Cruroplasty with or without mesh? A systematic literature review with a novel time-organized proportion meta-analysis.

BACKGROUND: Improved outcomes with the use of non-absorbable mesh (NAM) for inguinal hernia repairs led to its rapid adoption for hiatal hernia (HH) repairs; however, feared complications occurred, and the trend shifted toward using absorbable mesh (AM). We aimed to analyze the literature assessing objective HH recurrence rates after primary laparoscopic cruroplasty with or without the use of different mesh types. METHODS: A systematic literature review with both pairwise and time-organized proportion meta-analyses of articles published between January 1993 and September 2022 was performed using the MEDLINE, EMBASE, and Taylor & Francis databases to identify relevant studies comparing groups undergoing cruroplasty with suture repair (SR) alone, AM, NAM, or partially absorbable mesh (PAM). Studies documenting an objective follow-up ≥ 6 months were included. The primary outcome was the HH recurrence rate confirmed by barium esophagram or upper GI endoscopy. RESULTS: A total of 34 studies met the inclusion criteria, including 6 randomized clinical trials, 25 retrospectives studies, and 3 prospective cohort studies. A total of 2170 subjects underwent laparoscopic HH repair and completed an objective follow-up ≥ 6 months after surgery; the objective recurrence rate was 20.8% (99/477) at a mean follow-up of 25.8 ± 16.4 months for the SR group, 20.6% (244/1187) at 28.1 ± 13.8 months for the AM group, 13.7% (65/475) at 30.8 ± 15.3 months for the NAM group, and 0% (0/31) at 32.5 ± 13.5 months for the PAM group. However, the pairwise meta-analysis revealed that overall mesh use was not superior to SR in preventing long-term HH recurrence. CONCLUSION: The use of AM does not appear to reduce HH recurrence compared to SR alone. Although the data favors NAM to decrease objective HH recurrence in the mid-term, the long-term (≥ 48 months) recurrence rate was similar with or without any type of mesh.

Prevalence and severity of abdominal bloating in patients with gastroesophageal reflux disease.

Abdominal bloating (AB) is a common symptom among patients with gastroesophageal reflux disease (GERD); however, in clinical practice, its prevalence is likely underestimated due to the lack of objective tools to measure its frequency and severity. It is associated with dissatisfaction and worse quality of life, but data on its prevalence before and after mechanical control of GERD (i.e. fundoplication, magnetic sphincter augmentation, and antireflux mucosectomy) are lacking. To assess and determine the pre- and postoperative prevalence and severity of AB among patients with GERD, we conducted a structured literature search using MeSH and free-text terms in MEDLINE (via Pubmed), EMBASE, and Taylor & Francis Online between January 1977 and October 2022. Fifteen articles reporting the prevalence or severity of AB using quality-of-life questionnaires before or after antireflux surgery (ARS) were included. Overall, a high prevalence of AB before ARS was found. A decline in the prevalence and severity of AB was documented postoperatively in most cases independent of the surgical approach. Among surgical approaches, a complete fundoplication had the highest reported postoperative AB. Overall, patients reported less severe and less frequent AB after ARS than before. The traditional belief that postoperative bloating is a sequela of ARS should be reevaluated.

Pulmonary and esophageal function in lung transplantation: Fundamental principles and clinical application.

The lungs and esophagus have a close anatomical and physiological relationship. Over the years, reflux-induced pulmonary injury has gained wider recognition, but the full effects of pulmonary disease on esophageal function are still unknown. Intrathoracic pressure dynamics potentially affect esophageal function, especially in patients with end-stage lung disease, both obstructive and restrictive. Lung transplantation is the only viable option for patients with end-stage pulmonary disease and has provided us with a unique opportunity to study these effects as transplantation restores the intrathoracic environment. Esophageal and foregut functional testing before and after transplantation provide insights into the pathophysiology of the foregut-pulmonary axis, such as how underlying pulmonary disease and intrathoracic pressure changes affect esophageal physiology. This review summarizes the available literature and shares the research experience of a lung transplant center, covering topics such as pre- and posttransplant foregut function, esophageal motility in lung transplant recipients, immune-mediated mechanisms of graft rejection associated with gastroesophageal reflux, and the role of antireflux surgery in this population.

Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience.

PURPOSE: Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center. METHODS: After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed. RESULTS: During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5 days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length of ICU and total hospital stays were 11.5 and 22.5 days, respectively. There was no 30-day mortality. CONCLUSION: The incidence of esophageal ALs at our center is similar to that of other high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.

Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center.

BACKGROUND: Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues. METHODS: After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed. RESULTS: A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality. CONCLUSIONS: HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.

Magnetic sphincter augmentation may limit access to magnetic resonance imaging.

Magnetic sphincter augmentation (MSA) is an alternative surgical treatment for gastroesophageal reflux disease; however, >1.5 T magnetic resonance imaging (MRI) is contraindicated for patients who have undergone MSA with the LINX Reflux Management System (Torax Medical, Inc. Shoreview, Minnesota, USA). This drawback can impose a barrier to access of MRI, and cases of surgical removal of the device to enable patients to undergo MRI have been reported. To evaluate access to MRI for patients with an MSA device, we conducted a structured telephone interview with all diagnostic imaging providers in Arizona in 2022. In 2022, only 54 of 110 (49.1%) locations that provide MRI services had at least one 1.5 T or lower MRI scanner. The rapid replacement of 1.5 T MRI scanners by more advanced technology may limit healthcare options and create an access barrier for patients with an MSA device.

Antireflux surgery versus medical management of gastro-oesophageal reflux after lung transplantation.

OBJECTIVES: Gastro-oesophageal reflux disease after lung transplantation may be associated with chronic lung allograft dysfunction. Aspiration may continue on medical management of reflux, but antireflux surgery potentially reduces all reflux. We compared outcomes between medical and surgical management of reflux in lung recipients. METHODS: Lung recipients with an elevated DeMeester score (≥14.72) on post-transplant reflux testing between 2015 and 2020 were included. Patients were divided into 2 groups: group A (underwent surgery) and group B (medically managed). Endpoints were pulmonary function, allograft dysfunction-free survival and overall survival. Further analysis included subgroups: A1 (early surgery, <6 months) and A2 (late surgery, >6 months), and B1 (DeMeester <29.9) and B2 (DeMeester ≥30). RESULTS: A total of 186 included subjects were divided into groups A [n = 46 (A1, n = 36; A2, n = 10)] and B [n = 140 (B1, n = 78; B2, n = 62)]. Compared to medically managed patients, patients who underwent surgery had a higher prevalence of hiatal hernia (P < 0.001) and a lower prevalence of oesophageal motility disorders (P = 0.036). Recipients who underwent surgery had superior pulmonary function at 5 years compared to group B (P < 0.05) and longer allograft dysfunction-free survival than subgroup B2 (P = 0.028). Furthermore, early surgery was associated with longer survival than late surgery (P = 0.021). CONCLUSIONS: Antireflux surgery in recipients with reflux improved long-term allograft function, and early surgery showed a survival benefit. Allograft dysfunction-free survival of lung recipients who underwent surgery was significantly better than that of medically managed patients with DeMeester ≥30. We present an algorithm for appropriate selection of candidates for antireflux surgery after lung transplantation.

Magnetic sphincter augmentation for gastroesophageal reflux in overweight and obese patients.

Magnetic sphincter augmentation (MSA) is a successful treatment option for chronic gastroesophageal reflux disease; however, there is a paucity of data on the efficacy of MSA in obese and morbidly obese patients. To assess the relationship between obesity and outcomes after MSA, we conducted a literature search using MeSH and free-text terms in MEDLINE, EMBASE, Cochrane and Google Scholar. The included articles reported conflicting results regarding the effect of obesity on outcomes after MSA. Prospective observational studies with larger sample sizes and less statistical bias are necessary to understand the effectiveness of MSA in overweight and obese patients.

Association Between Antibodies Against Lung Self-Antigens and Gastroesophageal Reflux in Lung Transplant Candidates.

