Acute gastric volvulus complicated by gastric perforation following laparoscopic Nissen fundoplication; A case report.

INTRODUCTION: Laparoscopic Nissen Fundoplication is an effective standard surgical procedure for treatment of severe GERD. While it is generally safe and effective, a rare but potentially fatal complication known as acute gastric volvulus can occur following this procedure. CASE PRESENTATION: A 28-year-old male, ten months post Laparoscopic Nissen Fundoplication presented with a one-day history of severe epigastric pain, abdominal distention, unproductive retching, and difficulty in breathing. Examination revealed tachypnea, subcutaneous emphysema and a tender distended abdomen. Imaging studies showed a left pneumothorax, pneumoperitoneum, and a grossly distended stomach. Emergency exploratory laparotomy confirmed organoaxial gastric volvulus, necrosis of the greater curvature and gastric perforation. Partial gastrectomy and anterior gastropexy were performed. A left thoracostomy tube was placed to drain the left pneumothorax. He recovered fully post-operatively with complete resolution of all symptoms. DISCUSSION: Acute Gastric volvulus post Laparoscopic Nissen Fundoplication is attributed to adhesions, gastrostomy tubes, and foreign bodies like sutures. Life-threatening complications, such as gastric perforation, can ensue, underscoring the need for swift diagnosis and treatment. CONCLUSION: Acute gastric volvulus following Laparoscopic Nissen Fundoplication is a rare condition, and is difficult to diagnose. Given the steadily increasing rates of laparoscopic Nissen fundoplications performed in Uganda, maintaining a high index of suspicion is crucial for favorable patient outcomes among patients with this potentially fatal complication.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service.

Introduction: Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution. Methods: We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed. Results: We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%. Conclusion: LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Comparative analysis of laparoscopic nissen fundoplication and rossetti modification in gastroesophageal reflux disease: A focus on life quality enhancement.

OBJECTIVE: This study aims to investigate the focus of surgical treatment of gastroesophageal reflux disease (GERD) on enhancing life quality beyond symptom relief. The comparison involves laparoscopic Nissen fundoplication and Rossetti modification techniques. METHODS: Patients intolerant to or experiencing relapse after medical therapy underwent either standard Nissen procedure (Group 1, n = 61) or Rossetti modification (Group 2, n = 42). A disease-specific quality of life questionnaire for GERD was utilized for evaluating life quality preoperatively and 2 years postoperatively. Symptom scores and patient satisfaction were also assessed. RESULTS: Preoperatively, groups were similar in symptom duration, hiatal hernia presence, and DeMeester scores (p = 0.127, p = 0.427, and 0.584, respectively). Both groups exhibited a statistically significant increase in life quality postoperatively (p < 0.001), with no significant intergroup difference. Symptoms decreased after both surgeries, except for dysphagia and bloating. Bloating significantly increased in both groups after surgery (p = 0.018 and p = 0.017, respectively), and dysphagia increased significantly only in Group 2 (p = 0.007). The surgery refusal rate was significantly higher in Group 2 for similar preoperative symptoms (p = 0.040). CONCLUSION: Despite increased life quality scores, the combination of increased dysphagia and bloating in patients undergoing Rossetti modification resulted in a decreased satisfaction rate.

Repair of type II paraesophageal hernia with Nissen fundoplication in a patient with von Willebrand disease and spondylolisthesis - a clinical case report.

Hiatal hernias continue to be fairly common in clinical practice. However, the variety of different symptoms presented by patients may hinder establishing the ultimate diagnosis. Nevertheless, currently, the diagnosis of hiatal hernia can be easily established, based on barium swallow radiography. We would like to present a clinical case report of a patient with complex medical history, including von Willebrand disease, degenerative spinal disease, and chronic sinusitis, who was finally diagnosed with hiatal hernia and treated with a standard laparoscopic Nissen fundoplication. Our case focuses on the significance of comorbidities on patients' symptoms, which sometimes may mislead the therapeutic process.

