Low-calorie diets are effective for weight loss in patients undergoing benign upper gastrointestinal surgery: a systematic review and meta-analysis.

BACKGROUND: Obesity may increase surgical complexity in patients undergoing abdominal surgery by limiting visualization and increasing the risk of peri-operative complications. A preoperative reduction in weight and liver volume may improve surgical outcomes. The aim of our study was to evaluate the efficacy of a low-calorie diet (LCD) versus a very low-calorie diet (VLCD) in reducing weight and liver volume prior to laparoscopic surgery. METHODS: A systematic search was conducted using the following inclusion criteria: obese patients undergoing preoperative weight loss using a VLCD or LCD, evaluation of liver volume reduction, and the use of an imaging modality before and after the diet. RESULTS: A total of 814 patients from 21 different studies were included in this systematic review and meta-analysis, with 544 female patients (66.8%) and a mean age range between 24 and 54 years old. There was a total mean weight loss of 6.42% and mean liver volume reduction of 16.7%. Meta-analysis demonstrated that a preoperative diet (LCD or VLCD) significantly reduced weight [SMD = - 0.68; 95% CI (- 0.93, - 0.42), I2 = 82%, p ≤ 0.01] and liver volume [SMD = - 2.03; 95% CI (- 4.00, - 0.06), I2 = 94%, p ≤ 0.01]. When assessed individually, a VLCD led to significant weight reduction [SMD = - 0.79; CI (- 1.24; - 0.34), p ≤ 0.01, I2 = 90%], as did an LCD [SMD = - 0.60; CI (- 0.90; - 0.29), p ≤ 0.01, I2 = 68%). Similarly, there was a significant reduction in liver volume following a VLCD [SMD = - 1.40; CI (- 2.77, - 0.03), p ≤ 0.01, I2 = 96%], and an LCD [SMD = - 2.66; CI (- 6.13, 0.81), p ≤ 0.01, I2 = 93%]. However, there was no significant difference between the two regimens. CONCLUSIONS: Preoperative restrictive calorie diets are effective in reducing weight and liver volume prior to laparoscopic surgery. Whilst a VLCD was better than an LCD at reducing both weight and liver volume, the difference was not significant.

Antireflux surgery in patients with gastroesophageal reflux but a negative 24-hour pH study: late outcomes.

PURPOSE: Patients with gastroesophageal reflux disease often undergo a 24-hour pH test to confirm pathologic reflux before surgery. However, a negative pH test can occur in some individuals with reflux, and a case might still be made for antireflux surgery based on symptoms of reflux even in the absence of endoscopic esophagitis. The long-term outcomes in patients who underwent antireflux surgery despite negative preoperative test results were determined. METHODS: Patients were selected from a prospective database. A total of 745 patients met the inclusion criteria, which included typical esophageal reflux symptoms, absence of a large hiatus hernia, preoperative 24-hour pH study performed, endoscopy, and postoperative symptom and satisfaction follow-up available at 5 years. Patients were divided into 3 groups based on 24-hour pH study and endoscopy results: negative pH and negative endoscopy (n = 65), negative pH and positive endoscopy (n = 72), and positive pH (n = 608). The negative pH and negative endoscopy group underwent surgery based on clinical assessment and typical esophageal reflux symptoms. Baseline and follow-up outcomes at 5 years were evaluated using 0 to 10 analog scores, which assessed heartburn, dysphagia, and satisfaction with the overall outcome. Data were analyzed to compare the groups. RESULTS: The groups were well matched for demographics and preoperative symptom scores. At the median 5-year follow-up, clinical outcome scores were similar among the groups for heartburn, dysphagia, and overall satisfaction. The mean heartburn scores were 1.80 in the negative pH and negative endoscopy group, 1.88 in the negative pH and positive endoscopy group, and 1.91 in the positive pH group (P = .663). The mean satisfaction scores were high in all groups: 8.13, 7.31, and 7.72, respectively (P = .293). CONCLUSION: No difference in clinical outcome scores was observed. The negative pH and negative endoscopy group had high satisfaction scores and low heartburn and dysphagia scores. Our findings support antireflux surgery in well-selected symptomatic patients with a negative preoperative pH test.