Gastroesophageal reflux (GER) and pretransplant antibodies against lung self-antigens (SAbs) collagen-V and/or k-alpha 1 tubulin are both independently associated with allograft dysfunction after lung transplantation (LTx). The role of GER in inducing lung injury and SAbs is unknown. We aimed to study the association between pre-LTx GER and SAbs. After IRB approval, we retrieved SAb assays conducted between 2015 and 2019 and collected 24 hour GER data for these patients. Patients were divided into 2 groups: no reflux (GER-) and pathologic reflux (GER+) to compare the prevalence of SAbs. Multivariate analysis was used to study the association between GER and SAbs in the whole cohort and in restrictive lung disease (RLD) and obstructive lung disease (OLD) subsets. Proximal esophageal reflux (PER) events ≥5 was considered abnormal. Patients (n = 134; 73 men) were divided into groups: GER- (54.5%, n = 73) and GER+ (45.5%, n = 61). The prevalence of GER was higher in the RLD than in the OLD subset (p < 0.001). The overall prevalence of SAbs was 53.7% (n = 72), higher in the GER+ than the GER- group (65.6% vs 43.8%, p = 0.012), but comparable between RLD and OLD subsets. Overall, SAbs were associated with GER (p = 0.012) and abnormal PER (p = 0.017). GER and abnormal PER increased the odds of SAbs in the RLD subset (OR [95% CI]: 2.825 [1.033-7.725], p = 0.040 and OR [95% CI]: 3.551 [1.271-9.925], p = 0.014, respectively) but not in the OLD subset. LTx candidates have a high prevalence of SAbs, which are significantly associated with GER and abnormal PER in patients with RLD.

Morbidity of antireflux surgery in lung transplant and matched nontransplant cohorts is comparable.

BACKGROUND: Safety data on perioperative outcomes of laparoscopic antireflux surgery (LARS) after lung transplantation (LT) are lacking. We compared the 30-day readmission rate and short-term morbidity after LARS between LT recipients and matched nontransplant (NT) controls. METHODS: Adult patients who underwent LARS between January 1, 2015, and October 31, 2021, were included. The participants were divided into two groups: LT recipients and NT controls. First, we compared 30-day readmission rates after LARS between the LT and NT cohorts. Next, we compared 30-day morbidity after LARS between the LT cohort and a 1-to-2 propensity score-matched NT cohort. RESULTS: A total of 1328 patients (55 LT recipients and 1273 NT controls) were included. The post-LARS 30-day readmission rate was higher in LT recipients than in the overall NT controls (14.5% vs. 2.8%, p < 0.001). Compared to matched NT controls, LT recipients had a lower prevalence of paraesophageal hernia, a smaller median hernia size, and higher peristaltic vigor. Also compared to the matched NT controls, the LT recipients had a lower median operative time but a longer median length of hospital stay. The proportion of patients with a post-LARS event within 30 postoperative days was comparable between the LT and matched NT cohorts (21.8% vs 14.5%, p = 0.24). CONCLUSIONS: Despite a higher perceived risk of comorbidity burden, LT recipients and matched NT controls had similar rates of post-LARS 30-day morbidity at our large-volume center with expertise in transplant and foregut surgery. LARS after LT is safe.

Factors associated with esophageal motility improvement after bilateral lung transplant in patients with an aperistaltic esophagus.

OBJECTIVES: We reported that esophageal peristalsis can improve after lung transplant (LTx), even in patients with pretransplant esophageal aperistalsis. This improvement was associated with better outcomes. We analyzed preoperative factors and sought to predict persistent aperistalsis or motility improvement in patients with pre-LTx esophageal aperistalsis. METHODS: Patients with esophageal aperistalsis who underwent LTx between January 2013 and December 2016 were included. Preoperative barium esophagrams were blinded and re-examined; subjective scores were assigned to motility and dilation patterns. Postoperative high-resolution manometry was used to divide patients into 2 groups: persistent esophageal aperistalsis (PEA) or improved esophageal peristalsis (IEP). RESULTS: We identified 29 patients: 20 with restrictive lung disease, 7 with obstructive lung disease, and 2 with pulmonary arterial hypertension. Post-LTx, 10 patients had PEA and 19 had IEP (mean age, 53.3 ± 6.6 years and 61.2 ± 10.6 years, respectively; P = .04). All 9 patients (100%) with obstructive lung disease or pulmonary arterial hypertension but only 10 of 20 patients (50%) with restrictive lung disease had IEP post-LTx (P = .01). All 4 patients with scleroderma had PEA. Nearly absent contractility on preoperative esophagrams was more prevalent in the PEA group than in the IEP group (100% vs 58.8%; P = .06). No further differences were observed between the groups. CONCLUSIONS: Patients with esophageal aperistalsis and obstructive lung disease or pulmonary arterial hypertension, but not patients with restrictive lung disease and scleroderma, are likely to have IEP post-LTx. Additional studies may determine whether subjective esophagram assessment can help predict IEP post-LTx in patients with restrictive lung disease without scleroderma.

