Hiatal hernias are at high risk of recurrence. Mesh reinforcement after primary approximation of the hiatal crura has been advocated to reduce this risk of recurrence, analogous to mesh repair of abdominal wall hernias. However, the results of such repairs have been mixed, at best. In addition, repairs using some type of mesh have led to significant complications, such as erosion and esophageal stricture. At present, there is no consensus as to (1) whether mesh should be used, (2) indications for use, (3) the type of mesh, and (4) in what configuration. This lack of consensus is likely secondary to the notion that recurrence occurs at the site of crural approximation. We have explored the theory that many, if not most, “recurrences” occur in the anterior and left lateral aspects of the hiatus, normally where the mesh is not placed. We theorized that “recurrence” actually represents progression of the hernia, rather than a true recurrence. This has led to our development of a new mesh configuration to enhance the tensile strength of the hiatus and counteract continued stresses from intra-abdominal pressure.
Magnetic ring (MSA) implantation in the esophagus is an alternative surgical procedure to fundoplication for the treatment of gastroesophageal reflux disease.
The aim of this study was to analyse the effectiveness and safety of magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD).
A systematic literature review of articles on MSA was performed using the Medical Literature Analysis and Retrieval System Online (Medline) database between 2008 and 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.
A total of 22 studies comprising 4,663 patients with MSA were analysed. Mean follow-up was 27.3 (7–108) months. The weighted pooled proportion of symptom improvement and patient satisfaction were 93% (95%CI 83–98%) and 85% (95%CI 78–90%), respectively. The mean DeMeester score (pre-MSA: 34.6 vs. post-MSA: 8.9, p=0.03) and GERD-HRQL score (pre-MSA: 25.8 vs. post-MSA: 4.4, p<0.0001) improved significantly after MSA. The proportion of patients taking proton pump inhibitor (PPIs) decreased from 92.8 to 12.4% (p<0.0001). The weighted pooled proportions of dysphagia, endoscopic dilatation and gas-related symptoms were 18, 13, and 3%, respectively. Esophageal erosion occurred in 1% of patients, but its risk significantly increased for every year of MSA use (odds ratio — OR 1.40, 95%CI 1.11–1.77, p=0.004). Device removal was needed in 4% of patients.
Although MSA is a very effective treatment modality for GERD, postoperative dysphagia is common and the risk of esophageal erosion increases over time. Further studies are needed to determine the long-term safety of MSA placement in patients with GERD.
Gastroesophageal reflux disease (GERD) is probably one of the most prevalent diseases in the world that also compromises the quality of life of the affected significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals.
To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it.
The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication.
Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett's esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient's quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications.
GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic methods. The clinical treatment is useful in controlling the symptoms; however, the great problem is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who required continued drug use, intolerant to the drugs and with complicated forms of GERD.
The association of gastric plication with fundoplication is a reliable option for the treatment of individuals with obesity associated with gastroesophageal reflux disease.
To describe weight loss, endoscopic, and gastroesophageal reflux disease-related outcomes of gastric plication with fundoplication in individuals with mild obesity.
A retrospective cohort study was carried out, enrolling individuals who underwent gastric plication with fundoplication at a tertiary private hospital from 2015–2019. Data regarding perioperative and weight loss outcomes, endoscopic and 24-hour pH monitoring findings, and gastroesophageal reflux disease-related symptoms were analyzed.
Of 98 individuals, 90.2% were female. The median age was 40.4 years (IQR 32.1–47.8). The median body mass index decreased from 32 kg/m2 (IQR 30,5–34) to 29.5 kg/m2 (IQR 26.7–33.9) at 1–2 years (p<0.05); and to 27.4 kg/m2 (IQR 24.1–30.6) at 2–4 years (p=0.059). The median percentage of total weight loss at 1–2 years was 7.8% (IQR −4.1–14.7) and at 2–4 years, it was 16.4% (IQR 4.3–24.1). Both esophageal and extra-esophageal symptoms showed a significant reduction (p<0.05). A significant decrease in the occurrence of esophagitis was observed (p<0.01). The median DeMeester score decreased from 30 (IQR 15.1–48.4) to 1.9 (IQR 0.93–5.4) (p<0.0001).
