Increased Esophageal Exposure to Weakly Acidic Reflux 5 Years After Laparoscopic Roux-en-Y Gastric Bypass.

OBJECTIVE: To evaluate the long-term effects of laparoscopic Roux-en-Y Gastric Bypass (LRYGB) on gastroesophageal function. BACKGROUND: LRYGB is considered the weight loss procedure of choice for obese patients with gastroesophageal reflux disease (GERD). However, long-term instrumental evaluations of GERD after LRYGB are not available. METHODS: Morbidly obese patients selected for LRYGB were included in a prospective study. We performed clinical evaluation with GERD-HRQoL questionnaire, upper endoscopy, esophageal manometry, and 24-hour impedance pH (24-hour MII-pH) monitoring preoperatively and at 12 and 60 months after surgery. This trial is registered with ClinicalTrials.gov (no. NCT02618044). RESULTS: From May 2006 to May 2009, 86 patients entered the study and 72 (84%) completed the 5-year protocol. At preoperative 24-hour MII-pH monitoring, 54 patients (group A) had normal values, whereas 32 (group B) had diagnosis of GERD: 23 had acidic reflux, whereas 9 had combined reflux [acidic + weakly acidic reflux (WAR)]. The groups were similar in preoperative age, body mass index, and comorbidities. At 12 and 60 months, significant improvement in questionnaire scores was observed in group B patients. No manometric changes occurred in both groups; 24-hour MII-pH monitoring showed a significant reduction in acid exposure, but an increase of WAR in both group A (from 0% to 52% to 74%) and group B (from 35% to 42% to 77%). At long-term follow-up, esophagitis was found in 14 group A (30%) and in 18 group B patients (69%) (P < 0.001). CONCLUSIONS: LRYGB allows to obtain an effective GERD symptom amelioration and a reduction in acid exposure. However, 3 out 4 patients present with distal esophagus exposure to WAR.

Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation.

OBJECTIVE: To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) in morbidly obese patients. BACKGROUND: Symptomatic GERD is considered by many a contraindication to LSG. However, studies evaluating the relationship between LSG and GERD by 24-hour pH monitoring are lacking. METHODS: Consecutive morbidly obese patients selected for LSG were included in a prospective clinical study. Gastroesophageal function was evaluated using a clinical validated questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring before and 24 months after LSG. This trial is registered with ClinicalTrials.gov (no. NCT02012894). RESULTS: From June 2009 to September 2011, a total of 71 patients were enrolled into the study; 65 (91.5%) completed the 2-year protocol. On the basis of preoperative 24-hour pH monitoring, patients were divided into group A (pathologic, n=28) and group B (normal, n=37). Symptoms improved in group A, with the Gastroesophageal Reflux Disease Symptom Assessment Scale score decreasing from 53.1±10.5 to 13.1±3.5 (P<0.001). The DeMeester score and total acid exposure (% pH<4) decreased in group A patients (DeMeester score from 39.5±16.5 to 10.6±5.8, P<0.001; % pH<4 from 10.2±3.7 to 4.2±2.6, P<0.001). Real "de novo" GERD occurred in 5.4% group B patients. No significant changes in lower esophageal sphincter pressure and esophageal peristalsis amplitude were found in both groups. CONCLUSIONS: LSG improves symptoms and controls reflux in most morbidly obese patients with preoperative GERD. In obese patients without preoperative evidence of GERD, the occurrence of "de novo" reflux is uncommon. Therefore, LSG should be considered an effective option for the surgical treatment of obese patients with GERD.

Robot-assisted Heller myotomy for achalasia: technique and results.

