Gastroesophageal reflux disease and severe obesity:Fundoplication or bariatric surgery?

Increases in the prevalence of obesity and gastroesophageal reflux disease (GERD) have paralleled one another over the past decade, which suggests the possibility of a linkage between these two processes. In both instances, surgical therapy is recognized as the most effective treatment for severe, refractory disease. Current surgical therapies for severe obesity include (in descending frequency) Roux-en-Y gastric bypass, adjustable gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, while fundoplication remains the mainstay for the treatment of severe GERD. In several large series, however, the outcomes and durability of fundoplication in the setting of severe obesity are not as good as those in patients who are not severely obese. As such, bariatric surgery has been suggested as a potential alternative treatment for these patients. This article reviews current concepts in the putative pathophysiological mechanisms by which obesity contributes to gastroesophageal reflux and their implications with regards to surgical therapy for GERD in the setting of severe obesity.

Nissen fundoplication vs proton pump inhibitors for laryngopharyngeal reflux based on p H-monitoring and symptom-scale

AIM To compare the outcomes between laparoscopic Nissen fundoplication(LNF)and proton pump inhibitors(PPIs)therapy in patients with laryngopharyngeal reflux(LPR)and typeⅠhiatal hernia diagnosed by oropharyngeal p H-monitoring and symptom-scale assessment.METHODS From February 2014 to January 2015,70 patients who were diagnosed with LPR and type I hiatal hernia and referred for symptomatic assessment,oropharyngeal p H-monitoring,manometry,and gastrointestinal endoscopy were enrolled in this study.All of the patients met the inclusion criteria.All of the patients underwent LNF or PPIs administration,and completed a2-year follow-up.Patients’baseline characteristics and primary outcome measures,including comprehensive and single symptoms of LPR,PPIs independence,and satisfaction,and postoperative complications were assessed.The outcomes of LNF and PPIs therapy were analyzed and compared. RESULTS There were 31 patients in the LNF group and 39patients in the PPI group.Fifty-three patients(25 in the LNF group and 28 in the PPI group)completed reviews and follow-up.Oropharyngeal p H-monitoring parameters were all abnormal with high acid exposure,a large amount of reflux,and a high Ryan score,associated reflux symptom index(RSI)score.There was a significant improvement in the RSI and LPR symptom scores after the 2-year follow-up in both groups(P<0.05),as well as typical symptoms of gastroesophageal reflux disease.Improvement in the RSI(P<0.005)and symptom scores of cough(P=0.032),mucus(P=0.011),and throat clearing(P=0.022)was significantly superior in the LNF group to that in the PPI group.After LNF and PPIs therapy,13 and 53 patients achieved independence from PPIs therapy(LNF:44.0%vs PPI:7.14%,P<0.001)during follow-up,respectively.Patients in the LNF group were more satisfied with their quality of life than those in the PPI group(LNF:62.49±28.68 vs PPI:44.36±32.77,P=0.004).Body mass index was significantly lower in the LNF group than in the PPI group(LNF:22.2±3.1kg/m^2 vs PPI:25.1±2.9 kg/m^2,P=0.001).CONCLUSION Diagnosis of LPR should be assessed with oropharyngeal p H-monitoring,manometry,and the symptom-scale.LNF achieves better improvement than PPIs for LPR with type I hiatal hernia.

Systematic review:Laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors

AIM:To assess laparoscopic fundoplication(LF)in partial responders to proton pump inhibitors(PPIs)for gastroesophageal reflux disease(GERD).METHODS:We systematically searched PubMed and Embase(1966-Dec 2011)for articles reporting data on LF efficacy in partial responders.Due to a lack of randomized controlled trials,observational studies were included.Of 558 articles screened,17 were eligible for inclusion.Prevalence data for individual symptoms were collated across studies according to mutually compatible time points(before and/or after LF).Where suitable,prevalence data were presented as percentage of patients reporting symptoms of any frequency or severity.RESULTS:Due to a lack of standardized reporting of symptoms,the proportion of patients experiencing symptoms was recorded across studies where possible.After LF,the proportion of partial responders with heartburn was reduced from 93.1%(5 studies)to 3.8%(5 studies),with similar results observed for regurgitation[from 78.4%(4 studies)to 1.9%(4 studies)].However,10 years after LF,35.8%(2 studies)of partial responders reported heartburn and 29.1%(1 study)reported regurgitation.The proportion using acidsuppressive medication also increased,from 8.8%(4studies)in the year after LF to 18.2%(2 studies)at 10years.In the only study comparing partial responders to PPI therapy with complete responders,higher symptom scores and more frequent acid-suppressive medication use were seen in partial responders after LF.CONCLUSION:GERD symptoms improve after LF,but subsequently recur,and acid-suppressive medication use increases.LF may be less effective in partial responders than in complete responders.

