Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update.

Achalasia cardia, the most prevalent primary esophageal motility disorder, is predominantly characterized by symptoms of dysphagia and regurgitation. The principal therapeutic approaches for achalasia encompass pneumatic dilatation (PD), Heller's myotomy, and the more recent per-oral endoscopic myotomy (POEM). POEM has been substantiated as a safe and efficacious modality for the management of achalasia. Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy, the incidence of gastroesophageal reflux disease (GERD) following POEM is notably higher than with the aforementioned techniques. While symptomatic reflux post-POEM is relatively infrequent, the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications. Contemporary advancements in the field have enhanced our comprehension of the risk factors, diagnostic methodologies, preventative strategies, and therapeutic management of GERD subsequent to POEM. This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux, potential modifications in the POEM technique to mitigate GERD risk, and the strategies for managing reflux following POEM.

Prophylactic anti-reflux procedure for children undergoing laparoscopic gastrostomy: Rethinking of the routine practice.

AIM: Laparoscopic gastrostomy is a frequently performed procedure in children requiring long-term enteral nutrition. The role of prophylactic anti-reflux surgery during gastrostomy placements is controversial. The current study aims to evaluate the role of prophylactic anti-reflux procedures during gastrostomy placement. METHODS: A retrospective single-center analysis of all children without reflux receiving laparoscopic gastrostomy from January 2005 through December 2021 was performed. Demographics and clinical outcomes were compared between patients receiving gastrostomy placement alone and patients receiving gastrostomy with prophylactic anti-reflux surgery. RESULTS: A total of 79 patients had a confirmed absence of reflux by a 24-h pH/impedance study before operation. Thirty-six of these patients underwent prophylactic anti-reflux surgery (PAR) while 43 received gastrostomy (PG) alone. The operative time and conversion rate were significantly higher in the PAR group (140.5 ± 67.5 vs. 80.2 ± 66.8 min, p = 0.0001 and 8.3% vs. 0%, p = 0.04). There were no major complications in either group. De novo reflux was detected in five patients (11.6%) in the PG group. None of these patients progressed to require anti-reflux surgery. CONCLUSION: The occurrence of de novo reflux after laparoscopic gastrostomy was low and could be managed without anti-reflux surgery. A routine pre-operative pH study is helpful for appropriate patient selection to avoid unnecessary anti-reflux surgery, which lengthens operative time and increases the conversion rate.

Fundoplication at the time of paraesophageal hernia repair may not reduce postoperative reflux.

Hiatal hernias are observed in approximately 15% to 20% of the population in Western society. Most patients are diagnosed with a sliding-type hiatal hernia, of which gastroesophageal reflux is the predominant driving symptom. Surgical repair of these types of hernias often involves a wrap procedure during the index operation as standard of care. For type 2, 3, and 4 hernias, also known as paraesophageal hernias (PEHs), the symptom complexes vary and often involve symptoms other than reflux, including dysphagia, anemia, shortness of breath, and chest pain. We sought to evaluate whether patients who underwent PEH repair without fundoplication reported different rates of postoperative symptoms compared with those who did.

Proton pump inhibitors in esophageal atresia: A systematic review and meta-analysis.

Gastroesophageal reflux disease (GERD) is frequent and prolonged in esophageal atresia (EA) pediatric patients requiring routine use of proton pump inhibitors (PPIs). However, there are still controversies on the prophylactic use of PPIs and the efficacy of PPIs on GERD and EA complications in this special condition. The aim of the study is to assess the prophylactic use of PPIs in pediatric patients with EA and its complications. We, therefore, performed a systematic review including all reports on the subject from 1980 to 2022. We conducted meta-analysis of the pooled proportion of PPI-and no PPI groups using random effect model, meta-regression, and estimate heterogeneity by heterogeneity index I2 . Thirty-eight reports on the topic met the criteria selection, representing a cumulative 6044 patients with EA. Prophylactic PPI prescription during the first year of life does not appear to prevent GERD persistence at follow-up and is not associated with a significantly reduced rate of antireflux surgical procedures (ARP). PPIs improve peptic esophagitis and induce remission of eosinophilic esophagitis at a rate of 50%. Their effect on other GERD outcomes is uncertain. Evidence suggests that PPIs do not prevent anastomotic stricture, Barrett's esophagus, or respiratory complications. PPI use in EA can improve peptic and eosinophilic esophagitis but is ineffective on the other EA complications. Side effects of PPIs in EA are almost unknown.

Conventional versus oblique fiber-sparing endoscopic myotomy for achalasia cardia: a randomized controlled trial (with videos).