Impact of Age on Long-Term Outcomes of Laparoscopic Nissen Fundoplication-A Single Center Study.

Background and objectives: Gastroesophageal reflux disease (GERD) is a common disease affecting approximately 20% of the adult population. This study aimed to compare the results of laparoscopic Nissen fundoplication (LNF) in the treatment of GERD in patients of different age groups. Materials and Methods: A retrospective analysis was performed on patients who underwent LNF in one surgical department between 2014 and 2018. Patients were divided into three groups based on age: under 40 years of age, 40-65 years of age, and over 65 years of age. Results: A total of 111 patients (44.1% women) were analyzed in this study. The mean age was 50.2 ±15 years, and the mean follow-up was 50 months ± 16.6 months. Recurrence of symptoms occurred in 23%, 20%, and 23% in each age group, respectively (p = 0.13), and 85%, 89%, and 80% of patients from the respective groups reported that they would recommend the surgery to their relatives (p = 0.66). Furthermore, 83%, 92%, and 73% of patients from the respective age groups reported that they would undergo the surgery again with the knowledge they now had (p = 0.16). Conclusions: Given these results and observations, LNF has been shown to be a good method of treatment for GERD in every age group. In our study, there were no differences found in terms of satisfaction with surgery and associated recommendations between the studied age groups.

Stroke Secondary to Air Embolism Following Laparoscopic Nissen Fundoplication.

An air embolism is characterized by the entry of gas bubbles into the circulatory system, which can lead to the possible occlusion of blood vessels, posing a potentially life-threatening risk. While commonly associated with lung trauma or decompression sickness, it can also result from medical procedures such as central venous catheter insertion or, in our case, gas insufflation for laparoscopic surgery. We present the case of a 65-year-old female who suffered from a stroke secondary to an air embolism after undergoing a laparoscopic Nissen fundoplication in which carbon dioxide insufflation of the abdominal cavity was utilized. We also will discuss the elusive etiology of this complication as well as diagnosis, treatment, and proposed preventative measures.  A 65-year-old female with gastroesophageal reflux disease and a hiatal hernia elected to undergo a laparoscopic Nissen fundoplication for hernia repair. After a successful surgery, the patient was found with significant neurological deficits, including left-sided hemiplegia, numbness in the left hand, hemianopsia, dysarthria, and a National Institutes of Health Stroke Scale score of 20. CT head imaging revealed several low-density foci in the right frontal lobe, while CT neck and chest imaging revealed subcutaneous emphysema and pneumomediastinum. Subsequent labs were significant for an elevated lactate at 7.6 mmol/L. MRI of the brain depicted evidence of an acute infarct in the right frontal lobe with diffusion-weighted imaging (DWI) sequences. The imaging results were correlated with the patient's clinical presentation to establish the diagnosis of a nondominant hemisphere stroke, localized to an anterior branch of the right middle cerebral artery (MCA). After intubation and supportive treatment for three days, the patient was extubated and able to follow commands but had left facial weakness and diminished strength in the left upper and lower extremities. At the two-month follow-up visit, the patient no longer had any focal neurological deficits. Air emboli, though very rare, can occur as a complication in laparoscopic surgeries that utilize CO2 for body cavity insufflation. Patients may be asymptomatic with small, self-limiting emboli, while others may exhibit pulmonary symptoms, cardiac arrest, or focal neurologic changes, depending on the emoji's size and location. Given the wide range of patient presentations, the elevated mortality of laparoscopic procedures complicated by air emboli, and the rare occurrence of focal neurological symptoms as depicted in this case, rapid diagnosis and close postoperative observation and treatment are vital for both short-term and long-term patient outcomes.

A Three-Arm Randomized Controlled Trial of Primary One-Anastomosis Gastric Bypass: With FundoRing or Nissen Fundoplications vs. without Fundoplication for the Treatment of Obesity and Gastroesophageal Reflux Disease.