Redo fundoplication and early Roux-en-Y diversion for failed fundoplication: a 3-year single-center experience.

BACKGROUND: Redo fundoplication (RF) and Roux-en-Y diversion (RNY) are both accepted surgical treatments after failed fundoplication. However, due to higher reported morbidity, RNY is more commonly performed only after several surgical failures. In our experience, RNY at an earlier point of the disease progression seems to be related with better outcomes. The aim of this study was to investigate this aspect by comparing the results between RF and RNY performed by a single surgeon over 3 years at our institution. METHODS: A prospectively maintained database was reviewed to identify patients who underwent RF or RNY at our institution between 2016 and 2019 by a single surgeon (author SKM). Patients with previous bariatric surgery were excluded. RESULTS: Of 43 patients, 28 underwent RF and 15 underwent RNY (mean body mass index 28.6 and 32.7 kg/m2, respectively, p = 0.01). The number of previous antireflux surgeries for the RF and RNY groups was 1 (82% vs 80%, p > 0.99), 2 (18% vs 7%, p = 0.4), and more than 2 (0% vs 13%, p = 0.1). RNY took longer than RF (median, 165 vs 137 min, p = 0.02), but both groups had a median estimated blood loss of 50 ml (p = 0.82). There was no difference in intraoperative complications (25% vs 20% for RF and RYN, respectively, p > 0.99). Postoperative complications were more common in the RF than in the RYN group (21% vs 7%, p = 0.39). Median hospital stay was 3 days for both groups (p = 0.78). At short-term follow-up, the mean quality of life score was similar for the RF and RYN groups (11.5 vs 12.2, p = 0.8). CONCLUSIONS: RNY diversion, if performed by experienced hands and at an earlier point of disease progression, has comparable perioperative morbidity to RF and should be considered as a feasible and safe option for definitive treatment of failed antireflux surgery.

Bilateral Lung Transplant for a Connective Tissue Disorder: Esophageal Motility and 3-year Survival.

Connective tissue disorders (CTDs) are associated with esophageal dysmotility and gastroesophageal reflux disease, which may diminish survival after lung transplantation (LTx). We studied LTx outcomes in patients with a CTD stratified by esophageal motility. We identified patients who underwent bilateral LTx from 2012 to 2017. Patients with a CTD were classified by pre-LTx diagnosis: absent esophageal motility (AEM), ineffective esophageal motility (IEM), or preserved esophageal motility (PEM). The primary endpoint was 3-year survival. Sub-analysis compared survival between the AEM group and a propensity-matched (lung allocation score), non-CTD control group. Kaplan-Meier method and log-rank test were used. In total, 495 patients underwent LTx; 33 (6.7%) had a CTD. Median (IQR) age was 62 years (55.5-67.0); 24 (72.7%) were women. Survival trended lower for recipients with a CTD than without a CTD at 1-year (84.8% vs 91.8%; p = 0.2) and 3-years (66.7% vs 73.5%; p = 0.5). Within the CTD cohort, 1- and 3-year survival was significantly higher in the PEM (100%, 87.5%) and IEM (100%, 85.7%) groups than in the AEM group (50%, 20%; p < 0.001). The AEM group had significantly lower survival at 1-year (50% vs 92.5%) and 3-years (20% vs 65%) than a lung allocation score-matched cohort of patients without a CTD. LTx recipients with a CTD and AEM had significantly lower survival than those with PEM or IEM as well as significantly lower survival than that of a propensity-matched cohort of patients without a CTD. Patients with a CTD and AEM should be considered for LTx with extreme caution and counseled appropriately.

Current state of prognostication, therapy and prospective innovations for Barrett's-related esophageal adenocarcinoma: a literature review.

