Trends in gastrostomy tube placement with concomitant Nissen fundoplication for infants and young children at Pediatric Tertiary Centers.

PURPOSE: In infants and toddlers, gastrostomy tube placement (GT) is typically accompanied by consideration of concomitant Nissen fundoplication (NF). Historically, rates of NF have varied across providers and institutions. This study examines practice variation and longitudinal trends in NF at pediatric tertiary centers. METHODS: Patients ≤ 2 years who underwent GT between 2008 and 2018 were identified in the Pediatric Health Information System database. Patient demographics and rates of NF were examined. Descriptive statistics were used to evaluate the variation in the proportion of GT with NF at each hospital, by volume and over time. RESULTS: 40,348 patients were identified across 40 hospitals. Most patients were male (53.8%), non-Hispanic white (49.5%) and publicly-insured (60.4%). Rates of NF by hospital varied significantly from 4.2 to 75.2% (p < 0.001), though were not associated with geographic region (p = 0.088). Rates of NF decreased from 42.8% in 2008 to 14.2% in 2018, with a mean annual rate of change of - 3.07% (95% CI - 3.53, - 2.61). This trend remained when stratifying hospitals into volume quartiles. CONCLUSION: There is significant practice variation in performing NF. Regardless of volume, the rate of NF is also decreasing. Objective NF outcome measurements are needed to standardize the management of long-term enteral access in this population.

Advances in the diagnosis and management of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a multifaceted disorder encompassing a family of syndromes attributable to, or exacerbated by, gastroesophageal reflux that impart morbidity, mainly through troublesome symptoms. Major GERD phenotypes are non-erosive reflux disease, GERD hypersensitivity, low or high grade esophagitis, Barrett's esophagus, reflux chest pain, laryngopharyngeal reflux, and regurgitation dominant reflux. GERD is common throughout the world, and its epidemiology is linked to the Western lifestyle, obesity, and the demise of Helicobacter pylori. Because of its prevalence and chronicity, GERD is a substantial economic burden measured in physician visits, diagnostics, cancer surveillance protocols, and therapeutics. An individual with typical symptoms has a fivefold risk of developing esophageal adenocarcinoma, but mortality from GERD is otherwise rare. The principles of management are to provide symptomatic relief and to minimize potential health risks through some combination of lifestyle modifications, diagnostic testing, pharmaceuticals (mainly to suppress or counteract gastric acid secretion), and surgery. However, it is usually a chronic recurring condition and management needs to be personalized to each case. While escalating proton pump inhibitor therapy may be pertinent to healing high grade esophagitis, its applicability to other GERD phenotypes wherein the modulating effects of anxiety, motility, hypersensitivity, and non-esophageal factors may dominate is highly questionable.

Clinical outcomes of gastroesophageal reflux disease-related chronic cough following antireflux fundoplication.

BACKGROUND: Despite the effectiveness of antireflux fundoplication for typical gastroesophageal reflux disease, outcomes regarding surgical therapy for patients with gastroesophageal reflux disease-related chronic cough are currently unclear. The purpose of this study was to evaluate whether antireflux surgery for patients with chronic cough is effective, and to assess the correlation between indexes, such as symptom index and symptom association probability, and response to surgery. METHODS: We performed a retrospective review of a prospectively collected database from a 3-site institution from 2013 to 2017. Of 1149 patients who underwent antireflux surgery, 41 presented with chronic cough as a main symptom related to gastroesophageal reflux disease. Preoperatively, patients underwent a symptom assessment, esophagogastroduodenoscopy, esophageal 24-h pH monitoring, and manometry. Patients were followed up at 6 weeks and 12 months post-surgery. RESULTS: Thirty-three (80.5%) patients underwent Nissen fundoplication, while 8 (19.5%) underwent Toupet fundoplication. Isolated chronic cough was present in 8 (19.5%) patients, and median (range) DeMeester score was 28.9 (0.3-96.7). After 12-month follow-up, chronic cough was absent in 28 (68.3%) patients (P = .02). Typical reflux symptoms responded well to surgery, but response was not optimal. Postoperative dysphagia and atypical reflux symptoms were slightly worse on long-term follow-up; however, differences were not significant (P ≥ .2). When examining how the different symptom indexes correlated with complete, partial, or no response in patients with gastroesophageal reflux disease-related cough, there was no notable agreement on predicted response to surgery. CONCLUSIONS: Antireflux surgery, although less predictable, is effective for the treatment of gastroesophageal reflux disease-related chronic cough.