Background and Objectives: Obesity and gastroesophageal reflux disease (GERD) are steadily increasing world weight and antireflux surgery must be performed simultaneously with bariatric surgery in obese patients. The purpose of this study is to compare bariatric and antireflux results after OAGB with different methods of fundoplication using the excluded stomach and without fundoplication. Materials and methods: This open-label, randomized, parallel three-arm trial was conducted from March 2019 and December 2021. All patients underwent laparoscopic one-anastomosis gastric bypass and suture cruroplasty, and then had a follow-up at 24 months. Group 1 of patients had fundoplication FundoRing using the excluded stomach (FundoRingOAGB); Group 2, with Nissen fundoplication using the excluded stomach (NissenOAGB); and Group 3, without fundoplication (OAGB). We studied changes in BMI, GERD symptoms (GERD-HRQL), and the VISICK score. Results: Of 219 participants screened, 150 were randomly allocated to 3 groups: FundoRingOAGB group (n = 50), NissenOAGB group (n = 50), and OAGB group (n = 50). At post-treatment month 24, BMI changes were as follows: from 40.7 ± 5.9 (31-53) to 24.3 ± 2.8 (19-29) kg/m2 in FundoRingOAGB group; from 39.9 ± 5.3 (32-54) to 26.3 ± 2.9 (23-32) kg/m2 in Nissen group; and from 40.9 ± 6.2 (32-56) to 28.5 ± 3.9 (25-34) kg/m2 in OAGB group. The mean pre-operative GERD-HRQL heartburn score improved post-op in FundoRingOAGB group from 20.6 ± 2.24 (19.96, 21.23) to 0.44 ± 0.73 (0.23, 0,64); in NissenOAGB group from 21.34 ± 2.43 (20.64, 22.03) to 1.14 ± 1.4 (0.74, 1.53); and in OAGB group 20.5 ± 2.17 (19.9, 21.25) to 2.12 ± 1.36 (1.73, 2.5). GERD-HRQL total scores were from pre-op 25.2 ± 2.7 (24.4, 25.9) to 4.34 ± 1.3 (3.96, 4.7) post-op in FundoRingOAGB group; 24.8 ± 2.93 (24, 25.67) pre-op to 5.42 ± 1.7 (4.9, 5.9) in the NissenOAGB group; and from 21.46 ± 2.7 (20.7, 22.2) to 7.44 ± 2.7 (6.6, 8.2) in the OAGB group. The mean VISICK score improved from 3.64 ± 0.94 (3.7, 3.9) to 1.48 ± 1.26 (1.12, 1.84) in FundoRingOAGB, from 3.42 ± 0.97 (3.1, 3,7) to 2.5 ± 1.46 (2.06, 2.9) in NissenOAGB group and from 3.38 ± 0.88 (3.1, 3,69) to 2.96 ± 1.19 (2.62, 3.2) in OAGB group. Conclusions: Antireflux and bariatric results of FundoRingOAGB are better than using the NissenOAGB method and significantly better than OAGB without the use of fundoplication.

Laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastroesophageal reflux disease: a propensity score-matched comparison of the perioperative and 1-year follow-up outcome.