Since its first description in 1991, laparoscopic Heller myotomy has been associated with better short-term outcomes and shorter recovery time, compared to open operation and it is now generally accepted as the procedure of choice for achalasia. Despite the well-known short-term benefits of laparoscopy, esophageal perforation still occurs. Robotic technology has recently been introduced into laparoscopic clinical practice with the aim of improving surgical performance and excellent results have been described with robotically assisted Heller myotomy in patients with achalasia. The 3-D visualization, the very steady operative view and, above all, the articulated arms of the da Vinci Robotic Surgical System allow the surgeon to visualize and divide each individual muscular fiber, easily identifying the submucosal plane at the GE junction. However, no high-quality studies are available in literature. Moreover, from an economic point of view, the use of the robotic technology may increase both the costs and the volume of surgeries performed.

Gastric emptying as a prognostic factor for long-term results of total laparoscopic fundoplication for weakly acidic or mixed reflux.

OBJECTIVES: To evaluate the long-term effect of laparoscopic total fundoplication (LTF) on symptoms and reflux control in patients with combined (acidic and weakly acidic) (CR) or weakly acidic reflux (WAR), according to the gastric emptying (GE) rate. BACKGROUND: After LTF, 12% to 15% of patients experience persistent reflux symptoms and 20% and 25% develop gas-related symptoms. Both WAR and inability to belch have been suggestive of these symptoms. METHODS: Consecutive patients with CR and WAR selected for LTF were included in a prospective clinical study. Gastroesophageal function was assessed by clinical validated questionnaires, upper endoscopy, esophageal manometry, and 24-hour impedance-pH monitoring before and 12 and 60 months after LTF. Gastric scintigraphy was preoperatively performed in all patients to evaluate GE. This trial is registered with ClinicalTrials.gov (no. NCT01741441). RESULTS: Between June 2002 and June 2007, a total of 188 patients with CR and WAR underwent LTF; 172 (91.5%) completed the 5-year protocol. Among them, 42 (24.4%) had preoperative mild/moderate delayed GE (DGE). Quality of life at 12 and 60 months improved in patients with normal GE (Gastroesophageal Reflux Disease Health-Related Quality of Life score 18.2/2.5, P < 0.001; Health-Related Quality of Life score from 52.1 to 68.3, P < 0.001) but not in DGE patients. Manometric values of "gastroesophageal junction" significantly increased at 12 and 60 months in all patients with normal GE, whereas the values returned to the baseline at 60 months in 66.7% of DGE patients. Acidic and liquid reflux episodes significantly reduced in both groups, whereas a significant reduction of WAR and mixed (gas + liquid) reflux episodes occurred only in patients with normal GE (P < 0.001). CONCLUSIONS: DGE affects long-term results of LTF in CR and WAR patients.

Bariatric surgery improves urinary incontinence but not anorectal function in obese women.

BACKGROUND: While the association between obesity and urinary incontinence (UI) in women has been clearly documented, the relationship with anal incontinence (AI) is less well defined; moreover, while bariatric surgery has been shown to improve UI, its effect on AI is still unclear. METHODS: A total of 32 obese women were studied by means of PFDI-20 and PFIQ-7 questionnaires and anorectal manometry before and after bariatric surgery and compared with 71 non-obese women. RESULTS: Obese women showed worse overall questionnaire results (OR 5.18 for PFDI-20 and 2.66 for PFIQ-7). Whereas obese women showed worse results for urinary sub-items and a higher urge UI incidence (43.8 vs 18.3 %, p = 0.013), they did not show worsening in colorecto-anal symptoms. Post-operatively, median PFDI-20 total score did not change (24.2 vs 26.6, p = ns), while there was an improvement in urinary score (14.6 vs 8.3, p < 0.001); median PFIQ-7 improved (4.8 vs 0.0, p = 0.044), but while the urinary score improved (2.4 vs 0.0, p = 0.033), the colorecto-anal score did not change significantly. Although after surgery urge UI decreased from 43.8 to 15.6 % (p = 0.029), the incidence of any AI increased from 28.1 to 40.6 % (p = ns) and flatus incontinence increased from 18.8 to 37.5 % (p = ns). Anorectal manometry did not show significant changes after surgery. CONCLUSIONS: Obese women had worse questionnaire results, but while showing a higher incidence of UI, they did not experience anorectal function worsening. After bariatric surgery, there was a slight improvement in PFD symptoms related to UI, but anorectal function did not change significantly and flatus incontinence increased.