Effectiveness of transoral incisionless fundoplication compared to Toupet fundoplication for chronic or refractory gastroesophageal reflux disease: a systematic review protocol.

REVIEW OBJECTIVE/QUESTION: The objective of this review is to determine which 270-degree fundoplication procedure has a better outcome in patients with chronic or refractory gastroesophageal reflux disease (GERD). This review will identify the fundoplication approach for chronic or refractory GERD that provides better reflux control with minimal post-procedure complications.The question of this review is: what is the effectiveness of transoral incisionless fundoplication compared to Toupet fundoplication in adult patients with chronic or refractory GERD?

A modified Nissen fundoplication: subjective and objective midterm results.

PURPOSE: The failure rate of laparoscopic anti-reflux surgery is approximately 10-20%. The aim of our prospective study was to investigate whether a modified Nissen fundoplication (MNF) can improve reflux symptoms and prevent surgical treatment failure in the midterm. METHODS: The MNF consisted of (1) suturing the esophagus to the diaphragmatic crura on each side using four non-absorbable stitches, (2) reinforcing clearly weak crura with a tailored Ultrapro mesh, and (3) fixing the upper stitch of the valve to the diaphragm. Forty-eight consecutive patients experiencing typical gastroesophageal reflux disease (GERD) symptoms at least three times per week for 6 months or longer were assessed before and after surgery using validated symptom and quality of life (GERD-HRQL) questionnaires, high-resolution manometry, 24-h impedance-pH monitoring, endoscopy, and barium swallow. RESULTS: Mortality and perioperative complications were nil. At median follow-up of 46.7 months, the patients experienced significant improvements in symptom and GERD-HRQL scores. One patient presented with severe dyspepsia and another complained of dysphagia requiring a repeat surgery 12 months after the first operation. Esophageal acid exposure (8.8 vs 0.1; p < 0.0001), reflux number (62 vs 8.5; p < 0.0001), and symptom-reflux association (19 vs 0; p < 0.0001) significantly decreased postoperatively. The median esophagogastric junction contractile integral (EGJ-CI) from 31 cases (8.2 vs 21.2 mmHg cm; p = 0.0003) and the abdominal length of the lower esophageal sphincter (LES) (0 vs 16 mm; p = 0.01) increased postoperatively. CONCLUSIONS: Our data demonstrate that the MNF is a safe and effective procedure both in the short term and midterm.

Current Trends in the Management of Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) characterized by heartburn and/or regurgitation symptoms is one of the most common gastrointestinal disorders managed by gastroenterologists and primary care physicians. There has been an increase in GERD prevalence, particularly in North America and East Asia. Over the past three decades proton pump inhibitors (PPIs) have been the mainstay of medical therapy for GERD. However, recently there has been an increasing awareness amongst physicians and patients regarding the side effects of the PPI class of drugs. In addition, there has been a marked decline in the utilization of surgical fundoplication as well as a rise in the development of nonmedical therapeutic modalities for GERD. This review focuses on different management strategies for GERD, optimal management of refractory GERD with special focus on available endoluminal therapies and the future directions.

Utilization and costs associated with robotic surgery in children.

BACKGROUND: To evaluate utilization and costs associated with robotic surgery in children. MATERIALS AND METHODS: We identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. RESULTS: The number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. CONCLUSIONS: Use of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Surgical treatment of GERD: where have we been and where are we going?

Surgical management of gastroesophageal reflux disease has evolved from relatively invasive procedures requiring open laparotomy or thoracotomy to minimally invasive laparoscopic techniques. Although side effects may still occur, with careful patient selection and good technique, the overall symptomatic control leads to satisfaction rates in the 90% range. Unfortunately, the next evolution to endoluminal techniques has not been as successful. Reliable devices are still awaited that consistently produce long-term symptomatic relief with correction of pathologic reflux. However, newer laparoscopically placed devices hold promise in achieving equivalent symptomatic relief with fewer side effects. Clinical trials are still forthcoming.

Wrapped in controversy: trends in fundoplication at myotomy for achalasia in Christchurch, New Zealand.