INTRODUCTION: The debate continues as to whether laparoscopic total Nissen (LNF) versus partial posterior Toupet fundoplication (LTF) leads to better outcomes in the surgical treatment of axial hiatal hernia with gastroesophageal reflux disease. In the most recent meta-analysis including 13 RCTs with 1564 patients, no significant difference was found between the two procedures in terms of perioperative complications and recurrent reflux rates. Further comparative analyses are urgently needed. METHODS: This retrospective analysis of prospectively recorded data from the Herniamed Registry compared the perioperative and 1-year follow-up outcomes after total Nissen versus partial Toupet fundoplication. Propensity score matching was chosen as the statistical method. Matching was performed for n = 2290 pairs. RESULTS: No systematic discrepancy was found between the Nissen and Toupet fundoplication for any of the outcome parameters (intraoperative complications LNF 2.10% vs LTF 1.48%, general complications 2.27% vs 2.88%, postoperative complications 1.44% vs 1.18%, complication-related reoperation 1.00% vs 0.91%, recurrence on 1-year follow-up 6.55% vs 5.33%, pain on exertion on 1-year follow-up 12.49% vs 9.52%, pain at rest on 1-year follow-up 10.44 vs 9.52% and pain requiring treatment on 1-year follow-up 9.61% vs 8.17%). Also the postoperative dysphagia rate showed with 5.34% after LNF and with 4.64% after LTF no significant difference. CONCLUSION: The findings presented here did not show any significant difference up to 1 year after Nissen or Toupet fundoplication. This is in concordance with the findings of the meta-analyses. However, the perioperative and 1-year follow-up outcomes demonstrate that both operation techniques should be carried out by experienced surgeons.

Validity and reliability evidence support task-specific metrics for laparoscopic fundoplication.

BACKGROUND: Laparoscopic hiatal hernia repair (LHHR) is a complex operation requiring advanced surgical training. Surgical simulation offers a potential solution for learning complex operations without the need for high surgical volume. Our goal is to develop a virtual reality (VR) simulator for LHHR; however, data supporting task-specific metrics for this procedure are lacking. The purpose of this study was to develop and assess validity and reliability evidence of task-specific metrics for the fundoplication phase of LHHR. METHODS: In phase I, structured interviews with expert foregut surgeons were conducted to develop task-specific metrics (TSM). In phase II, participants with varying levels of surgical expertise performed a laparoscopic Nissen fundoplication procedure on a porcine stomach explant. Video recordings were independently assessed by two blinded graders using global and TSM. An intraclass correlation coefficient (ICC) was used to assess interrater reliability (IRR). Performance scores were compared using a Kruskal-Wallis test. Spearman's rank correlation was used to evaluate the association between global and TSM. RESULTS: Phase I of the study consisted of 12 interviews with expert foregut surgeons. Phase II engaged 31 surgery residents, a fellow, and 6 attendings in the simulation. Phase II results showed high IRR for both global (ICC = 0.84, p < 0.001) and TSM (ICC = 0.75, p < 0.001). Significant between-group differences were detected for both global (χ2 = 24.01, p < 0.001) and TSM (χ2 = 18.4, p < 0.001). Post hoc analysis showed significant differences in performance between the three groups for both metrics (p < 0.05). There was a strong positive correlation between the global and TSM (rs = 0.86, p < 0.001). CONCLUSION: We developed task-specific metrics for LHHR and using a fundoplication model, we documented significant reliability and validity evidence. We anticipate that these LHHR task-specific metrics will be useful in our planned VR simulator.

Esophageal body adaptation to Nissen fundoplication: Increased esophagogastric outflow resistance yields delayed and sustained peristaltic contractions without increased amplitude.