Gastroesophageal reflux disease and esophageal motility in morbidly obese patients submitted to laparoscopic adjustable silicone gastric banding or laparoscopic vertical banded gastroplasty.

BACKGROUND: Laparoscopic adjustable silicone gastric banding (LASGB) and laparoscopic vertical banded gastroplasty (LVBG) are the most frequently performed restrictive operations for morbid obesity. The question of whether bariatric restrictive procedures increase or reduce gastroesophageal reflux disease (GERD) remains open. This study aimed to compare the long-term results of LASGB with those of LVBG in terms of postoperative GERD and esophageal motility function. METHODS: From February 1999 to December 2000, 175 patients underwent bariatric surgery. After 75 of these patients were excluded from the study, the remaining 100 patients were randomly assigned to one of two treatment groups: LASGB or LVBG. The end points of the study were evaluation of clinical and instrumental GERD and esophageal function. The follow-up protocol included clinical assessment using the Gastroesophageal Reflux Health-Related Quality-of-Life (GERD-HRQOL) scale at 3, 12, and 96 months. Esophageal manometry, 24-h pH monitoring, and endoscopy were performed at 12 and 96 months. RESULTS: At 12 months, GERD had developed in 13 (26%) LASGB and 11 (21.6%) LVBG patients. In the majority of cases, GERD resulted from pouch dilation or poor compliance and required either reoperation (ten after LASGB and three after LVBG) or endoscopic dilation of the neopylorus (four after LVBG). In all, 71 patients completed the 96-month follow-up protocol. The findings showed that three (11.5%) of 26 LASGB patients and four (9%) of 45 LVBG patients were receiving proton pump inhibitor (PPI) therapy for GERD. Postoperative lower esophageal sphincter (LES) pressure and esophageal motility did not differ from preoperative data except for the presence of aperistaltic waves in one LASGB and two LVBG symptomatic GERD patients. CONCLUSIONS: No significant association between gastric restrictive procedures and GERD or esophageal function was found during long-term follow-up assessment. The increased occurrence of GERD in the early follow-up period often is due to a technical defect or poor patient compliance.

Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results.

OBJECTIVES: To compare in a prospective, randomized trial the long-term results of laparoscopic Heller myotomy plus Dor fundoplication versus laparoscopic Heller myotomy plus floppy-Nissen for achalasia. SUMMARY BACKGROUND DATA: Anterior fundoplication is usually performed after Heller myotomy to control GER; however, the incidence of postoperative GER ranges between 10% and 30%. Total fundoplication may aid in reducing GER rates. METHODS: From December 1993 to September 2002, 153 patients with achalasia underwent Heller laparoscopic myotomy plus antireflux fundoplication. Of these, 9 were excluded from the study. The remaining 144 patients were randomly assigned to 2 treatment groups: Heller laparoscopic myotomy plus anterior fundoplication (Dor procedure) or Heller laparoscopic myotomy plus total fundoplication (floppy-Nissen procedure). The primary end point was incidence of clinical and instrumental GER after a minimum of 60 months follow-up. The secondary end point was recurrence of dysphagia. Follow-up clinical assessments were performed at 1, 3, 12, and 60 months using a modified DeMeester Symptom Scoring System (MDSS). Esophageal manometry and 24-hour pH monitoring were performed at 3, 12, and 60 months postoperative. RESULTS: Of the 144 patients originally included in the study, 138 were available for long-term analysis: 71 (51%) underwent antireflux fundoplication plus a Dor procedure (H + D group) and 67 (49%) antireflux fundoplication plus a Nissen procedure (H + N group). No mortality was observed. The mean follow-up period was 125 months. No statistically significant differences in clinical (5.6% vs. 0%) or instrumental GER (2.8% vs. 0%) were found between the 2 groups; however, a statistically significant difference in dysphagia rates was noted (2.8% vs. 15%; P < 0.001). CONCLUSIONS: Although both techniques achieved long-term GER control, the recurrence rate of dysphagia was significantly higher among the patients who underwent Nissen fundoplication. This evidence supports the use of Dor fundoplication as the preferred method to re-establish GER control in patients undergoing laparoscopic Heller myotomy.