Quality of life following laparoscopic Nissen fundoplication: Assessing short-term and long-term outcomes

AIM: To investigate the quality of life following lapa-roscopic Nissen fundoplication by assessing short-term and long-term outcomes. METHODS: From 1992 to 2005, 249 patients under-went laparoscopic Nissen fundoplication. Short-term outcome data including symptom response, side effects of surgery, endoscopy, and patient's perception of over-all success were collected prospectively. Long-term out-comes were investigated retrospectively in patients witha median follow-up of 10 years by assessment of reflux symptoms, side effects of surgery, durability of antire-flux surgery, need for additional treatment, patient's perception of success, and quality of life. Antireflux sur-gery was considered a failure based on the following criteria: moderate to severe heartburn or regurgitation; moderate to severe dysphagia reported in combination with heartburn or regurgitation; regular proton pump inhibitor medication use; endoscopic evidence of erosive esophagitis Savary-Miller grade 1-4; pathological 24-h pH monitoring; or necessity to undergo an additional surgery. The main outcome measures were short-and long-term cure rates and quality of life, with patient sat-isfaction as a secondary outcome measure. RESULTS: Conversion from laparoscopy to open sur-gery was necessary in 2.4% of patients. Mortality was zero and the 30-d morbidity was 7.6% (95%CI: 4.7%-11.7%). The median postoperative hospital stay was 2 d [interquartile range (IQR) 2-3 d]. Two hundred and forty-seven patients were interviewed for short-term analysis following endoscopy. Gastro-esophageal reflux disease was cured in 98.4% (95%CI: 95.9%-99.6%) of patients three months after surgery. New-onset dysphagia was encountered postoperatively in 13 patients (6.7%); 95% reported that the outcome was better after antireflux surgery than with preopera-tive medical treatment. One hundred and thirty-nine patients with a median follow-up of 10.2 years (IQR 7.2-11.6 years) were available for a long-term evalu-ation. Cumulative long-term cure rates were 87.7% (81.0%-92.2%) at 5 years and 72.9% (64.0%-79.9%) at 10 years. Gastrointestinal symptom rating scores and RAND-36 quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. Of the patients available for long-term follow-up, 83% rated their operation a success. CONCLUSION: For the long-term, our results indicate decreasing effectiveness of laparoscopic antirefluxsurgery, although most of the patients seem to have an overall quality of life similar to that of the general population.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease. METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using metaanalysis. RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients' satisfaction, perioperative complications, postoperative heartburn, refluxrecurrence and reoperation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gasbloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Transoral incisionless fundoplication for gastro-esophageal reflux disease: Techniques and outcomes

Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric content.GERD can be currently treated by medical therapy,surgical or endoscopic transoral intervention.Medical therapy is the most common approach,though concerns have been increasingly raised in recent years about the potential side effects of continuous longterm medication,drug intolerance or unresponsiveness,and the need for high dosages for long periods to treat symptoms or prevent recurrences.Surgery too may in some cases have consequences such as longlasting dysphagia,flatulence,inability to belch or vomit,diarrhea,or functional dyspepsia related to delayed gastric emptying.In the last few years,transoral incisionless fundoplication(TIF)has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy.This review describes the steps of the TIF technique,using the Esophy X&#174;device and the MUSETM system.Complications and their management are described in detail,and the recent literature regarding the outcomes is reviewed.TIF reconfigures the tissue to obtain a full-thickness gastroesophageal valve from inside the stomach,by serosato-serosa plications which include the muscle layers.To date the procedure has achieved lasting improvement of GERD symptoms(up to six years),cessation or reduction of proton pump inhibitor medication in about 75%of patients,and improvement of functional findings,measured by either p H or impedance monitoring.