BACKGROUND: Improvement in lower esophageal sphincter (LES) competency after laparoscopic Nissen fundoplication (LNF) is well established, yet esophageal body physiology data are limited. We aimed to describe the impact of LNF on whole esophagus physiology using standard and novel manometric characteristics. METHODS: A cohort of patients with an intact fundoplication without herniation and no postoperative dysphagia were selected and underwent esophageal manometry at one-year after surgery. Pre- and post-operative manometry files were reanalyzed using standard and novel manometric characteristics and compared. KEY RESULTS: A total of 95 patients were included in this study. At 16.1 (8.7) months LNF increased LES overall and abdominal length and resting pressure (p < 0.0001). Outflow resistance (IRP) increased [5.8 (3-11) to 11.1 (9-15), p < 0.0001] with a 95th percentile of 20 mmHg in this cohort of dysphagia-free patients. Distal contractile integral (DCI) also increased [1177.0 (667-2139) to 1321.1 (783-2895), p = 0.002], yet contractile amplitude was unchanged (p = 0.158). There were direct correlations between pre- and post-operative DCI [R: 0.727 (0.62-0.81), p < 0.0001] and postoperative DCI and postoperative IRP [R: 0.347 (0.16-0.51), p = 0.0006]. Contractile front velocity [3.5 (3-4) to 3.2 (3-4), p = 0.0013] was slower, while distal latency [6.7 (6-8) to 7.4 (7-9), p < 0.0001], the interval from swallow onset to proximal smooth muscle initiation [4.0 (4-5) to 4.4 (4-5), p = 0.0002], and the interval from swallow onset to point when the peristaltic wave meets the LES [9.4 (8-10) to 10.3 (9-12), p < 0.0001] were longer. Esophageal length [21.9 (19-24) to 23.2 (21-25), p < 0.0001] and transition zone (TZ) length [2.2 (1-3) to 2.5 (1-4), p = 0.004] were longer. Bolus clearance was inversely correlated with TZ length (p = 0.0002) and time from swallow onset to proximal smooth muscle initiation (p < 0.0001). Bolus clearance and UES characteristics were unchanged (p > 0.05). CONCLUSIONS & INFERENCES: Increased outflow resistance after LNF required an increased DCI. However, this increased contractile vigor was achieved through sustained, not stronger, peristaltic contractions. Increased esophageal length was associated with increased TZ and delayed initiation of smooth muscle contractions.

Budget Impact of RefluxStop™ as a Treatment for Patients with Refractory Gastro-oesophageal Reflux Disease in the United Kingdom.

Background: Gastro-oesophageal reflux disease (GORD) is a common condition associated with heartburn and regurgitation. Standard of care for GORD patients in the UK involves initial treatment with proton pump inhibitors (PPIs) and laparoscopic antireflux surgery in patients unwilling to continue or intolerant of long-term PPI treatment. Recently, RefluxStop™, a novel, implantable medical device, has proven to be an efficacious and cost-effective treatment for patients with GORD. The current analysis aimed to describe the budget impact of introducing RefluxStop™ within National Health Service (NHS) England and Wales. Objectives: To estimate the more immediate, short-term clinical and economic effects of introducing RefluxStop™ as a therapeutic option for patients with GORD treated within NHS England and Wales. Methods: A model adherent to international best practice guidelines was developed to estimate the budget impact of introducing RefluxStop™ over a 5-year time horizon, from an NHS perspective. Two hypothetical scenarios were considered, one without RefluxStop™ (comprising PPI treatment, laparoscopic Nissen fundoplication, and magnetic sphincter augmentation using the LINX® system) and one with RefluxStop™ (adding RefluxStop™ to the aforementioned treatment options). Clinical benefits and costs associated with each intervention were included in the analysis. Results: Over 5 years, introducing RefluxStop™ allowed the avoidance of 347 surgical failures, 39 reoperations, and 239 endoscopic esophageal dilations. The financial impact of introducing RefluxStop™ was £3 029 702 in year 5, corresponding to a 1.68% increase in annual NHS spending on GORD treatment in England and Wales. Discussion: While the time horizon was too short to capture some of the adverse events of PPIs and complications of GORD, such as the development of Barrett's esophagus or esophageal cancer, the use of RefluxStop™ was associated with a substantial reduction in surgical complications, including surgical failures, reoperations, and endoscopic esophageal dilations. This favorable clinical profile resulted in cost offsets for the NHS and contributed to the marginal budget impact of RefluxStop™ estimated in the current analysis. Conclusions: Introducing RefluxStop™ as a treatment option for patients with GORD in England and Wales may be associated with clinical benefits at the expense of a marginal budget impact on the NHS.

Efficacy of Nissen Sleeve Gastrectomy on Mid-term Barrett's Esophagus Regression.