[Robot-assisted laparoscopic surgery. Preliminary results at our Center]. / Chirurgia laparoscopica robot-assistita. Risultati preliminari del nostro Centro.

The aim of our study was to evaluate the advantages and disadvantages of robot-assisted laparoscopic surgery, in terms of operative times, complications and length of hospital stay, using the Da Vinci Robotic Surgical System (Intuitive Surgical, Inc.). Twenty-five patients underwent robotic procedures. The indications were gastro-oesophageal reflux disease in 13 cases, achalasia in 2, cholelithiasis in 2, adrenal adenoma in Cushing syndrome in 6, pheochromocytoma in 2, and incidentaloma in 1. Robotic surgery was compared with the traditional laparoscopic approach. From January to September 2002 13 Nissen-Rossetti fundoplications, 2 Heller myotomies with Dor fundoplication, 2 cholecystectomies and 9 adrenalectomies (6 left adrenalectomies, 3 right adrenalectomies) were performed. There were no significant differences in age, preoperative body mass index (mean 28; range: 18-32) or sex between patients treated by robotic surgery and those treated by traditional laparoscopy. Operative times were significantly longer in the robotic surgery group (97.1 minutes, range: 77-126 minutes, versus 82.5 minutes, range: 65-100 minutes, for Nissen-Rossetti fundoplication; 132.8 minutes, range 104-181 minutes, versus 82.1 minutes, range 55-120 minutes, for adrenalectomy). There were no intraoperative complications. Conversion to traditional laparoscopy was necessary owing to technical difficulties in 4/9 adrenalectomies (44.4%; 3 left, 1 right). There was no significant difference in length of hospital stay (3.2 days, range 2-7 days, for Nissen-Rossetti fundoplication; 5.7 days, range 4-9 days, for adrenalectomy). Our study confirms the safety and feasibility of robot-assisted laparoscopic surgery. However, operative times were longer and costs higher, with no difference in outcomes. Given the current level of technology and experience, robotic surgery would not appear to afford any advantage over standard laparoscopic approaches.

Improving the analysis of esophageal acid exposure by a new parameter: area under H+.

OBJECTIVES: We aimed to compare the data provided by 24-h continuous esophageal pH monitoring in a group of patients with gastroesophageal reflux disease (GERD) to those from a group of healthy volunteers using both conventional parameters and calculated area under the curve of hydrogen ion activity (AUH+), a new value that describes the true acid exposure, through both duration and depth of acidity changes. METHODS: Thirty healthy controls and 60 patients with GERD (30 symptomatic patients without endoscopic esophagitis or nonerosive GERD and 30 symptomatic patients with Savary I-IV endoscopic esophagitis or erosive GERD) were enrolled in a study based on 24-h pH monitoring to compare reference values by means of receiver operating characteristic (ROC) discriminant analysis. RESULTS: The best ROC cutoff value for nonerosive GERD patients was AUH+ = 103.7 (mmol/L) x min with sensitivity of 76.7% and specificity of 93.3%. The best ROC cutoff value for erosive GERD patients was AUH+ = 114.1 (mmol/L) x min with sensitivity of 100% and specificity of 96.7%. These cutoff values increase the sensitivity by 16.7% for nonerosive GERD patients and 10% for erosive GERD patients when compared to a common parameter such as the percentage of total time pH is <4 with a limit of 4.2%. CONCLUSIONS: AUH+ is a valid quantitative parameter to measure 24-h esophageal acid exposure. It may be a reliable and significant clinical aid because it is a more sensitive test in discriminating negative or positive adult patients with or without esophagitis who are submitted to 24-h esophageal pH monitoring.