Persistent severe hypomagnesemia caused by proton pump inhibitor resolved after laparoscopic fundoplication

Magnesium deficiency can cause a variety of symptoms, including potentially life-threatening complications such as seizures, cardiac arrhythmias and secondary electrolyte disturbances. Hypomagnesemia can be a serious adverse effect to proton pump inhibitor(PPI) therapy, which is worrying due to the widespread use of PPIs. Current evidence suggest that the mechanism of PPI induced hypomagnesemia is impaired intestinal magnesium absorption. In this report, we present the case of a long-term PPI user with persistent hypomagnesemia with severe symptoms at presentation. He was unable to stop PPI treatment because of severe reflux symptoms, and was dependent on weekly intravenous magnesium infusions, until his magnesium levels finally normalized without the need for supplementation after a successful laparoscopic fundoplication.

Is Dor fundoplication optimum after laparoscopic Heller myotomy for achalasia? A meta-analysis

AIM:To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy(LHM)for achalasia.METHODS:Electronic database PubMed,Ovid(Evidence-Based Medicine Reviews,EmBase and Ovid MEDLINE)and Cochrane Library were searched between January 1995 and September 2012.Bibliographic citation management software(EndNote X3)was used for extracted literature management.Quality assessment of random controlled studies(RCTs)and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0and a modification of the Newcastle-Ottawa Scale,respectively.The data were analyzed using Review Manager(Version 5.1),and sensitivity analysis was performed by sequentially omitting each study.RESULTS:Finally,6 studies,including a total of 523achalasia patients,compared Dor fundoplication with other types of fundoplication after LHM(Dor-other group),and 8 studies,including a total of 528 achalasia patients,compared Dor fundoplication with no fundoplication after LHM(Dor-no group).Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group(OR=7.16,95%CI:1.25-40.93,P=0.03,and OR=3.79,95%CI:1.23-11.72,P=0.02,respectively).In addition,there were no significant differences between Dor fundoplication and no fundoplication in all subjects.Other outcomes,including complications,dysphagia,postoperative physiologic testing,and operation-related data displayed no significant differences in the two comparison groups.CONCLUSION:Dor fundoplication is not the optimum procedure after LHM for achalasia.We suggest more attention should be paid on quality of life among different fundoplications.

Esophagogastric junction outflow obstruction successfully treated with laparoscopic Heller myotomy and Dor fundoplication: First case report in the literature

BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication(Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication.CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole,without resolution of symptoms. An upper gastrointestinal series(barium swallow) revealed a "bird's beak" sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution.Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation.CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment.

Single incision laparoscopic fundoplication: A systematic review of the literature

BACKGROUND Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision(SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.AIM To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.METHODS The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases(Medline, Scopus and Web of Science) was performed.RESULTS Literature search resulted in the identification of 19 studies. Overall, 266, 137 and110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.CONCLUSIONDue to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.

Wrap choice during fundoplication

Gastro-oesphageal reflux disease is an increasing health burden.The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication.The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications.These complications include“gas bloat”and dysphagia and can occur relatively frequently.Various modifications have been described to the original operation and some of these have been described.In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use.This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique.The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms.The advantages and disadvantages of an anterior wrap are discussed.The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.

Robotic Foregut Surgery: One Surgeon’s Experience with Nissen Fundoplication, Esophagomyotomy, and Hiatal Hernia Repair

Purpose: The purpose of the study was to review a single surgeon, seven-year experience, using the Da Vinci Telerobotic system performing 124 foregut operations. Methods: Data review from 2002-2009 including 71 Nissen fundoplications, 26 esophagomyotomies, and 27 hiatal hernia repairs was performed. Parameters collected included gender, age, body mass index (BMI), estimated blood loss (EBL), port set up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions, and resident involvement. Statistical analysis was con-ducted. Results: 124 foregut operations: 45 males, 79 females, mean age of 54.8 ± 16.7 (18 - 85) years, mean TCT 174.4 ± 45.0 (102 - 321) min. Nissen fundoplication: mean BMI of 30.8 ± 3.9 (22.4 - 46.8) kg/m2, EBL 30.2 ± 21.8 (5 - 100) ml, PST 32.3 ± 9 (14 - 63) min, ROT 111.4 ± 37.3 (51 - 229) min, TCT 175.0 ± 46.4 (102 - 321) min, median LOS 1 (0 - 9) day, complication rate 7.0% (5/71), conversion rate 5.6%, resident involvement 69.0% (49/71). Esophagomyotomy: mean BMI of 26.5 ± 6.1 (15.4 - 36.6) kg/m2, EBL 39.1 ± 41.7 (10 - 200) ml, PST 28.0 ± 8.6 (16 - 47) min, ROT 122.9 ± 45 (31 - 217) min, and TCT 178.0 ± 40.5 (105 - 262) min, median LOS 1 (0 - 6) day, complication rate 15.4% (4/26), conversion rate 0%, resident involvement 69.2% (18/26). Hiatal hernia repair: mean BMI of 28.4 ± 4.2 (21.9 - 36.8) kg/m2, EBL 38.4 ± 32.7 (10 - 150) ml, PST 28.8 ± 8.0 (17 - 52) min, ROT 109.0 ± 44.5 (49 - 250) min, and TCT 169.2 ± 46.5 (102 - 299) min, median LOS 1 (1 - 14) day, complication rate 11.1% (3/27), conversion rate 3.7%, resident involvement 66.7% (18/27). Conclusion: Robotic-assisted foregut surgery is safe and effective. This series compares favorably with other robotic studies in length of hospital stay, total case time, and complication and conver-sion rates. Foregut surgery is an excellent robotic training ground for residents.

Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication

AIM:To evaluate the feasibility and outcomes of laparoscopic Nissen fundoplication after failed transoral incisionless fundoplication(TIF).METHODS:TIF is a new endoscopic approach for treating gastroesophageal reflux disease(GERD).In cases of TIF failure,subsequent laparoscopic fundoplication may be required.All patients from 2010 to 2013 who had persistence and objective evidence of recurrent GERD after TIF underwent laparoscopic Nissen fundoplication.Primary outcome measures included operative time,blood loss,length of hospital stay and complications encountered.RESULTS:A total of 5 patients underwent revisional laparoscopic Nissen fundoplication(LNF)or gastrojejunostomy for recurrent GERD at a median interval of 24mo(range:16-34 mo)after TIF.Patients had recurrent reflux symptoms at an average of 1 mo following TIF(range:1-9 mo).Average operative time for revisionalsurgical intervention was 127 min(range:65-240 min)and all surgeries were performed with a minimal blood loss(<50 m L).There were no cases of gastric or esophageal perforation.Three patients had additional finding of a significant hiatal hernia that was fixed simultaneously.Median length of hospitalization was 2 d(range:1-3 d).All patients had resolution of symptoms at the last follow up.CONCLUSION:LNF is a feasible and safe option in a patient who has persistent GERD after a TIF.Previous TIF did not result in additional operative morbidity.

Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial

BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter(LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy(POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy,has emerged as a promising minimally invasive technique for the management of this condition.AIM To compare POEM and laparoscopic myotomy and partial fundoplication(LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria(dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis(as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min(on a barium esophagogram), pressure at the LES, the occurrence of adverse events(AEs), length of stay(LOS), and quality of life(QoL).RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up(P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group(P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group(185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min,respectively;P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia,shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

Suspected cerebral arterial gas embolism during a laparoscopic Nissen fundoplication

We present the first case report known to us of a suspected cerebral arterial gas embolism(CAGE) leading to transient left-sided hemiparesis after a laparoscopic Nissen fundoplication. During the operation there was no evidence of hemodynamic compromise and the endtidal carbon dioxide level and oxygen saturation had been within normal limits. Radiological studies and transesophageal echocardiography showed no abnormalities. We conclude that CAGE can occur during uncomplicated laparoscopic surgery even in the absence of demonstrable intracardiac shunts.

Belsey Mark IV Repair for Recurrent Hiatal Hernia and Failed Fundoplication: An Analysis of Outcomes in 206 Patients

Background: With the increasing number of laparoscopic fundoplications, many more patients with a failed primary antireflux operation are being referred for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery using the Belsey Mark IV (BMIV) Repair. Methods: A retrospective analysis of the patients who underwent BMIV repair following a failed fundoplication was performed. The primary endpoint was failure of the redo procedure and recurrent hiatal hernia. Secondary endpoints were assessment of the functional results of the redo fundoplication and quality of life with a Dysphagia Score, and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL) questionnaire. Results: 206 patients underwent surgery for failed primary fundoplication. Most patients had one prior antireflux surgery 148/206 (71.8%). The most common primary failed fundoplication was the Nissen procedure (189/206, 91.7%). The median time from the prior operation to the redo operation was 34 months. Median follow-up was 25.6 months. The Dysphagia score decreased from 3.6 ± 0.5 preoperatively to 1.0 ± 0.4 postoperatively (p < 0.0001). At the time of follow-up, the Median GERD-HRQL score was 4 (range 0 - 9), classified as excellent, compared to a preoperative Median GERD-HRQL score of 43 (range 41 - 50) which was classified as poor. (p < 0.0001). There was no recurrence of the hiatal hernia. Conclusion: Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of a redo antireflux procedure. The BMIV repair as the choice of reopertaive procedure results in excellent symptom relief, significant improvement in quality of life, and is associated with excellent medium-term durability in terms of recurrence of the hiatal hernia.

