Gastrocutaneous fistula and gastrointestinal bleeding due to left superior epigastric artery haemorrhage as a rare complication of anterior gastropexy.

A woman in her 70s was referred to our institution with upper gastrointestinal (GI) bleeding 3 months after a Toupet fundoplication with anterior gastropexy, performed due to gastro-oesophageal reflux disease and a large paraoesophageal hernia. Clinical investigation revealed two ulcers, with one of them at the gastropexy site. A couple of weeks later, the patient presented with a gastrocutaneous fistula. Failure of conservative and endoscopic treatment of the fistula and GI bleeding demanded surgical treatment. The gastropexy tissue was excised and bleeding from the left superior epigastric artery, involved at the ulcerated gastropexy site, was identified; a definitive surgical repair was performed at a second stage. This is an extremely rare complication of anterior gastropexy and bleeding from the gastropexy site, especially when refractory to endoscopic treatment, should raise suspicion for involvement of superior left epigastric artery. The timing of the definitive surgical repair might be of major relevance.

Two years of experience with robot-assisted anti-reflux surgery: A retrospective cohort study.

BACKGROUND AND AIMS: Robot-assisted anti-reflux surgery (RAAS) is an alternative to conventional laparoscopic anti-reflux surgery (CLAS). The purpose of this study was to evaluate initial Danish experiences with robot-assisted anti-reflux surgery compared to conventional laparoscopic anti-reflux surgery incorporating follow-up and evaluation of possible learning curve. MATERIAL AND METHODS: Patients undergoing primary RAAS or CLAS at The Department of Surgery A, Odense University Hospital and The Department of General Surgery, Kolding Hospital from April 2013 to April 2015 was included. Demographic data, comorbidity, docking time, length of procedure, type of fundic wrap as well as perioperative complications and postoperative complications, need for reoperation or any upper gastrointestinal endoscopy from surgery to final follow-up was retrospectively extracted from patient records. RESULTS: 103 patients were included in this study. 39 patients underwent RAAS and 64 patients underwent CLAS. There were no statistically significant differences in demographic data or comorbidities except distribution of heart disease (RAAS: 5.1% vs. CLAS: 18.8%, p = 0.05) and previous abdominal surgery (RAAS: 28.2% vs. CLAS: 48.4%, p = 0.04). Duration of surgery was significantly increased in patients undergoing RAAS (RAAS: 135 ± 27 min vs. CLAS: 86 ± 19 min, p < 0.01). There was no statistical significant difference in intraoperative complications (p = 0.20), 30-day postoperative complication rate (p = 0.20) or mortality (p = 1.00). At follow-up in April 2016, there were no statistically significant differences in patients having undergone upper endoscopy postoperatively (p = 0.92), the use of anti-secretory drugs (p = 0.46) or patients having undergone reoperation (p = 0.60). Reasons for reoperation were significantly dependent on type of fundic wrap with reoperation of Nissen fundoplication being dysphagia and reoperation of Toupet being recurrent reflux (p = 0.008). There was no clearly determined learning curve. CONCLUSIONS: RAAS was safe, feasible and with equal efficacy to CLAS. There were however no particular advantages to performing antireflux surgery as robot-assisted procedures neither intra-operatively nor at follow-up.