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.

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.

Transoral incisionless fundoplication for Jehovah's Witnesses: A case report discussing safety and durability.

Jehovah's Witness patients pose a unique surgical challenge due to their refusal of transfusion of whole blood or major blood products. One of the surgical strategies is to offer the least invasive approach with the least likelihood of losing blood. In the context of surgical treatment of gastroesophageal reflux disease, endoluminal approaches such as transoral incisionless fundoplication represent an appropriate approach for Jehovah's Witness patients. This patient is a devout Jehovah's Witness who was troubled with gastroesophageal reflux disease for many years which was refractory to proton pump inhibitor therapy. Her standard preoperative workup showed that she was a candidate for transoral incisionless fundoplication. Surgery was performed by a transoral incisionless fundoplication certified surgeon and this patient was his second case. Patient had no immediate or long-term complications. She was successfully weaned off proton pump inhibitors. Transoral incisionless fundoplication is an appropriate option for Jehovah's Witness patients with refractory gastroesophageal reflux disease. This case report shows that the procedure is safe and durable, even in the early stage of the physician's learning curve.