OBJECTIVE: Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), which has one of the lowest 5-year survival rates in oncology. The reasons for poor survival are twofold: the large majority of diagnoses are in advanced stages (~80%) and limited treatment options, with a deficit of biology-guided therapies. As a rapidly growing public health concern with poor prognosis, research into the molecular progression for BE and novel therapeutics for EAC currently has high clinical utility. Review of the literature reveals that innovative analysis of metaplastic progression from BE to EAC at a molecular level can shed light on the underlying transformative probabilities of BE into malignant pathologies and may impact current of future therapeutic modalities for management of these diseases. BACKGROUND: EAC is the fastest increasing cancer in the United States with a 600% increase over the past 25 years. This cancer arises from dysplastic tissue of BE, a complication of gastroesophageal reflux disease (GERD). Chronic acid and bile reflux in the distal esophagus initiates a metaplastic conversion of normal squamous epithelium to premalignant intestinalized columnar epithelium. Patients with BE have a 125-fold higher risk of cancer compared to the general population. METHODS: We critically reviewed the current status of BE monitoring, and subsequent therapeutic strategies being used in patients who have progressed to cancer. Also, new diagnostic tools and therapeutic candidates for BE-related EAC are discussed. Highly-targeted searches of databases containing recent original peer-reviewed papers were utilized for this review. CONCLUSIONS: Novel and well-described biomarkers analyzed in the patient's diseased tissue will provide for more powerful diagnostics, but also possess the potential to develop strategies for personalized management and identify targets for intervention to either cease disease progression or treat BE and/or EAC. Since millions of Americans develop BE without progressing to cancer, there is a critical need to identify the small percentage of Barrett's patients who possess hallmarks of disease progression or carcinogenesis with novel screening techniques. Incorporation of such tools into standard screening protocols for BE surveillance and/or therapy would be critical to detect malignant transformations before clinically obvious cancer ever develops.

Clinical spectrum and presentation of patients with absent contractility.

BACKGROUND: Primary absent contractility is an uncommon finding on high-resolution manometry (HRM). The goal of this study was to describe the clinical spectrum and presentation of patients with primary absent contractility. METHODS: We queried a prospectively maintained esophageal testing registry to identify patients with absent contractility who presented between August 2016 and September 2018. Patients with poor quality studies and patients with insufficient clinical records as well as those with a history of previous foregut surgery or esophagram consistent with achalasia were excluded. RESULTS: A total of 2068 patients underwent HRM during the study period. Of these, 66 patients (3.2%) met the inclusion criteria and formed the study cohort; 52 patients in the cohort had an upper gastrointestinal contrast study, 50 had endoscopy, and 51 completed a foregut symptom questionnaire. Thirty-eight patients (57.6%) were women. The mean age was 56.6±13.86 years, and the mean body mass index was 26.37±5.7 kg/m2. Almost half of the patients (29/66, 43.9%) were undergoing lung transplant evaluation, and 22 patients (37.3%) had a history of autoimmune immune-mediated or myopathic diseases. On the symptom questionnaire, 42 of 51 patients (82.3%) reported heartburn, 24 of 51 (47.1%) reported dysphagia, and 23 of 51 patients (45.1%) reported both. On ambulatory pH monitoring, 23 of 37 patients (62.2%) had pathological esophageal acid exposure (acid exposure time >6%). CONCLUSIONS: Absent contractility on HRM is uncommon and is frequently associated with connective tissue, myopathic or autoimmune disorders. The usual clinical presentation is reflux, dysphagia or both.

A Collective Review of Gore Bio-A Absorbable Synthetic Mesh in Cruroplasty Reinforcement.

Background: Laparoscopic repair of hiatal hernia (HH) is associated with a considerable failure rate. Compared to suture repair alone, mesh-reinforced cruroplasty may be associated with fewer short-term recurrences, yet its use remains controversial. The aim of this study was to analyze the current literature assessing the use of Bio-A absorbable synthetic mesh in the reinforcement of primary crural closure after laparoscopic HH repair. Methods: A systematic review of primary literature in the MEDLINE and PubMed databases was conducted. We searched for investigations reporting patient outcomes in laparoscopic HH repair with onlay Gore Bio-A tissue reinforcement (W. L. Gore & Associates, Inc.) published between January 2008 and December 2019. The primary outcome was anatomical recurrence rate. Secondary outcomes were complication rate, symptomatic outcomes, and mortality. Results: Eight studies met inclusion criteria. There were two prospective and six retrospective cohort studies. In the included studies, laparoscopic HH repair was performed with Bio-A absorbable synthetic mesh in 734 patients. The anatomical recurrence data were extracted across all studies, and an objective recurrence was identified in 21/280 (7.5%) patients. There was only 1 (0.17%) mesh-related complication in the included studies. Conclusions: The use of Bio-A absorbable synthetic mesh in the repair of HHs may be promising, as it offers low rates of anatomical recurrence and mesh-related complications, but more data are still necessary to validate these findings. This collective review of literature is a basis for future randomized controlled trials to identify the most effective and safe mesh in the long term.