Quality of life following repair of large hiatal hernia is not influenced by the use of mesh-Longer-term follow-up from a randomized trial.

INTRODUCTION: The use of prosthetic mesh in laparoscopic repair of large hiatus hernias remains controversial. Clinical and quality of life outcomes from a randomized controlled trial of mesh versus suture repair previously showed few differences at early follow-up. This study evaluated longer-term quality of life outcomes from that trial. METHODS: A prospective, multicentre, double blind randomized controlled trial assessed three methods of repair for large hiatus hernias: sutures-only versus absorbable mesh versus non-absorbable mesh. Quality of life was assessed using the Short-Form 36 (SF-36) questionnaire which was completed preoperatively and then at 3, 6, 12 months following surgery and annually thereafter. SF-36 outcomes were compared across the three repair techniques at longer-term follow-up (3-6 years), and to earlier baseline and 12-month outcomes. RESULTS: 126 patients were randomized; 43-suture-only, 41-absorbable mesh and 42-non-absorbable mesh. Questionnaires were completed by 118 patients preoperatively, 115 at 12 months and 98 at longer-term follow-up (median 5 years). There were no significant differences between the repair techniques for the subscale and composite scores at longer-term follow-up. The mental component score improved significantly after surgery and was sustained across follow-up for all techniques. The physical component score also improved significantly but was lower at longer-term follow-up compared to the 12-month follow up in both mesh groups. CONCLUSION: Surgical repair of large hiatus hernias provides sustained long-term improvement in quality of life. The addition of mesh does not improve quality of life. TRIAL REGISTRATION: This trial is registered with the Australia and New Zealand Clinical Trials Registry ACTRN12605000725662.

Mucosal impedance as a diagnostic tool for gastroesophageal reflux disease: an update for clinicians.

Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett's esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett's esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.

Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus.

Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.

Assessment of laparoscopic fundoplication with endoscopy: room for improvement.

INTRODUCTION: Gastroesophageal reflux disease affects a significant portion of the Australian and world population. Minimally invasive laparoscopic fundoplication is a highly effective treatment in appropriately selected patients, with a 90% satisfaction rate. However, up to 5% will undergo revisional surgery. Endoscopy is an important investigation in the evaluation of persistent or new symptoms after fundoplication. Our study sought to evaluate the inter-rater reliability and variability in assessing fundoplication with endoscopy. METHODS: Upper gastrointestinal (UGI) surgeons and gastroenterologists were invited to join the cohort study through their professional membership with two societies based in Australia. Participants completed a two part 25-item multiple choice questionnaire, involving the analysis of ten static endoscopic images post-fundoplication. RESULTS: A total of 101 participants were included in the study (64 UGI surgeons and 37 gastroenterologists). Over 95% of participants were consultant level, working in non-rural tertiary hospitals. Total accuracy for all 10 cases combined was 76% for UGI surgeons and 69.9% for gastroenterologists. In three of the 10 cases, UGI surgeons performed significantly better than gastroenterologists (p < 0.05). When assessing performance across each of the 4 questions for each case, UGI surgeons were more accurate than gastroenterologists in describing the integrity of the wrap (p = 0.014). Inter-rater reliability was low across both groups for most domains (kappa < 1). CONCLUSION: Our study confirms low inter-rater reliability between endoscopists and large variations in reporting. UGI surgeons performed better than gastroenterologists in certain cases, usually when describing the integrity of the fundoplication. Our study provides further support for the use of a standardized reporting system in post-fundoplication patients.

Surgical approaches for achalasia and obesity: a systematic review and patient-level meta-analysis.