AIM: A surgical approach to the management of achalasia involves myotomy, typically with added anti-reflux procedure. The most appropriate fundoplication in this setting (total Nissen, partial anterior Dor, or partial posterior Toupet) remains controversial. We present the trends in fundoplication procedures performed at myotomy in Christchurch between 1997 and 2009, and compare this with the literature. METHODS: 34 cases of achalasia managed with myotomy and various types of fundoplication in Christchurch between 1997 and 2009 were separated into two temporal groups, and the type of surgery in each group analysed. Data was obtained from the clinical records on specific short and long-term postoperative complications. RESULTS: There is a decrease over time in myotomy without fundoplication and in total Nissen fundoplications performed. The number of posterior fundoplications remains equal over both time periods; however the proportion of anterior fundoplications is significantly increased in the later group. Three cases of mucosal perforation occurred during myotomy associated with anterior fundoplication, and reintervention rates were highest in myotomy only and anterior fundoplication patients. CONCLUSION: Trends in anti-reflux surgery in Christchurch reflect the development of the evidence base in the literature. The change in fundoplication procedure is not clearly explained by the complication rates.

Twenty years of experience with laparoscopic antireflux surgery.

BACKGROUND: There are few reports of large patient cohorts with long-term follow-up after laparoscopic antireflux surgery. This study was undertaken to evaluate changes in surgical practice and outcomes for laparoscopic antireflux surgery over a 20-year period. METHODS: A standardized questionnaire, prospectively applied annually, was used to determine outcome for all patients undergoing laparoscopic fundoplication in two centres since commencing this procedure in 1991. Visual analogue scales ranging from 0 to 10 were used to assess symptoms of heartburn, dysphagia and satisfaction with overall outcome. Data were analysed to determine outcome across 20 years. RESULTS: From 1991 to 2010, 2261 consecutive patients underwent laparoscopic fundoplication at the authors' institutions. Follow-up ranged from 1 to 19 (mean 7.6) years. Conversion to open surgery occurred in 73 operations (3.2 per cent). Revisional surgery was performed in 216 patients (9.6 per cent), within 12 months of the original operation in 116. There was a shift from Nissen to partial fundoplication across 20 years, and a recent decline in operations for reflux, offset by an increase in surgery for large hiatus hernia. Dysphagia and satisfaction scores were stable, and heartburn scores rose slightly across 15 years of follow-up. Heartburn scores were slightly higher and reoperation for reflux was more common after anterior partial fundoplication (P = 0.005), whereas dysphagia scores were lower and reoperation for dysphagia was less common (P < 0.001). At 10 years, satisfaction with outcome was similar for all fundoplication types. CONCLUSION: Laparoscopic Nissen and partial fundoplications proved to be durable and achieved good long-term outcomes. At earlier follow-up, dysphagia was less common but reflux more common after anterior partial fundoplication, although differences had largely disappeared by 10 years.

[Gastroesophageal reflux disease -- current trends]. / Boala de reflux gastro-esofagian--tendinte actuale.

GERD has long been recognized as a significant public health concern in USA generating along the time, many disscusions between gastroenterologists and surgeons. Once antireflux barrier was identified, and mechanism of reflux established, GERD can be defined as the failure of the antireflux barrier (represented especially by the lower esophageal sphincter, by gastric empty disorders or failed esophageal peristalsis), allowing abnormal reflux of gastric contents into the esophagus. Positiv diagnosis is setting by the presence of documented esophageal mucosal injury (esophagitis) or excessive reflux during 24 hours intra-edophageal pH monitoring. Medical treatament is efficient in acid suppression, but does not address the mechanical etiology, is too expansive and affect the quality of life of pacients. Miniinvasive surgery was a boom in management of GERD, offering great sathysfaction to pacients, low costs and rapid social integration. We present in folwing pages the role of surgery in GERD, therapy GERD which occur 85-93% control of reflux simptomathology, providing data from the literature on the techniques used, their advantages and limitations.

Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons.

BACKGROUND/PURPOSE: The purpose of the study was to identify influential factors contributing to the variation with which antireflux procedures (ARPs) are performed at freestanding children's hospitals in the United States. METHODS: We conducted an online survey of pediatric surgeons working in Child Health Corporation of America (CHCA) member hospitals in which we examined decision making for ARPs. RESULTS: Thirty-six percent (n = 121) of contacted surgeons responded. Eighty percent reported requiring preoperative upper gastrointestinal series before ARPs, and 13% require a pH probe study. Although surgeons ranked their own opinion as the most important in preoperative decision making, parents and referring physicians played significant roles in hypothetical scenarios. In children with negative/equivocal objective studies, more than half of surgeons reported offering ARP when the referring specialist felt that ARP was indicated. Despite equivocal studies, 20% of the surgeons reported offering ARP when the parents were convinced that ARP would help. In a patient with both a positive pH probe and upper gastrointestinal series, 46% of surgeons reported declining ARP if parents were hesitant. CONCLUSIONS: These data suggest that a surgeon's final decision to perform ARP may be just as influenced by nonobjective factors, such as referring physician and parental opinions, as it is by objective studies. Our survey reinforces the need for further examination of specific factors in preoperative decision making for ARPs in the pediatric population.