INTRODUCTION: Sleeve gastrectomy is the most commonly performed bariatric operation globally. The main complication is GERD. In the medium term, it can increase the incidence of Barrett's esophagus (BE), which is a risk factor for esophageal adenocarcinoma. Following conventional sleeve gastrectomy, BE is noted in up to 16% of patients postoperatively. Recently, Nissen sleeve gastrectomy (NSG) has been shown to reduce the frequency of postoperative GERD compared to conventional sleeve gastrectomy. This study aims to evaluate the impact of NSG on the incidence and remission of BE in the long term. MATERIAL AND METHOD: This bicentric retrospective study included 692 patients who received NSG from September 2013 to July 2021. All patients underwent preoperative upper GI endoscopy and were then scheduled to receive upper GI endoscopy between 1 and 2 years and then between 3 and 5 years postoperatively. BE was systematically confirmed by biopsies. RESULTS: Seventy-four patients had endoscopic suspicion of BE, which was confirmed on 54/692 patients by histology. The BE lesions consisted of 18.5% intestinal metaplasia and 75.9% fundal metaplasia. Among these 54 patients, 38 underwent endoscopic investigation within 2 years postoperatively. The biopsies showed healed BE in 25/38 patients (64.1%). At 5 years, two patients had proven BE. Concerning the incidence of BE post NSG: 234 performed the follow-up endoscopy within 2 years. The incidence of de novo BE is nil. CONCLUSION: The NSG is associated with healing of known BE in approximately two-thirds of patients at 2-year follow-up. This is consistent with the GERD improvement that has been shown with NSG.

Robotic-Assisted Nissen Fundoplication in Pediatric Patients: A Matched Cohort Study.

BACKGROUND: Nissen Fundoplication (NF) is a frequently performed procedure in children. Robotic-assisted Nissen Fundoplication (RNF), with the utilization of the Senhance® Surgical System (SSS®) (Asensus Surgical® Inc., Durham, NC, USA) featuring 3 mm instruments, aims to improve precision and safety in pediatric surgery. This matched cohort study assesses the safety and feasibility of RNF in children using the SSS®, comparing it with Laparoscopic Nissen Fundoplication (LNF). METHODS AND RESULTS: Twenty children underwent RNF with the SSS® between 2020 to 2023 and were 1:1 matched with twenty LNF cases retrospectively selected from 2014 to 2023. Both groups were similar regarding male/female ratio, age, and weight. Two of the twenty RNF cases (10%) experienced intraoperative complications, whereas three in the LNF group of whom two required reinterventions. The observed percentage of postoperative complications was 5% in the RNF group compared to 15% in the LNF group (p = 0.625). The operative times in the RNF group significantly dropped towards the second study period (p = 0.024). CONCLUSIONS: Utilizing SSS® for NF procedures in children is safe and feasible. Observational results may tentatively suggest that growing experiences and continued development will lead to better outcomes based on more accurate and safe surgery for children.

Pressure dynamics of the esophagogastric junction at rest and during inspiratory maneuvers after Nissen fundoplication.

Low sphincter pressure and inability of the crural diaphragm to elevate it at the esophagogastric junction are important pathophysiological mechanisms of gastroesophageal reflux disease (GERD). The object of this study was to depict how Nissen fundoplication changed the resting and inspiratory pressures of the anti-reflux barrier. We selected 14 patients (eight males; mean age 42.7 years; mean body mass index 27.8) for surgery. They answered symptoms questionnaires and underwent high-resolution manometry (HRM) before and 6 months after Nissen fundoplication. We used a standard manometric protocol (resting and liquid swallows) and assessment of esophagogastric junction (EGJ) pressure metrics during standardized forced inspiratory maneuvers against increasing loads (Threshold Maneuvers). We used the Wilcoxon test for comparison of pre and postoperative data. After fundoplication, heartburn and regurgitation scores diminished remarkably (from 4.5 and 2, respectively, to zero; P = 0.002 and P = 0.0005, respective medians). Also, the median expiratory EGJ pressure had a significant increase from 8.1 to 18.1 mmHg (P = 0.002), while mean respiratory pressure and EGJ contractility integral (EGJ-CI) increased without statistical significance (P = 0.064 and P = 0.06, respectively). Axial EGJ displacement was lower after fundoplication. The EGJ relaxation pressure (P = 0.001), the mean distal esophageal intrabolus pressure (P = 0.01) and the distal latency (P = 0.017) increased after fundoplication. There was a reduction in the contraction front velocity (P = 0.043). During evaluation with standardized inspiratory maneuvers, the inspiratory EGJ pressures (under loads of 12, 24, 36 and 48 cmH2O) were lower after surgery for all loads (median for load 12 cmH2O: 145.6 vs. 102.7 mmHg; P = 0.004). Fundoplication and hiatal closure increased the expiratory EGJ pressure and promoted a great GERD symptom relief. The surgery seemed to overcompensate a reduced EGJ mobility and inspiratory pressure.

