosal (2) carcinoma in 10, HGIN in 24, and LGIN in 11. Patients underwent a total of 166 procedures (median 3/patient, range 1?C9). These included 120 radiofrequency ablation sessions, 38 EMRs, and 8 cryoablations. Mean follow-up was 21.3?months. Neoplasia and intestinal metaplasia were eradicated in 87.2% and 56.4% of patients, respectively, while 15.4% developed metachronous neoplasia. Three patients underwent esophagectomy. No patient developed unresectable disease or died.

Conclusion

Endoscopic treatment of early esophageal neoplasia is safe and effective in the short term. A minority of treated patients developed recurrent neoplasia, which is usually amenable to further endoscopic therapy. Complications are relatively minor and uncommon. Endoscopic therapy as the initial treatment for early esophageal neoplasia is an emerging standard of care.     

The use of esophageal transit and gastric emptying studies in the evaluation of patients undergoing laparoscopic fundoplication

Background

Preservation of esophageal and gastric function is a hallmark principle in ensuring optimal surgical outcomes after gastric fundoplication. In this study, we evaluated the impact of fundoplication on esophageal transit and gastric emptying using scintigraphy studies and related these functional findings to symptomatic outcomes.

Methods

A total of 106 consecutive patients (37 women, 69 men) with both preoperative and 6-month postoperative nuclear scintigraphy studies undergoing partial (Toupet) fundoplication at a single institution were analyzed. Primary variables included alterations in esophageal transit and gastric emptying times after fundoplication (1 = rapid; 2 = normal; 3 = mild delay; 4 = severe delay). Symptomatic variables included heartburn, regurgitation, dysphagia, pulmonary symptoms, and bloating.

Results

Mean age was 57.2 years. Symptomatic improvement was achieved in 91.5% of patients. Significant reduction of all symptoms (heartburn, regurgitation, pulmonary symptoms, and dysphagia) was noted after fundoplication, except gas bloating (4.7 vs. 20.8%). There were no significant differences in preoperative and postoperative esophageal transit (2.53 vs. 2.52) and gastric emptying (2.13 vs. 2.06) scores after fundoplication. Interestingly, 17% of esophageal transit times and 18% of gastric emptying times improved after fundoplication. However, worsening scores were seen in 16 and 12%, respectively. There was no significant postoperative dysphagia, even in patients with impaired transit times.

Conclusions

Nuclear scintigraphic assessment of esophageal transit and gastric emptying are valuable, user-friendly tools to identify and avoid functional motility problems in the setting of fundoplication. These studies seem to be a reasonable alternative to manometry in assessing esophageal function before surgery in this setting. Postoperative symptoms may be related to objective changes in esophageal transit or gastric emptying. The causes may be iatrogenic in nature or related to vagal denervation with associated changes in esophagogastric compliance. Awareness of these physiologic changes may prompt further technical precautions at the time of surgery to avoid vagal injury and also may facilitate postoperative medical management.     

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

Background

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

Methods

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

Results

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

Conclusions

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.     

Age and body mass index: significant predictive factors for successful laparoscopic antireflux surgery

Purpose

Laparoscopic antireflux surgery (LARS) is a feasible treatment for gastroesophageal reflux disease (GERD) patients, but it is unclear who will benefit from the surgery. This study investigated patients’ GERDspecific quality of life (GsQOL) and analyzed the factors leading to the performance of successful LARS.

Methods

Twenty-six (57.8%) of 45 consecutive patients who underwent LARS for GERD during the last decade were enrolled. All patients were evaluated by 24-h pH monitoring, esophageal manometry, esophagogastro-duodenoscopy and physical examinations. GsQOL was assessed by a visual analog scale, and the difference between the pre- and postoperative scores was defined as the visual analog scale improvement score (VASIS). The patients were classified into three groups based on the VASIS, and their clinical factors and surgical outcomes were compared.

Results

The high VASIS group patients (>70 VASIS; Excellent group) patients were significantly younger and obese in comparison to low the VASIS group (<30 VASIS; Poor group) consisting of older nonobese patients (P < 0.05). A multiple regression analysis revealed that age <60 years and body mass index (BMI) >25 kg/m² were significant factors that affected postoperative GsQOL. No other clinical or surgical factors had any influence on the postoperative GsQOL.