PURPOSE: Synchronous and metachronous presentations of achalasia and obesity are increasingly common. There is limited data to guide the combined or staged surgical approaches to these conditions. METHODS: A systematic review (MEDLINE, Embase, and Web of Science) and patient-level meta-analysis of published cases were performed to examine the most effective surgical approach for patients with synchronous or metachronous presentations of achalasia and obesity. RESULTS: Thirty-three studies with 93 patients were reviewed. Eighteen patients underwent concurrent achalasia and bariatric surgery, with the most common (n = 12, 72.2%) being laparoscopic Heller's myotomy (LHM) and Roux-en-Y gastric bypass (RYGB). This combination achieved 68.9% excess weight loss and 100% remission of achalasia (mean follow-up: 3 years). Seven (6 RYGB, 1 biliopancreatic diversion) patients had bariatric surgery following achalasia surgery. Of these, all 6 RYGBs had satisfactory bariatric outcomes, with complete remission of their achalasia (mean follow-up: 1.8 years). Sixty-eight patients underwent myotomy following bariatric surgery; the majority (n = 55, 80.9%) were following RYGB. In this scenario, per-oral endoscopic myotomy (POEM) achieved higher treatment success than LHM (n = 33 of 35, 94.3% vs. n = 14 of 20, 70.0%, p = 0.021). Moreover, conversion to RYGB following a restrictive bariatric procedure during achalasia surgery was also associated with higher achalasia treatment success. CONCLUSION: In patients with concurrent achalasia and obesity, LHM and RYGB achieved good outcomes for both pathologies. For those with weight gain post-achalasia surgery, RYGB provided satisfactory weight loss, without adversely affecting achalasia symptoms. For those with achalasia after bariatric surgery, POEM and conversion to RYGB produced greater treatment success.

What Is the Optimal Time on a Low-Calorie Diet Prior to Laparoscopic Anti-reflux Surgery? A Prospective Case-Controlled Study.

INTRODUCTION: A very low-calorie diet (VLCD) or low-calorie diet (LCD) is often used prior to laparoscopic surgery to optimize access to the hiatus. Much debate exists in the literature regarding the required duration for a VLCD or LCD, and how to evaluate the presence of a fatty liver. The aim of our study was to determine the optimal amount of time on an LCD to achieve maximal liver volume reduction, and to assess the accuracy of the InBody 230® vs. bedside ultrasonography vs. magnetic resonance imaging (MRI) in the measurement of liver volume. METHODS: Seventeen consecutive patients undergoing laparoscopic anti-reflux surgery were recruited into the study. Each patient underwent body composition analysis with the InBody® 230, liver ultrasound, and liver MRI. Patients then began an LCD with a weekly ultrasound assessment until the day before surgery when they underwent repeat body composition analysis, liver ultrasound, and MRI. RESULTS: The mean age was 54 years (range 21, 74). Maximal liver volume loss was noted within 3 weeks for 88% of participants, with 47% achieving their maximal liver volume reduction after the first week of an LCD. The mean reduction in liver volume was 16%, 18.6%, and 19% for MRI, ultrasound, and body composition analysis, respectively. CONCLUSION: Close to 90% of patients require 3 weeks or less on an LCD to achieve maximal liver volume loss prior to laparoscopic anti-reflux surgery. Body composition analysis and bedside ultrasonography were both as accurate as the gold standard MRI in the assessment of liver volume.

Achalasia.

Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.

Randomized Trial of Laparoscopic Nissen Versus Anterior 180 Degree Partial Fundoplication - Late Clinical Outcomes at 15 to 20 years.

OBJECTIVE: To determine very late clinical outcomes at up to 20 years follow-up from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication. SUMMARY BACKGROUND DATA: Nissen fundoplication for gastroesophageal reflux can be followed by troublesome side effects. To address this, partial fundoplications have been proposed. Previously reports from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication at up to 10 years follow-up showed good outcomes for both procedures. METHODS: One hundred seven participants were randomized to Nissen versus anterior 180-degree partial fundoplication. Fifteen to 20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardized questionnaire with 0 to 10 analog scores and yes/no questions to determine reflux symptoms, side-effects, and satisfaction with surgery. RESULTS: After anterior fundoplication heartburn (mean score 3.2 vs 1.4, P = .001) and proton pump inhibitor use (41.7% vs 17.1%, P = .023) were higher, offset by less dysphagia for solids (mean score 1.8 vs 3.3, P = .015), and better ability to belch (84.2% vs 65.9%, P = .030). Measures of overall outcome were similar for both groups (mean satisfaction score 8.4 vs 8.0, P = .444; 86.8% vs 90.2% satisfied with outcome). Six participants underwent revision after anterior fundoplication (Nissen conversion for reflux - 6), and 7 underwent revision after Nissen fundoplication (Nissen to partial fundoplication for dysphagia - 5; redo Nissen for reflux - 1; paraesophageal hernia -1). CONCLUSIONS: At 15 to 20 years follow-up Nissen and anterior 180-degree partial fundoplication achieved similar success, but with trade-offs between better reflux control versus more side-effects after Nissen fundoplication.