Laparoscopic fundoplication in the treatment of gastroesophageal reflux disease:analysis of 372 cases

Objective To investigate the feasibility and clinical value of laparoscopic surgery in treating patients with gastroesophageal reflux disease. Methods From September 2001 to August 2009,372 patients with gastroesophageal reflux disease undertwent laparoscopic fundoplication,including 146 cases of Nissen fundoplication,

Gastroesophageal reflux after per-oral endoscopic myotomy:Management literature

In this editorial,we respond to a review article by Nabi et al,in which the authors discussed gastroesophageal reflux(GER)following peroral endoscopic myotomy(POEM).POEM is presently the primary therapeutic option for achalasia,which is both safe and effective.A few adverse effects were documented after POEM,including GER.The diagnostic criteria were not clear enough because approximately 60%of patients have a long acid exposure time,while only 10%experience reflux symptoms.Multiple predictors of high disease incidence have been identified,including old age,female sex,obesity,and a baseline lower esophageal sphincter pressure of less than 45 mmHg.Some technical steps during the procedure,such as a lengthy or full-thickness myotomy,may further enhance the risk.Proton pump inhibitors are currently the first line of treatment.Emerging voices are increasingly advocating for the routine combining of POEM with an endoscopic fundoplication method,such as peroral endoscopic fundoplication or transoral incisionless fundoplication.However,more research is necessary to determine the safety and effectiveness of these procedures in the long term for patients who have undergone them.

Navigating reflux disease after achalasia treatments:Balancing risks and benefits

The peroral endoscopic myotomy(POEM)procedure has revolutionized the management of achalasia in many centres around the world as it offers patients a minimally invasive endoscopic solution to their dysphagia caused by achalasia.Alongside its success in alleviating dysphagia,concerns regarding postoperative gastroesophageal reflux disease have emerged as a pertinent issue which are not fully resolved.In this study,Nabi et al have comprehensively reviewed the topic of the prediction,prevention and management of gastroesophageal reflux after POEM.POEM is a purely endoscopic procedure which is usually performed without any anti-reflux procedure.Certain patients may be better served by a laparoscopic Heller’s myotomy and fundoplication and it is important that gastroenterologists and surgeons provide comprehensive risks and benefits of each achalasia treatment option so that patients can decide what treatment is best for them.This article by Nabi et al provides a comprehensive review of the current status of this issue to allow these discussions to occur.

Outcome of Stretta radiofrequency and fundoplication for GERD- related severe asthmatic symptoms

This study aimed to investigate the outcome of treatment with Stretta radiofrequency （SRF） or laparoscopic Nissen fundoplication （LNF）. A total of 137 gastroesophageal reflux disease （GERD） patients with severe asthmatic symptoms who responded inadequately to medical treatment for asthma were investigated. The patients were followed up 1 year and 5 years after SRF （n = 82） or LNF （n = 55） treatment. A questionnaire covering 29 related symptoms and medication use was employed. Digestive, respiratory, and ear-nose-throat （ENT） symptom scores significantly decreased after antireflux treatment. Symptom scores respectively changed from 17.2 ± 10.1, 31.9 ± 6.6, and 21.1± 11.8 to 5.0 ±6.2, 11.5 ±10.2, and 6.3± 6.8 at 1 year and to 5.6 ± 6.5, 13.1± 10.1, and 7.8 ± 7.2 at 5 years （P 〈 0.001）. The outcome of LNF was significantly better than that of SRF in terms of digestive （P 〈 0.001, P = 0.001）, respiratory （P = 0.006, P = 0.001）, and ENT symptoms （P = 0.006, P = 0.003） at both 1 year and 5 years. SRF and LNF were both effective against the digestive symptoms of GERD as well as GERD-related severe asthmatic and ENT symptoms, with better outcomes exhibited by the LNF group. Severe asthmatic symptoms and GERD were closely associated, and this finding warrants further study.