Conclusion

These results suggest that age and BMI can be predictive factors for the performance of successful LARS.     

Preoperative enteral access is not necessary prior to multimodality treatment of esophageal cancer

Background

Surgical enteral access prior to multimodality treatment for esophageal cancer is controversial as dysphagia is often used for feeding tube referral. We hypothesized that enteral access before neoadjuvant chemoradiation for esophageal cancer provides no benefit compared to that placed during definitive esophagectomy.

Short- and Long-Term Results of Laparoscopic Versus Open Anti-Reflux Surgery: a Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

There is an ongoing debate about whether laparoscopic anti-reflux surgery (LARS) or open anti-reflux surgery (OARS) is the better option for the surgical treatment of gastroesophageal reflux disease (GERD). This study was aimed to evaluate and compare the short- and long-term results of both surgical strategies by means of a systematic review and meta-analysis.

Methods

A systematic search of electronic databases (PubMed, Embase, The Cochrane Library) for studies published from 1970 to 2013 was performed. All randomized controlled trials (RCTs) that compared LARS with OARS were included. We analyzed the outcomes of each type of surgery over short- and long-term periods.

Results

Twelve studies met final inclusion criteria (total n?=?1,067). A total of 510 patients underwent OARS and 557 had LARS. The pooled analyses showed, despite of longer operation time, the hospital stay and sick leave were significantly reduced in the LARS group. Significant reductions were also observed in complication rates for the LARS group in both short (odds ratio (OR) 0.31, 95 % CI 0.17 to 0.56) and long-term periods (OR 0.24, 95 % CI 0.07 to 0.80). Although complaints of reflux symptoms were more frequent among LARS patients in the short-term follow-up, LARS achieved better control of reflux symptoms in the long-term period (P?<?0.05). Reoperation rate, patient’s satisfaction, and 24-h pH monitoring were all comparable between the two groups (all P?>?0.05).

Conclusions

LARS is an effective and safe alternative of OARS for the surgical treatment of GERD, which enables a faster convalescence, better control of long-term reflux symptoms, and with reduced risk of complications.     

The impact of laparoscopic anti-reflux surgery in patients with Barrett’s esophagus

Background

Barrett’s esophagus (BE) is a major risk factor for esophageal adenocarcinoma. It is believed that BE is caused by chronic gastro-esophageal reflux disease (GERD). Laparoscopic anti-reflux surgery (LARS) restores the competency of the cardia and may thereby change the natural course of BE. We studied the impact of LARS on the histological profile of BE and on the control of GERD.

Methods

We identified all patients with BE who underwent LARS from 1994 to 2007 and contacted them to assess post-operative GERD symptoms via questionnaire. Endoscopy findings, histology, 24 hour pH monitoring, and manometry were also collected using our prospectively maintained database. Histological regression was defined as either loss of dysplasia or disappearance of BE.

Results

Two hundred and fifteen patients met the initial inclusion criteria; in 82 of them histology from post-operative endoscopy was available for review. Endoscopy was performed a median of 8 years (range, 1–16 years) after surgery. Regression of BE occurred in 18 (22 %) patients while in 6 (7 %) BE progressed to dysplasia or cancer. Thirty-six (43 %) patients underwent pre- and post-operative manometry. The median lower esophageal sphincter pressure increased from 9 to 17 mmHg in these patients. Thirty-four (41 %) patients underwent pre- and post-operative pH studies. The median DeMeester score decreased from 54 to 9. Sixty-seven (82 %) of 82 patients completed the post-operative questionnaire; 86 % of these patients reported improvement in heartburn and regurgitation.

Conclusions

LARS was associated with both physiologic and symptomatic control of GERD in patients with BE. LARS resulted in regression of BE in 22 % of patients and progression in 7 %. Thus, continued surveillance of Barrett’s is needed after LARS.     

Can Different Subsets of Ineffective Esophageal Motility Influence the Outcome of Nissen Fundoplication?

Background

Ineffective esophageal motility (IEM) in patients with gastroesophageal reflux disease includes three different subsets that may affect symptom profiles. Our aim was to assess symptoms and functional outcome in patients with erosive esophagitis according to different subsets of IEM, before and after Nissen fundoplication (NF).