The gastric plication with fundoplication proved to be an effective and safe technique, leading to a significant and sustained weight loss in addition to endoscopic and clinical improvement of gastroesophageal reflux disease.
Laparoscopic total fundoplication is currently considered the gold standard for the surgical treatment of gastroesophageal reflux disease. Short-term outcomes after laparoscopic total fundoplication are excellent, with fast recovery and minimal perioperative morbidity. The symptom relief and reflux control are achieved in about 80 to 90% of patients 10 years after surgery. However, a small but clinically relevant incidence of postoperative dysphagia and gas-related symptoms is reported. Debate still exists about the best antireflux operation; during the last three decades, the surgical outcome of laparoscopic partial fundoplication (anterior or posterior) were compared to those achieved after a laparoscopic total fundoplication. The laparoscopic partial fundoplication, either anterior (180°) or posterior, should be performed only in patients with gastroesophageal reflux disease secondary to scleroderma and impaired esophageal motility, since the laparoscopic total fundoplication would impair esophageal emptying and cause dysphagia.
: Gastroesophageal reflux disease is a worldwide prevalent condition that exhibits a large variety of signs and symptoms of esophageal or extra-esophageal nature and can be related to the esophagic adenocarcinoma. In the last few years, greater importance has been given to the influence of physical exercises on it. Some recent investigations, though showing conflicting results, point to an exacerbation of gastroesophageal reflux during physical exercises.
: To evaluate the influence of physical activities in patients presenting with erosive and non erosive disease by ergometric stress testing and influence of the lower esophageal sphincter tonus and body mass index during this situation.
: Twenty-nine patients with erosive disease (group I) and 10 patients with non-erosive disease (group II) were prospectively evaluated. All the patients were submitted to clinical evaluation, followed by upper digestive endoscopy, manometry and 24 h esophageal pH monitoring. An ergometric testing was performed 1 h before removing the esophageal pH probe. During the ergometric stress testing, the following variables were analyzed: test efficacy, maximum oxygen uptake, acid reflux duration, gastroesophageal reflux symptoms, influence of the lower esophageal sphincter tonus and influence of body mass index in the occurrence of gastroesophageal reflux during these physical stress.
: Maximum oxigen consumption or VO 2 max, showed significant correlation when it was 70% or higher only in the erosive disease group, evaluating the patients with or without acid reflux during the ergometric testing (p=0,032). The other considered variables didn't show significant correlations between gastroesophageal reflux and physical activity (p>0,05).
: 1) Highly intensive physical activity can predispose the occurrence of gastroesophageal reflux episodes in gastroesophageal reflux disease patients with erosive disease; 2) light or short sessions of physical activity have no influence on reflux, regardless of body mass index; 3) the lower esophageal sphincter tonus does not influence the occurrence of reflux disease episodes during exercise testing.
Barrett’s esophagus (BE) represents the morphological premalignant manifestation of gastroesophageal reflux disease (GERD), which develops as a consequence of the dysfunction and failure of the antireflux mechanism38. BE involves the formation of intestinal metaplasia (IM) from the squamous epithelium of the esophagus, which is a reparative response to reflux-induced damage37. Although the prevalence in Western countries is about 1-2% in the general population and about 10% in population who report acid reflux symptoms, the accurate prevalence of BE in the general population is difficult to determine as the majority of individuals with BE are not diagnosed40,42. Epidemiological and histopathological evidence indicate that many cases of esophageal adenocarcinoma (EAC) arise in individuals with BE by the progression of IM (nondysplastic Barrett’s esophagus [NDBE]) and indefinite for dysplasia (IND) to dysplasia (including low-grade dysplasia [LGD] and high-grade dysplasia [HGD]) and finally to neoplasia46. To date, dysplasia remains the best available marker of cancer risk in patients with BE.
