Building a Comprehensive Rural Anti-Reflux Center.

BACKGROUND: Gastroesophageal disease (GERD) is a highly prevalent gastrointestinal disease. In rural areas, general surgeons perform esophagogastroduodenoscopy (EGD) despite its low diagnostic yield. When EGD findings are equivocal, GERD patients are usually referred to tertiary hospitals for further workup. We envisaged establishing a comprehensive anti-reflux program with diagnostic and therapeutic capabilities in a rural setting. STUDY DESIGN: This is an IRB approved retrospective chart review of patients who presented with GERD symptoms to a rural anti-reflux clinic between August 2015 and February 2021. Standardized workup included upper gastrointestinal study and EGD with concomitant wireless pH placement. High resolution impedance manometry and gastric emptying scans were selectively utilized initially, then were performed routinely. We used endoFLIP impedance planimetry system starting in February 2019. RESULTS: A total of 830 patients were evaluated. There were 537 (64.6%) females and 293 (35.4%) males. The average age was 57.7 ± 15.2 years. The average BMI was 30.8 ± 6.7 kg/m2. Approximately one-third of these patients were referred by the primary care provider (PCP) within our health system and a comparable percentage from external PCPs. Self referral was noted in 15.4% and 19.2% were referred by different specialties such as pulmonary (10.7%), surgical for large hiatal hernia (5.8%), inpatient and emergency room (2%), and gastroenterology (0.7%). CONCLUSION: Rural surgeons with appropriate endoscopic and laparoscopic training can establish a comprehensive anti-reflux program with diagnostic and therapeutic capabilities. It meets the high community need and can expand to be a regional center. The revenues generated are critical for the financial survival of rural hospitals.

Advanced Endoscopic Evaluation of Gastroesophageal Reflux Disease in Morbidly Obese Patients in a Rural Setting.

INTRODUCTION: Obesity is a known risk factor for gastroesophageal reflux disease (GERD). Morbidly obese patients in rural areas are usually referred to the local surgeon for endoscopic evaluation. This situation poses significant challenges given the increased risk for perioperative complications due to anatomical and metabolic factors. This study aims to evaluate the safety of performing GERD diagnostic workup studies in a rural setting. METHODS: Institutional review board approval was obtained for a retrospective chart review of patients who presented with GERD symptoms to a rural antireflux clinic between August 2015 and October 2020. Patients were included if their body mass index (BMI) was over 35 with comorbidities or over 40 kg/m2 who underwent upper gastrointestinal endoscopy with or without concomitant placement of wireless pH probe and/or functional luminal imaging probe. RESULTS: A total of 117 patients met the inclusion criteria. There were 94 (80.3%) females and 23(19.7%) males. The average age was 56.0 ± 13.4 years. The average BMI was 40.4 (35-66.4). Proton pump inhibitor use was noted in 97/117 (82.9%) with an average duration of 12.0 ± 9.2 years. The average GERD-Health Related Quality of Life, Reflux Symptom Index and GERD Symptom Score (GERSS) were 29.8 ± 20, 24.5 ± 14.2 and 21.3 ± 15.4 respectively. There were no procedural complications. All the endoscopic examinations were successfully completed and patients were discharged. CONCLUSION: Performing diagnostic studies for GERD for morbidly obese patients in critical access hospitals is safe. Patient selection, proper training and adequate preparation are critical prerequisites for good outcomes.

The Outcomes of Performing Partial Fundoplication Based on Endoflip Versus Manometric Findings.