Methodology

A retrospective study with prospective follow-up of 72 patients with reflux esophagitis and IEM in whom open NF was performed. Based on principal manometric esophageal body motility disorder, patients were divided in three groups: predominantly low-amplitude (LAC, N?=?38), non-propulsive (NPC, N?=?18), and simultaneous low-amplitude esophageal contractions (SC, N?=?16). Patients underwent symptomatic questionnaire and stationary esophageal manometry before and 6 months, 1 year, and 3 years after surgery.

Results

Preoperatively, patients in NPC and SC groups had higher mean scores of dysphagia, without statistical significance as opposed to the LAC group (p?=?0.239). Postoperative dysphagia occurred in 36 patients, without statistical significance between groups regarding dysphagia grades (p?=?0.390). A longer duration of postoperative dysphagia was noted in the SC group (p?p?Conclusion Three years after NF, successful symptomatic and functional outcome was achieved in analyzed groups of patients with erosive esophagitis regardless of IEM subtype.     

Esophageal Dysmotility After Laparoscopic Gastric Band Surgery

Background

The effect of the laparoscopic adjustable gastric band (LAGB) on the esophagus has been the subject of few studies despite recognition of its clinical importance. The aim of this study was to investigate the frequency and clinical effect of esophageal dysmotility and dilatation after LAGB.

Methods

We undertook a retrospective analysis of 50 consecutive patients with no dysmotility on perioperative video contrast swallow who underwent primary LAGB operation. All patients had serial focused postoperative contrast studies for band adjustments at least 6 months post-LAGB. Clinical and radiological outcomes were assessed.

Results

Median follow-up time was 18 months (range 7–39 months), and the median number of contrast swallows per patient was 5. The mean excess weight loss (EWL) overall was 47 % (standard deviation (SD) 22.3). Radiological abnormalities were recorded in 17 patients (34 %, 95 % confidence interval (CI) 21–49 %), of whom 15 had radiological dysmotility and 7 had esophageal dilatation (five patients had both dysmotility and dilatation). Of these 17 patients, six (35 %) developed significant symptoms of dysphagia, gastroesophageal reflux disease (GERD) or regurgitation requiring fluid removal. In comparison, 12 of 33 (36 %) patients without radiological abnormalities developed symptoms requiring fluid removal (p?=?1.00). Patients with radiological abnormalities were significantly older than those without these abnormalities. Symptoms were alleviated by removing fluid in most patients.

Conclusions

The LAGB operation results in the development of radiological esophageal dysmotility in a significant proportion of patients. It is not clear if these changes are associated with an increased risk of significant symptoms. Fluid removal can reverse these abnormalities and their associated symptoms.     

Effects of Gastric Band Adjustments on Intraluminal Pressure

Background

Understanding of the effects of adjustments to laparoscopic adjustable gastric band (LAGB) volume is limited. Changes in intraluminal pressure may be important and explain patients reporting a tighter LAGB after saline is removed and an identical volume replaced.

Methods

Using high-resolution manometry, changes in the basal intraluminal pressure at the level of the LAGB in response to sequential, small alterations in LAGB volume were recorded. All fluid was removed from the LAGB and replaced, pressures and motility were reassessed.

Results

Sixteen patients (four males, age 45.4?±?13.2 years) participated. A linear increase (r ²?=?0.87?±?0.12) in intraluminal pressure was observed after a threshold volume was reached. The threshold volume varied considerably (1.0 to 5.8 ml). The gradient of the linear increase was 21.2?±?8.7 mmHg/ml. The mean basal intraluminal pressure at the level of the LAGB was initially 19.1?±?8.9 mmHg and increased to 37.0?±?20.4 mmHg (p?=?0.001) after removing and replacing the same volume of saline. There was an increase in distal esophageal peristaltic pressure (123.5?±?34.7 vs. 157.4?±?52.6 mmHg, p?=?0.003) and a decrease in the proportion of normal swallows (0.85?±?0.22 vs. 0.53?±?0.47, p?=?0.02). Nine patients also developed adverse symptoms.

Conclusions

Intraluminal pressure at the level of the LAGB is an objective measure of the restriction produced by LAGBs. The addition of fluid to the LAGB results in a linear increase in intraluminal pressure once a threshold volume is reached. The removal and replacement of the same volume of saline from the LAGB may temporarily increase intraluminal pressure.