Twenty years of laparoscopic fundoplication for GERD.

The first laparoscopic Nissen fundoplication was performed 20 years ago. Surgical management of gastroesophageal reflux disease (GERD) should be offered only to appropriately studied and selected patients, with the ultimate aim of improving the well-being of the individual, the "quality of life." The choice of fundoplication should be dictated by the surgeon's preference and experience.

Trends and perioperative outcomes of inpatient antireflux surgery in the United States, 1993-2006.

Antireflux surgery is an effective treatment for gastroesophageal reflux disease, but postoperation complications and durability may be problematic. The objective of the study was to determine whether inpatient antireflux surgery continued to decline in the United States due to concerns about its long-term effectiveness and the popularity of gastric bypass surgery and to assess recent changes in its perioperative outcomes. Using the Nationwide Inpatient Sample, we identified adult patients undergoing inpatient antireflux surgery during 1993-2006 and compared the trends of inpatient antireflux surgery with inpatient gastric bypass surgery. Perioperative complications included laceration, splenectomy, transfusion, esophageal dilation, total parenteral nutrition, and infection. Inpatient antireflux surgery increased from 9173 in 1993 to 32 980 in 2000 (+260%) but then decreased to 19 668 in 2006 (-40%). Compared with 2000, patients undergoing inpatient antireflux surgery in 2006 were older (49.9 ± 32.4 vs. 54.6 ± 33.6 years) and had a longer length of stay (3.1 ± 10.0 vs. 3.7 ± 13.4 days), more complications (4.7% vs. 6.1%), and higher mortality (0.26% vs. 0.54%) (all P < 0.05). Compared with inpatient gastric bypass surgery, length of stay was longer and mortality was higher for inpatient antireflux surgery in 2006, but neither was significant controlling for age. In 2006, perioperative outcomes of inpatient antireflux surgery were better in high-volume hospitals (all P < 0.01). Inpatient antireflux surgery continued to decline in the United States from 2000 to 2006, concomitant with a dramatic increase in inpatient gastric bypass surgery. Older patient age and worsening perioperative outcomes for inpatient antireflux surgery suggest increased medical complexity and possibly a larger share of reoperations over time. Designating centers of excellence for antireflux surgery based on local expertise may improve outcomes.

Changing work patterns for benign upper gastrointestinal and biliary disease: 1994-2007.

BACKGROUND: The evolution of surgical technology has impacted on surgical practice. We determined trends in surgical caseload for common benign biliary and upper gastrointestinal conditions in Australia over the last 15 years. METHODS: Using the Medicare Australia web site, the use of Medicare item numbers specific to gall stone, bariatric and anti-reflux procedures were determined nationally and for each Australian state for each year from 1994 to 2007. Rates of operative cholangiography, laparoscopic to open cholecystectomy conversion and bile duct exploration were calculated. Per capita use of bariatric procedures was also determined. Anti-reflux surgery was analysed as total and specific subgroups of anti-reflux procedures. RESULTS: The use of intra-operative cholangiography has increased over time, and the conversion to open cholecystectomy and application of common bile duct exploration both decreased. A rapid increase in restrictive bariatric procedures has occurred, and this has been followed by a similar increase in revision bariatric surgery and lap band adjustments. The application of anti-reflux surgery has also increased significantly with the repair of large hiatus hernia accounting for most of the increase over the last five years, whereas revision anti-reflux surgery remains uncommon. CONCLUSIONS: These data demonstrate significant increases in the application of some laparoscopic surgical techniques, particularly for morbid obesity. Future health-care planning will need to consider the impact of these changes.

[Rises and falls of antireflux surgery].

The review of world literature highlights the evolution of antireflux surgery. Based on the literature review reflected the appropriateness of antireflux operations in the period of increasing prevalence of GERD complications with a view to their prevention, as well as the historical stages of fundoplication development. The failures and complications of antireflux operations depending on the choice of fundoplication and method of surgical access has been still interesting. The tendency to the preoperative examination of patients has been noted in recent world surgical practice as try to reduce the prevalence of postoperative failures.