BACKGROUND: The surgical management of gastroesophageal reflux disease (GERD) involves extensive diagnostic studies and sophisticated surgical techniques. The workup should be comprehensive and purposeful. High resolution impedance manometry (HRIM) provides valuable information regarding peristalsis and lower esophageal sphincter relaxation. The disadvantages of HRIM such as intolerance or inability to pass the catheter led to its selective use or even omission especially in laparoscopic hiatal hernia repair with partial fundoplication. This pragmatic approach risks missing motility disorders in patients with secondary reflux symptoms related to achalasia or scleroderma. Endolumenal functional lumen imaging probe (endoFLIP) can fill this void as it evaluates the dynamics of the esophagogastric junction under sedation. This study aims to compare the outcomes of preoperative use of HRIM vs endoFLIP for laparoscopic repair of hiatal hernia with partial fundoplication. METHODS: This is a retrospective cohort study for consecutive patients who underwent antireflux surgery with partial fundoplication between July 2018 and February 2021. Preoperative and postoperative outcomes were compared between two cohorts of patients: those with preoperative HRIM and those with preoperative endoFLIP. RESULTS: A total of 72 patients were evaluated, 41 had preoperative HRIM and 31 had endoFLIP. There was no statistically significant difference in their age, sex, BMI, duration of GERD symptoms, or proton pump inhibitors use. The endoscopic findings of esophagitis, hiatal hernia, and Hill's grade were comparable. There was no difference in the American Society of Anesthesiology classification or the choice of antireflux surgery. The improvement of postoperative GERD scores and dysphagia subscore was similar between the two groups. CONCLUSION: Performing partial fundoplication based on endoFLIP evaluation of the dynamics of the esophagogastric junction is safe and does not increase postoperative dysphagia compared to preoperative manometric use. Randomized prospective studies are needed to confirm the findings of this study.

Impact of Participation of Surgeons in Diagnostic Studies of Gastroesophageal Reflux Disease on Completion of Workup and Utilization of Antireflux Surgery.

Introduction. Patients presenting with symptoms of gastroesophageal reflux disease (GERD) are usually evaluated by gastroenterologists who perform the diagnostic workup and determine when to refer for surgical consideration. The multiple diagnostic studies can be overwhelming, and this leads to dropouts. In a rural setting, without gastroenterology services, the surgeon can diagnose GERD and perform antireflux procedures. This study aimed to assess the completion of the required diagnostic studies and progression to surgical intervention. Methods. This is a retrospective chart review of patients who presented with GERD symptoms between August 2015 and January 2018. Standardized workup included the upper gastrointestinal study and esophagogastroduodenoscopy with concomitant wireless pH placement. High-resolution impedance manometry and the gastric emptying scan were selectively utilized. Results. 429 patients were evaluated. Proton pump inhibitors were used by 82.2% of patients. The required diagnostic workup was completed by 92.7% of all patients. Nearly 75% were suitable candidates for antireflux surgery. Approximately 2/3 of these patients proceeded with antireflux surgery. Discussion. The lack of gastroenterology services in rural hospitals provides a unique opportunity for general surgeons to diagnose and treat GERD patients locally. This avoids fragmentation of care and enables the surgeon to evaluate the entire spectrum of GERD. This structured approach results in increased completion of multiple diagnostic studies. Moreover, surgical candidates are likely to proceed with surgical intervention. Conclusion. A surgical antireflux program with diagnostic and therapeutic capabilities results in increased completion of diagnostic workup and utilization of antireflux surgery.

Laparoscopic-Assisted Abdominal Wall Pexy of Peritoneal Dialysis Catheter.

BACKGROUND: Peritoneal dialysis (PD) for rural patients with end-stage renal disease (ESRD) is convenient, efficient, and durable. However, patients with a history of previous abdominal surgeries or peritonitis are at an increased risk of PD malfunction. This case highlights the impact of securing the catheter to the abdominal wall laparoscopically to keep the PD catheter in an adhesion-free area to maintain patency and function in a patient with extensive intraperitoneal adhesions. SUBJECT: A 76-year-old white male was on PD which later was complicated with peritonitis and sepsis and subsequent catheter removal. A year later, the patient desired replacement of the PD catheter. Intraoperatively, diagnostic laparoscopy revealed significant intraperitoneal adhesions mainly located at the left side of the abdomen with the right side of the abdomen spared. The Tenckhoff PD catheter, which was straightened by a steel stylet, was inserted via a 5-mm trocar. The stylet was removed. The pig tail of the PD catheter was navigated away from the adhesion and directed to the right side of the abdomen for internal fixation. The catheter at 9 cm from the PD catheter cuff was attached to the right paramedian peritoneum. RESULTS: PD started 1 week after placement. The patient had excellent inflow and outflow for 14 months to date without complication or need for revision. CONCLUSION: The laparoscopic pexy of the PD catheter to the abdominal wall to keep the catheter in an adhesion-free compartment is beneficial in selected patients. A future study with a larger number of patients is needed to further validate this strategy.

