Esophagogastric junction morphology assessment by high resolution manometry in obese patients candidate to bariatric surgery.

INTRODUCTION: Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and hiatal hernia development. Pure restrictive bariatric surgery should not be indicated in case of hiatal hernia and GERD. However it is unclear what is the real incidence of disruption of esophagogastric junction (EGJ) in patients candidate to bariatric surgery. Actually, high resolution manometry (HRM) can provide accurate information about EGJ morphology. Aim of this study was to describe the EGJ morphology determined by HRM in obese patients candidate to bariatric surgery and to verify if different EGJ morphologies are associated to GERD-related symptoms presence. METHODS: All patients underwent a standardized questionnaire for symptom presence and severity, upper endoscopy, high resolution manometry (HRM). EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and < 2 cm); Type III, >2 cm separation. RESULTS: One hundred thirty-eight obese (BMI>35) subjects were studied. Ninety-eight obese patients referred at least one GERD-related symptom, whereas 40 subjects were symptom-free. According to HRM features, EGJ Type I morphology was documented in 51 (36.9%) patients, Type II in 48 (34.8%) and Type III in 39 (28.3%). EGJ Type III subjects were more frequently associated to Symptoms than EGJ Type I (38/39, 97.4%, vs. 21/59, 41.1% p < 0.001). CONCLUSIONS: Obese subjects candidate to bariatric surgery have a high risk of disruption of EGJ morphology. In particular, obese patients with hiatal hernia often refer pre-operative presence of GERD symptoms. Testing obese patients with HRM before undergoing bariatric surgery, especially for restrictive procedures, can be useful for assessing presence of hiatal hernia.

The incidence of hiatal hernia after minimally invasive esophagectomy.

INTRODUCTION: Minimally invasive esophagectomy (MIE) has evolved as a means to minimize the morbidity of an operation which is traditionally associated with a significant risk. However, this approach may have its own unique postoperative complications. In this study, we describe the incidence and outcomes of hiatal hernia in a cohort of MIE patients. METHODS: Clinical follow-up data on 114 patients who had undergone minimally invasive esophagectomy between 2003 and 2011 were retrospectively reviewed. Clinical presentation and computed tomography (CT) scans of the chest and abdomen were used to establish the diagnosis of hiatal herniation after minimally invasive esophagectomy. Age, gender, presenting complaint, comorbid conditions, clinical tumor stage, surgical specimen size, length and cost of hospital admissions, operation performed for hiatal herniation, and mortality were all recorded for analysis. RESULTS: Nine (8%) of the 114 patients who underwent MIE had postoperative hiatal herniation. Five of these patients were asymptomatic. All patients except two who presented emergently were repaired laparoscopically on an elective basis. The average length of stay after hiatal hernia repair was 5.5 days (range 2-12) at an average charge of $40,785 (range $25,264-$83,953). At follow-up, one patient complained of symptoms associated with reflux. CONCLUSION: Hiatal herniation is not a rare event after MIE. It is also associated with significant health-care cost and may be lethal. Most occurrences appear to be asymptomatic and, if detected, can be repaired with good resolution of symptoms, minimal associated morbidity, and no mortality.

Laparoscopic antireflux surgery: disease-related quality of life assessment before and after surgery in GERD patients with and without Barrett's esophagus.

BACKGROUND: Several findings suggest that gastroesophageal reflux disease (GERD) has a significant impact on patients' quality of life. The aim of this prospective study was (a) to evaluate and compare quality-of-life data before and after laparoscopic antireflux surgery (LARS) in GERD patients with and without Barrett's esophagus (BE); and (b) to compare quality-of-life data of these patients to normative data for a comparable general population. METHODS: The Gastrointestinal Quality of Life Index (GIQLI) was administrated to 75 BE patients and to 174 patients with GERD without BE (Savary-Miller classification: grade 1: n = 49; grade 2: n = 69; grade 3: n = 56). The questionnaire was given to all patients preoperatively, 3months, 1 year, and 3 years after laparoscopic "floppy" Nissen fundoplication. RESULTS: Before surgery, BE patients (mean: 96.8 +/- 9.3 points) had a better but not significant (p<0.06) general score of the GIQLI when compared with patients without BE (mean: 86.4 +/- 10.1 points). This difference is solely based on the subdimension "gastrointestinal symptoms" which means that GERD symptoms are less intensively and frequently recognized in BE patients than in patients without BE. There are no other differences in the other four subdimensions of the GIQLI between both groups. Three months, 1 year, and 3 years after LARS, GIQLI was significantly (p<0.01) improved in both groups (BE patients mean after 3 years: 121.9 +/- 8.2 points; non-BE patients mean after 3 years: 122.8 +/- 9.3 points). This improvement was significantly better (p<0.05) in patients without BE than in BE patients. Before surgery, both groups scored significantly below average on all subscores of GIQLI compared to general population (mean: 122.6 +/- 8.5 points). After surgery, there are no differences detectable. CONCLUSION: As our data show, non-BE patients undergoing LARS achieve a better quality-of-life improvement than those patients with BE. However, after surgery GIQLI of both groups is comparable to the mean value of general population. This means that LARS is able to improve quality of life significantly in all GERD patients, with and without BE.