The laparoscopic Nissen-Hill hybrid: pilot study of a combined antireflux procedure.

BACKGROUND: Laparoscopic antireflux surgery is highly effective in patients with uncomplicated gastroesophageal reflux disease (GERD). However, long-term failure rates in paraesophageal hernia (PEH) and Barrett's metaplasia (BE) are higher and warrant a more durable repair. Outcomes for the laparoscopic Nissen fundoplication (LNF) and Hill repair (LHR) are equivalent, but their anatomic components are different and may complement each other (Aye R Ann Thorac Surg, 2012). We designed and tested the feasibility and safety of an operation that combines the essential components of each repair. METHODS: A prospective, phase II pilot study was performed on patients with symptomatic giant PEH hernias and/or GERD with nondysplastic Barrett's metaplasia. Pre- and postoperative esophagogastroduodenoscopy (EGD), upper gastrointestinal study (UGI), 48-hour pH testing, manometry, and three quality-of-life metrics were obtained. RESULTS: Twenty-four patients were enrolled in the study. Three patients did not complete the planned procedure, leaving 21 patients, including 12 with PEH, 7 with BE, and 2 with both. There were no 30-day or in-hospital mortalities. At a median follow-up of 13 (range 6.4-30.2) months, there were no reoperations or clinical recurrences. Two patients required postoperative dilation for dysphagia, with complete resolution. Mean DeMeester scores improved from 54.3 to 7.5 (p < 0.0036). Mean lower esophageal sphincter pressures (LESP) increased from 8.9 to 21.3 mmHg (p < 0.013). Mean short-term and long-term QOLRAD scores improved from 4.09 at baseline to 6.04 and 6.48 (p < 0.0001). Mean short-term and long-term GERD-HQRL scores improved from 22.9 to 7.5 and 6.9 (p < 0.03). Mean long-term Dysphagia Severity Score Index improved from 33.3 to 40.6 (p < 0.064). CONCLUSIONS: The combination of a Nissen plus Hill hybrid reconstruction of the gastroesophageal junction (GEJ) is technically feasible, safe, and not associated with increased side effects. Short-term clinical results in PEH and BE suggest that this may be an effective repair, supporting the value of further study.

Repair of symptomatic giant paraesophageal hernias in elderly (>70 years) patients results in improved quality of life.

INTRODUCTION: Giant paraesophageal hernias (PEH) involve herniation ofstomach and/or other viscera into the mediastinum. These are usually symptomatic and commonly occur in the elderly. The benefits and risks of operating on elderly patients with giant PEH have not been clearly elucidated. MATERIALS AND METHODS: We performed a retrospective chart review of consecutive patients aged 70 or greater with giant PEHs undergoing repair.Quality of life data were gathered using QOLRAD, GERD-HRQL and adysphagia severity score. RESULTS: Fifty-eight patients (34 females), median 78 years old, presented for repair. Nine patients presented urgently. There was no 30-day mortality. Major morbidity was 15.5%. At mean follow-up of 1.3 years, 81% were symptom free compared to baseline (p < 0.0001). Both short-term (p < 0.001) and long term QOLRAD (p < 0.001) scores improved significantly, as did GERD HRQL scores (p < 0.001). Dysphagia scores worsened in the short term but returned to baseline at long term follow up. CONCLUSIONS: Symptomatic giant PEH in this elderly population can be repaired with symptomatic improvement, minimal morbidity and mortality in both the elective and urgent setting. The decision to operate should be made by a physician experienced in managing this complex patient population.

Endoscopic and manometric position-related characteristics of the normal gastroesophageal junction.

BACKGROUND: The relationship between body position and the gastroesophageal junction (GEJ) has been subject to intense interest in its role in gastroesophageal reflux disease (GERD). Few studies have looked at the position related changes of the gastroesophageal valve (GEV) in asymptomatic individuals. PURPOSE: To define the normal physiology of the GEJ in left lateral decubitus (LLD) and upright position in asymptomatic individuals. METHODS: Ten healthy asymptomatic volunteers with no previous history of GERD were recruited. Patients underwent upper endoscopy, with detailed observation and grading of the gastroesophageal valve (Hill Grade 1-4; 1 = normal closed valve, 4 = open valve, associated hiatus hernia) in both LLD and upright positions. Patients underwent high resolution manometry, with wet swallows performed in LLD and upright positions. A Bravo pH probe was placed in the distal esophagus and used to perform 48-h pH studies in all patients. RESULTS: Four out of 10 patients were noted to have abnormal 48 h pH studies (DeMeester score >14.7). Endoscopically, there was an overall increase in mean Hill Grade when patients were moved from LLD to upright position (1.6, 2.3, p = 0.04, respectively), with no significant differences between normal and abnormal pH patients. In the abnormal pH group, on endoscopy, 75% were found to have prolonged opening of the GEV on passive retroflexed observation in LLD position, compared with 16.7% of normal pts (p = 0.1). Manometrically, this was correlated with lower mean LES resting pressures and shorter intra-abdominal LES length for the abnormal pH patients in all positions compared to normals. As well, for the abnormal pH group, LESP trended down slightly when moved from LLD to upright position (11.2 vs. 8.0 mmHg, respectively; p = 0.3). CONCLUSIONS: In normal individuals, the GEV exhibits a temporary weakening when moved from LLD to upright position. However, the normal GEV is able to maintain LESP in upright position. In contrast, in patients with early GERD, a greater degree of valve incompetence at the GEJ is seen. This is correlated manometrically with a trend toward shorter LES length and lower LESP when moved from LLD to upright position. This upright incompetence of the GEV may be one of the earliest manifestations in GERD. Proper evaluation of the GEV should include endoscopic evaluation in both recumbent and upright positions. Further studies are needed to evaluate the corresponding changes of the GEV in varying degrees of symptomatic GERD.

Use of Polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery.

BACKGROUND: This study examined the feasibility of using Polyflex stents in the treatment of enteric leaks after various bariatric operations. Chronic and acute leaks were treated. METHODS: We performed a retrospective case series review. Four patients received 6 Polyflex stents to treat complications of bariatric surgery. Two presented with early sepsis before stenting. One presented with abdominal pain. One presented with a chronic persistent fistula with an associated abscess. Stenting was performed under endoscopy with fluoroscopic guidance. The stents were left in place for 6 weeks. RESULTS: All patients tolerated a clear liquid diet within 24 hours of stenting and were able to be advanced to a pureed diet. All patients improved clinically after stenting. Three patients with acute leaks sealed their leaks after stent placement. One patient with a chronic leak persisted and required operative closure after a second stent was placed and failed. All patients experienced short-term nausea, as well as early satiety that lasted the duration of the stenting. One patient experienced hypersialisis while the stent was in place. Two stents migrated, although this had no effect on leak closure. One patient had an anastomotic stenosis successfully treated with a second stent. CONCLUSIONS: Polyflex stents are useful in bypassing acute upper intestinal leaks after various bariatric operations. They provide a temporary bridge for wound healing with continued oral intake. Stenting provides a minimally invasive option in the management of acute leaks and, in our experience, had no serious associated morbidity.