Omentoplasty Combined With Endoscopic Stenting in the Treatment of Lateral Duct Injury at Hepatic Duct Bifurcation.

BACKGROUND: Common bile duct injury (CBDI) is a devastating complication from laparoscopic cholecystectomy. The endoscopic retrograde cholangiopancreatography (ERCP)-based sphincterotomy and stenting were reportedly effective in treating low or distal lateral CBDI. However, in the circumstance of proximal lateral CBDI, the routine biliary stent may not provide coverage of the leak site, which posed a unique clinical challenge when such proximal CBDI occurred. METHODS: This patient is an 85-year-old man who underwent laparoscopic cholecystectomy for acute cholecystitis. The gallbladder was contracted and atrophic with extensive dense adhesions in the infundibular area. A dome-down approach was attempted, and a small side hole was identified from a tubular structure with minimal bilious leakage. The intraoperative cholangiogram showed a bile leak at the hepatic duct confluence. A vascularized omental patch was fashioned and secured to the vicinity of the CBDI in a tension-free manner. Two drains were placed. ERCP and endoscopic stenting were undertaken the following day. RESULTS: There was minimal bilious fluid output from the Jackson-Pratt drains in the first 24 hours. This was reduced further following ERCP and resolved in 2 days while tolerating a regular diet. All laboratory studies were normal. The drains were removed week postoperatively. The patient was seen in the clinic at 12 months, and there was no evidence of bile leak or stricture. CONCLUSION: The combination of omentopexy and endoscopic stenting is safe in managing high lateral bile duct injury. Prospective studies are needed to further validate this technique.

Ten Reasons for Laparoendoscopic Repair of Hiatal Hernia : Case Presentation With Long-Term Follow-Up.

Laparoendoscopic hiatal hernia repair (LEHHR) involves laparoscopic repair of hiatal hernia with concomitant transoral incisionless fundoplication (TIF). The objective of this case presentation is to highlight the benefits of LEHHR in a patient with long term follow up. This patient is a 56-year-old woman with symptoms of gastroesophageal reflux disease for 40 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm hiatal hernia. DeMeester score was 21.3. She underwent LEHHR 33 months ago. The patient underwent laparoscopic cholecystectomy for symptomatic biliary dyskinesia. This provided the opportunity to examine the operative anatomy. There were minimal adhesions to the liver. The partial fundoplication was intact. The angle of His was preserved. The fundus was spared from any adhesions as TIF utilizes the cardia rather than the fundus to create the wrap. The plane behind the stomach was undisturbed. LEHHR has 10 main benefits. Anatomical benefits result from the preservation of the angle of His. Functional benefits relate to a partial fundoplication which normalizes pH values. LEHHR avoids bleeding from short gastric vessels and the creation of a wrap when anatomical obstacles present. Strategic benefits are directed toward any subsequent revisional reflux surgery. The lack of adhesions, easy access to the base of left crus, and sparing the fundus render revisional surgery straightforward.

The Benefits of Nonablative Radiofrequency Treatment of the Lower Esophageal Sphincter After Transoral Incisionless Fundoplication.

Non-ablative radiofrequency treatment to the lower esophageal sphincter (Stretta) has been shown to be beneficial after failed Nissen fundoplication. To our knowledge, this is the first report of Stretta after transoral incisionless fundoplication (TIF). This patient is a 17-year-old female who had gastroesophageal reflux disease (GERD) symptoms for 9 years. She presented with heartburn, regurgitation, and epigastric discomfort. She used omeprazole for 9 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm sliding hiatal hernia and DeMeester score of 25. The GERD Health-Related Quality of Life (GERD-HRQL) score on omeprazole was 14. Patient underwent a TIF procedure, which was uneventful. Her symptoms resolved, and she discontinued omeprazole. Six months later, she had episodes of repeated violent vomiting followed by recurrence of regurgitation, nausea, bloating, and dysphagia. She resumed omeprazole. Diagnostic workup included gastric emptying scan, which was normal. EGD showed no hiatal hernia and partial disruption of the TIF valve. DeMeester score was 36.3. Esophageal manometry with impedance showed intact peristalsis and normal relaxation of the lower esophageal sphincter. The patient underwent Stretta, which was uneventful. The previous TIF did not increase the complexity of the procedure. There were no immediate or postoperative complications. The patient reported gradual improvement of her symptoms with complete resolution 2 months postoperatively. She discontinued omeprazole. The GERD-HRQL score 17 months post-Stretta was 0. This case highlights the feasibility, safety, and efficacy of performing Stretta following TIF. It provides an endoluminal alternative to complex revisional antireflux surgery. Prospective studies with longer follow-up are required to validate this concept.