How I do it: robotic hiatal hernia repair with stapled conversion from Nissen to Toupet fundoplication.

The purpose of this paper is to describe a robotic surgical technique for converting a slipped Nissen fundoplication to a Toupet fundoplication. Our technique utilizes four 8 mm robotic ports placed in a horizontal pattern above the umbilicus. The robotic tools we used are a vessel sealer, bipolar forceps, and Cadière forceps. In addition, an esophagogastroduodenoscopy (EGD) is placed through the esophagus into the stomach to be used as a bougie. If a hernia is present, we dissect it from the mediastinum until the posterior confluence is identified. Next sutures from the previous Nissen fundoplication are identified and removed to mobilize the crus. All adhesions around the stomach are removed to mobilize the esophagus, ensuing 3 cm of intraabdominal esophagus is available. Using an EGD as a bougie, we used two interrupted, 0 silk suture over Teflon pledgets placed in a horizontal mattress fashion to close the hiatal defect. Using an endoscope, we identified the previous Nissen fundoplication and used a 60 mm blue load stapler to transect the wrap from the stomach. The 360° Nissen fundoplication had now been converted into a 270° Toupet fundoplication, which is confirmed with the EGD. The functionality of the wrap is confirmed if the "Stack of Coins" sign is present, and the wrap lies tight against the scope. A Nissen-to-Toupet fundoplication conversion using a robotic-assisted surgical technique may be useful in reducing reoperations and complications in patients undergoing fundoplication surgery.

A Rare Case of Chylothorax Following a Redo Laparoscopic Nissen Fundoplication.

Gastroesophageal reflux disease (GERD) is a highly prevalent disease. Mechanical etiology, including hiatal hernia, can be resistant to empiric proton pump inhibitor (PPI) trials; Nissen fundoplication is commonly used to treat mechanical GERD. Chylothorax is a rare complication of abdominal surgeries, including anti-reflux procedures. In this case report, a 75-year-old female presented with shortness of breath following a redo laparoscopic Nissen fundoplication. Chest CT pulmonary angiography (CTPA) showed bilateral large pleural effusions that were managed by fluid restriction, repeated thoracocentesis, and chest tube insertion; the pleural fluid analysis was significant for fluid triglycerides high at 232 mg/dL which was diagnostic for chylothorax. The patient was treated conservatively. Appropriate management of chylothorax is crucial to avoid subsequent respiratory failure, immunodeficiency, and malnutrition. Chylomicrons and triglycerides in the pleural fluid can be diagnostic for chylothorax. Treatment of chylothorax includes three main approaches: controlling the cause, conservative treatment, and surgical interventions.

A prospective randomized trial on laparoscopic total vs partial fundoplication in patients with atypical symptoms of gastroesophageal reflux disease.