Routine Esophagograms After Hiatus Hernia Repair Minimizes Reoperative Morbidity: A Multicenter Comparative Cohort Study.

OBJECTIVE: Determine the utility of routine esophagograms after hiatus hernia repair and its impact on patient outcomes. BACKGROUND: Hiatus hernia repairs are common. Early complications such asre-herniation, esophageal obstruction and perforation, although infrequent, incur significant morbidity. Whether routine postoperative esophagograms enable early recognition of these complications, expedite surgical management, reduce reoperative morbidity, and improve functional outcomes are unclear. METHODS: Analysis of a prospectively-maintained database of hiatus hernia repairs in 14 hospitals, and review of esophagograms in this cohort. Results: A total of 1829 hiatus hernias were repaired. Of these, 1571 (85.9%) patients underwent a postoperative esophagogram. Overall, 1 in 48 esophagograms resulted in an early (<14 days) reoperation, which was undertaken in 44 (2.4%) patients. Compared to those without an esophagogram, patients who received this test before reoperation (n = 37) had a shorter time to diagnosis (2.4 vs 3.9 days, P = 0.041) and treatment (2.4 vs 4.3 days, P = 0.037) of their complications. This was associated with lower rates of open surgery (10.8% vs 42.9%, P = 0.034), gastric resection (0.0% vs 28.6%, P = 0.022), postoperative morbidity (13.5% vs 85.7%, P < 0.001), unplanned intensive care admission (16.2% vs 85.7%, P < 0.001), and decreased length-of-stay (7.3 vs 18.3 days, P = 0.009). Furthermore, we identified less intraoperative and postoperative complications, and superior functional outcomes at 1-year follow-up in patients who underwent early reoperations for an esophagogram-detected asymptomatic re-herniation than those who needed surgery for late symptomatic recurrences. CONCLUSIONS: Postoperative esophagograms decrease the morbidity associated with early and late reoperations, and should be considered for routine use after hiatus hernia surgery.

Partial Fundoplication is Effective Treatment for Female Patients with Gastroesophageal Reflux and Scleroderma: A Multicenter Comparative Cohort Study.

BACKGROUND: Patients with scleroderma often suffer from dysphagia and gastroesophageal reflux disease (GERD). Partial fundoplication is a validated anti-reflux procedure for GERD but may worsen dysphagia in scleroderma patients. Its utility in these patients is unknown. Here, we evaluate the efficacy and acceptability of partial fundoplication for the treatment of medically refractory GERD in patients with scleroderma. METHODS: Analysis of a prospectively maintained database of patients who underwent fundoplication across 14 hospitals between 1991 and 2019. Perioperative outcomes, reintervention rates, heartburn, dysphagia, and patient satisfaction were assessed at 3 months, 1- and 3-years post-surgery. RESULTS: A total of 17 patients with scleroderma were propensity score matched to 526 non-scleroderma controls. All underwent a partial fundoplication. Perioperative outcomes including complication rate, length of stay, and need for reoperation were similar between the two groups. Compared to baseline, both groups reported significantly improved heartburn at 3 months, 1- and 3-years following partial fundoplication. Surgery was equally effective at controlling heartburn across all follow-up timepoints in patients with or without scleroderma. Dysphagia to solids was more common in patients with scleroderma than controls at 3-months post-surgery, but was not significantly different to controls at 1- and 3-year follow-up. Satisfaction scores were high and comparable between both groups across all postoperative timepoints, with 100% of patients with scleroderma reporting that their initial choice to undergo surgery was correct. CONCLUSIONS: Partial fundoplication controls reflux and is associated with a transient period of dysphagia to solids in patients with scleroderma. This approach is safe, effective and acceptable for patients with scleroderma and medically refractory GERD.

How to insert a naso-enteric tube using an ultrathin scope.

Although not a technically challenging procedure, the correct insertion of a naso-enteric feeding tube is an important skill for the surgeon. The described technique has been refined over two decades, and is well tolerated, reliable and reproducible.