Since BE is considered a complication of chronic GERD, it is perhaps not surprising that risk factors for gastric reflux are also strongly associated with BE30,54. Reflux-induced injury has been linked to cellular and molecular changes in the esophagus12,39. Symptoms of heartburn and regurgitation are strongly associated with the presence of BE, and duration of GERD symptoms may also be a risk factor for BE7. Although GERD is a strong risk factor for both BE and EAC, 40-50% of patients with these disorders do not report chronic reflux symptoms, suggesting that silent reflux or other risk factors such as male sex57, age 50 or older43, white race58, central obesity28, and cigarette smoking9 also likely play a role in the pathogenesis of BE and EAC.
Although BE is well-established precursor for EAC, the assumption that all patients who develop EAC go through the same reflux-induced response leading to adenocarcinoma was challenged by a retrospective analysis that found that only 46% of patients with EAC presented with endoscopic confirmation of BE and histopathological evidence of IM45. Furthermore, comparison of patients with EAC who had confirmed BE at presentation to those without BE suggested the existence of two EAC phenotypes with different tumor behavior and response to therapy45. These findings raise the question of whether EAC always develops through the IM-dysplasia-EAC sequence.
Accepting that a controversy exists, the natural course of progression to dysplasia and cancer in BE in the majority of patients is thought to be stepwise from NDBE to LGD to HGD and cancer. The annual cancer risk depends on the degree of dysplasia, such as 0.33% if there is no dysplasia, 0.54% with LGD, and 7% with HGD47. Thus, the management is based on disease stages.
Proton-pump inhibitor (PPI) therapy is recommended to control reflux symptoms in patients with NDBE. The American College of Gastroenterology (ACG)47, American Gastroenterological Association (AGA)52, and American Society for Gastrointestinal Endoscopy (ASGE)46 all recommend that surveillance endoscopy with four-quadrant biopsies at 2-cm intervals every 3-5 years for NDBE. PPI therapy is associated with a 71% decrease in the risk of developing HGD and EAC in patients with BE50. Long-term therapy (>2-3 years) has a higher protective effect50. Chemoprevention to inhibit the progression to cancer in patients with BE is currently being assessed. Various medications such as aspirin, metformin, and statins have been studied. A randomized controlled trial indicated that the combination of high-dose esomeprazole plus aspirin had the strongest protective effect compared with low-dose esomeprazole without aspirin at a median follow-up of 8.9 years25. However, the ACG guidelines do not currently recommend chemoprevention for all patients with BE, but suggest it should be considered in patients with BE who are appropriate candidates for aspirin use for cardioprotection47.
In BE IND, either the epithelial abnormalities are insufficient for a diagnosis of dysplasia, or the nature of the epithelial abnormalities is uncertain due to inflammation or technical difficulties with specimen processing. The risk of HGD or cancer within 1 year of the diagnosis of IND varies between 1.9% and 15%55. The recommendation from ACG47 for management is to optimize acid suppressive therapy for 3-6 months and then to repeat esophagogastroduodenoscopy (EGD). If indefinite dysplasia is noted again, repeat endoscopy in 12 months is recommended59.
Most patients with an initial diagnosis of LGD (73%) are downstaged to NDBE or to IND after review by expert gastrointestinal pathologists10. Patients with confirmed and persistent LGD are at higher risk of progression11. Once LGD is confirmed by a second gastrointestinal pathologist, the patient should be considered for endoscopic ablation. A landmark study demonstrated the benefit of radiofrequency ablation in achieving complete eradication of dysplasia (90.5% vs. 22.7% for a sham procedure) and complete eradication of IM (77.4% vs. 2.3% for a sham procedure)49. Patients with confirmed LGD who do not undergo eradication therapy should have surveillance endoscopy every 6-12 months.