BACKGROUND: Currently very little is known about the impact of anti-reflux surgery on extra-esophageal manifestations of gastroesophageal reflux disease (GERD) when compared with the typical symptoms of reflux. The aim of our study was to evaluate the clinical effect of total (360°) and partial (270°) laparoscopic fundoplication on extraesophageal GERD symptoms. METHODS: One hundred and twenty patients with documented extraesophageal GERD symptoms were randomized to either undergo floppy Nissen (n= 60) or Toupet fundoplication (n= 60). Symptom scores of throat clearing, globus sensation, cough, throat pain, and vocal changes were prospectively evaluated. A reflux symptom index (RSI) questionnaire was used to accurately document the improvement of extraesophageal symptoms. Quality of life was determined according to the laryngopharyngeal reflux-health-related quality of life (LPR-HRQL) questionnaire. RESULTS: No significant differences were identified between the groups regarding demographic data, such as age, gender, or body mass index. The median RSI score before operation and at 24-month follow-up was 22.8 ± 5.3 and 10.4 ± 5.4 respectively in the laparoscopic Nissen fundoplication (LNF) group (p < 0.05) and 21.7 ± 5.0 and 11.6 ± 5 respectively in the laparoscopic Toupet fundoplication (LTF) group (p < 0.05). The median LPR-HRQL score in the LNF group improved from 42.9 ± 13.8 before treatment to 10.7 ± 6.5 at 24 months (p < 0.05). In the LTF group, there was an improvement in the median LPR-HRQL score from 40.4 ± 10.9 prior to treatment to 11.7 ± 5.7 at 24 months (p < 0.05). The median RSI score and LPR-HRQL scores were similar between the groups at follow-up (p > 0.05). CONCLUSIONS: Our report demonstrates that LNF and LTF provide equivalently good results for patients with extraesophageal manifestations of GERD. Quality of life is similar after LNF and LTF.

The Utility of Symptom Association Probability (SAP) in Predicting Outcome After Laparoscopic Fundoplication in Patients with Abnormal Esophageal Acid Exposure.

INTRODUCTION: Abnormal DeMeester score on pH monitoring is a well-established predictor of favorable outcome after antireflux surgery (ARS). Esophageal pH monitoring also facilitates analysis of the temporal association between symptoms and reflux episodes. This association can be expressed with several symptom-reflux association indices with symptom association probability (SAP) being the most reliable. SAP is often used as an adjunct to DeMeester score during preoperative assessment of patients seeking ARS. However, data on the utility of SAP in predicting ARS outcome is limited. The aim of this study was to determine the utility of SAP as an adjunct to DeMeester score in predicting outcomes after fundoplication. METHODS: Records of patients who underwent primary fundoplication from 2015 to 2021 were reviewed. Patients with a preoperative DeMeester score >14.7 on Bravo pH monitoring were included. A SAP >95% was considered SAP-positive. Favorable outcome was defined as freedom from proton pump inhibitors (PPIs) and patient satisfaction at 1 year postoperatively. Outcomes were compared based on the presence and number of SAP-positive symptoms, individual typical and atypical SAP-positive symptoms, and within demographic, clinical, and reflux severity subgroups. RESULTS: The final study population consisted of 597 patients (71.4% female) with a median (IQR) age of 59.0 (49-67). At a mean (SD) follow-up of 10.5 (8) months, 82.0% patients achieved favorable outcome (satisfaction and freedom from PPI), freedom from PPI was 91.7%, and satisfaction was 87.4%. SAP was positive in 430 (72.0%) patients, of which 221 (37.0%) had one SAP-positive symptom, 164 (27.5%) had two SAP-positive symptoms, and 45 (7.5%) had all three SAP-positive symptoms. There was no association between having at least one SAP-positive symptom and favorable outcome (p=0.767). There was no difference in favorable outcome between patients with one, two, or all SAP-positive symptoms (0.785). Outcomes were comparable for SAP-positive typical (p=0.873) and atypical symptoms (p=1.000) and all individual symptoms (p>0.05). Outcomes were also comparable within all subgroups (p>0.05). CONCLUSION: Symptom association probability with an abnormal DeMeester score did not enhance the prediction of antireflux surgery outcome. These findings suggest that SAP should not be used in surgical decision-making in patients with objective evidence of reflux.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review.

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.