Drawbacks of the Current Algorithm for Patients With Symptoms of Gastroesophageal Reflux Disease and the Impact of Adding Wireless pH Study to the Initial Diagnostic Endoscopy: Data From High-Volume Rural Antireflux Center.

BACKGROUND: Patients with symptoms of gastroesophageal reflux disease (GERD) are often given a trial of proton pump inhibitors (PPIs). When they respond, patients usually continue PPI therapy. If this empiric treatment fails, esophagogastroduodenoscopy (EGD) is recommended. When EGD findings are equivocal, pH study is warranted. We hypothesize that this algorithm results in prolonged PPI therapy, repetition of EGDs and patient dissatisfaction. This study evaluates the impact of placing a pH probe at the time of the initial EGD. METHODS: IRB approval was obtained for retrospective chart review of patients who presented with GERD symptoms between August 2015 and March 2019. Patients were included if they underwent EGD with placement of wireless pH probe. RESULTS: A total of 379 patients (260 females, 119 males) with average age was 56.7±14.2 years. There were 253/379 (66.7%) patients who had previous EGDs (1-10). Health Satisfaction Survey was completed by 357/379 (94.2%) patients and 250/357 (70%) reported dissatisfaction with GERD control. PPI use was noted in 299/379 (78.8%) patients with average duration of 10.9±9.1 years. Testing off antisecretory medication was performed in 360/379 (94.9%). The average time interval between the clinic visit and performing EGD and pH study was 22±25 days. CONCLUSION: The current GERD algorithm results in prolonged PPI therapy, repeated endoscopies and patient dissatisfaction. Placing a pH probe at the time of initial endoscopy is safe and expedient in a rural setting. Positive pH studies avoid repeating EGDs and negative pH studies warrant a search for potential alternative diagnosis.

Benefit of Laparoendoscopic Repair of Hiatal Hernia in the Presence of Aberrant Left Hepatic Artery.

BACKGROUND AND OBJECTIVES: An aberrant left hepatic artery (ALHA) limits the already confined operative field of laparoscopic antireflux surgery (LARS) and laparoscopic hiatal hernia repair (LHHR). The aim of this study is to provide a safe laparoendoscopic technique for hiatal hernia repair in the presence of an ALHA. METHODS: We conducted a retrospective chart review of patients who underwent LARS or LHHR between March 2016 and March 2018. We reviewed clinical and laboratory data and operative reports and images. Follow-up data included gastroesophageal reflux disease (GERD) questionnaire results and the results of esophagogastroduodenoscopy (EGD) and upper gastrointestinal studies. RESULTS: One hundred thirty-one LARS and LHHR procedures were performed by a single surgeon. Eight (6.1%) patients had an ALHA. There were 6 female and 2 male patients. The average age was 54.5 (±10.4) years, and the average body mass index was 28.1 (±5.5) kg/m2. The duration of their GERD symptoms was 16.6 (±6.9) years. Patients underwent LHHR followed by transoral incisionless fundoplication. Hiatoplasty was performed with extracorporeal sliding arthroscopic knots. The ALHA was preserved in all cases. There was no intraoperative bleeding, mortality or postoperative complications. All antireflux medications were discontinued with significant improvement of GERD questionnaires. All patients had EGD at 3 months postoperatively with no recurrence of hiatal hernia. Five patients who had the surgery longer than 1 year ago had an upper gastrointestinal study without evidence of hiatal hernia recurrence. CONCLUSION: The laparoendoscopic technique of hiatal hernia repair, using extracorporeal arthroscopic sliding knots and concomitant transoral incisionless fundoplication, is safe, preserves an ALHA, and allows proper surgical techniques in a confined operative field.