As with LGD, the diagnosis of HGD needs to be confirmed by a second pathologist with gastrointestinal expertise. In the past, the treatment was esophagectomy, but due to demonstrated lower morbidity and equivalent efficacy of radiofrequency ablation, the current treatment of choice is endoscopic mucosal resection (EMR) of raised lesions, followed by radiofrequency ablation of the entire affected segment23. Pathology is best assessed by EMR, especially in areas of nodularity and ulceration. A randomized controlled study of 42 patients with HGD was randomized between radiofrequency ablation and sham procedure. Complete eradication of dysplasia was achieved in 81% of ablation patients versus 19% with the sham procedure49. Eradication of IM was achieved in 77% of ablation patients versus 2% of patients with the sham therapy49. Results of 3-year follow-up from the same cohort showed complete eradication of dysplasia in 98% and of IM in 91%48. Endoscopic eradication therapy is recommended for all patients with BE and HGD without the potential comorbidity and side effects associated with esophageal resection. Short segment Barrett’s (<3 cm) with HGD can also be assessed for complete ablation with EMR alone. Alternatively, surveillance every 3 months is an option if the patient does not wish to undergo eradication therapy48.
Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested.
This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C).
This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up.
Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery.
Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.
The influence of body mass index on perioperative complications of hiatal hernia surgery is controversial in the surgical literature.
The aim of this study was to evaluate the influence of body mass index on perioperative complications and associated risk factors for its occurrence.
Two groups were compared on the basis of body mass index: group A with body mass index <32 kg/m2 and group B with body mass index ³32 kg/m2. A multivariate analysis was carried out to identify independent predictors for complications. Complications were classified based on the Clavien-Dindo score.
A total of 49 patients were included in this study, with 30 in group A and 19 in group B. The groups were compared based on factors, such as age, Charlson Comorbidity Index, surgical techniques used, type and location of hiatal hernia, and length of stay. Findings showed that 70% of patients had complex hiatal hernia. In addition, 14 complications also occurred: 7 pleuropulmonary and 7 requiring reoperation. From the seven reoperated, there were three recurrences, two gastrointestinal fistulas, one diaphragmatic hernia, and one incisional hernia. Complications were similar in both the groups, with type IV hiatal hernia being the only independent predictor.
Body mass index does not affect perioperative complications in anti-reflux surgery and type IV hiatal hernia is an independent predictor of its occurrence.
Laparoscopic Roux-en-Y gastric bypass (LGB) is the recommended procedure for morbidly obese patients with gastroesophageal reflux disease (GERD). However, there have been reported gastroesophageal reflux symptoms or esophagitis after LGB. Few functional esophageal studies have been reported to date.
To evaluate the anatomic and physiologic factors contributing to the appearance of these problems in patients who underwent LGB.
This prospective study included 38 patients with postoperative gastroesophageal reflux symptoms submitted to LGB. They were subjected to clinical, endoscopic, radiologic, manometric, and 24-h pH-monitoring evaluations.
Eighteen (47.4%) of 38 patients presented with heartburn or regurgitation, 7 presented with pain, and 4 presented with dysphagia. Erosive esophagitis was observed in 11 (28.9%) patients, and Barrett’s esophagus (5.7%) and jejunitis (10.5%) were also observed. Hiatal hernia was the most frequent finding observed in 15 (39.5%) patients, and most (10.5%) of these patients appeared with concomitant anastomotic strictures. A long blind jejunal loop was detected in one (2.6%) patient. Nearly 75% of the patients had hypotensive lower esophageal sphincter (9.61±4.05 mmHg), 17.4% had hypomotility of the esophageal body, and 64.7% had pathologic acid reflux (% time pH <4=6.98±5.5; DeMeester’s score=32.4±21.15).
Although rare, it is possible to observe gastroesophageal reflux and other important postoperative symptoms after LGB, which are associated with anatomic and physiologic abnormalities at the esophagogastric junction and proximal gastric pouch.
Desenvolvido por Surya MKT