BACKGROUND AND AIMS: GERD is common after peroral endoscopic myotomy (POEM). Selective sparing of oblique fibers may reduce the incidence of reflux esophagitis after POEM. In this study, we compared the incidence of GERD between conventional myotomy (CM) versus oblique fiber-sparing (OFS) myotomy in patients with achalasia. METHODS: Eligible patients with type I and II achalasia who underwent POEM from January 2020 to October 2020 were randomized into 2 groups (CM and OFS myotomy). Exclusion criteria were type III achalasia, sigmoid esophagus, and history of Heller's myotomy. The primary study outcome was incidence of reflux esophagitis (at least grade B) in the 2 groups. Secondary outcomes were reflux symptoms, esophageal acid exposure, clinical success, and adverse events. RESULTS: One hundred fifteen patients were randomized into CM (n = 58) and OFS myotomy (n = 57) groups. POEM was technically successful in all patients. Overall, reflux esophagitis was found in 56 patients (48.7%). The incidence of at least grade B esophagitis was similar in both groups (CM vs OFS myotomy: 25.9% vs 31.6%, P = .541). The mean number of reflux episodes (48.2 ± 36.6 vs 48.9 ± 40.3, P = .933), increased esophageal acid exposure >6% (45.5% vs 31.7%, P = .266), and high DeMeester scores (38.6% vs 41.5%, P = .827) were similar in both groups. There was no difference in the rate of symptomatic reflux (GERD questionnaire score >7) or use of proton pump inhibitors at 1 year. CONCLUSIONS: Sparing of sling fibers has no significant impact on the incidence of significant reflux esophagitis after POEM. Novel strategies need to be explored to prevent reflux after POEM. (Clinical trial registration number: NCT04229342.).

[Research progress of bariatric and metabolic surgery in the prevention of gastroesophageal reflux disease].

Gastroesophageal reflux disease (GERD) is a common digestive tract disease. Obesity is an independent risk factor for GERD. Laparoscopic sleeve gastrectomy (laparoscopic sleeve gastrectomy, LSG) is becoming more popular in bariatric metabolic surgery and is simple to perform with fewer complications, but its efficacy in treating postoperative anti-reflux in obese patients remains controversial. LSG has been reported to disrupt anti-reflux barrier function, such as altered cardiac notch, disruption of diaphragmatic continuity, and increased hiatal hernia after surgery. The cardiac notch is one of the important anti-reflux barriers at the gastroesophageal junction, and its accentuation has been shown to be effective in alleviating the symptoms of GERD, and LSG combined with angle of cardiac notch accentuation is expected to be an effective measure to prevent GERD after obesity surgery. Therefore, this article mainly reviews the research on the prevention of GERD by bariatric surgery, aiming to explore the effective treatment of GERD in obese patients after surgery, so as to improve the symptoms and quality of life of patients with GERD, and provide reference for the surgical treatment of GERD.

Antral Preservation in Sleeve Gastrectomy Appears to Protect Against Prolonged Vomiting and Gastroesophageal Reflux Disease. A Meta-Analysis of Randomized Controlled Trials.

The optimal distance between the starting point of gastric transection and the pylorus during laparoscopic sleeve gastrectomy (LSG), which can be referred to as the distance from pylorus (DFP), is controversial. No consensus exist for what DFP is considered antral preservation, and what DFP is considered antral resection. Some surgeons prefer shorter DFP to maximize excess weight loss percentage (EWL%), while others prefer longer DFP because they believe that it shortens length of stay (LOS) and protects against leaks, prolonged vomiting, and gastroesophageal reflux disease (GERD). We sought to compare 6-cm DFP and 2-cm DFP in postoperative outcomes. In addition, we sought to evaluate the magnitude of any observed benefit through number needed to treat (NNT) analysis.

[Endoscopic negative pressure treatment : From management of complications to pre-emptive active reflux drainage in abdominothoracic esophageal resection-A new safety concept for esophageal surgery]. / Endoskopische Unterdrucktherapie : Vom Komplikationsmanagement zur präemptiven aktiven Refluxdrainage bei abdomino-thorakaler Ösophagusresektion ­ ein neues Sicherheitskonzept für die Ösophaguschirurgie.

INTRODUCTION: Early postoperative reflux (PR) can compromise anastomotic healing after Ivor Lewis esophagectomy (ILE) and poses a risk for aspiration. Anastomotic insufficiency is the most threatening surgical complication. We present the protective method of pre-emptive active reflux drainage (PARD) with simultaneous enteral feeding. We report our experience with this new safety concept in esophageal surgery in a cohort of 43 patients. MATERIALS AND METHODS: For PARD we use a double lumen open porous film drainage (dOFD). To create the dOFD, the gastric tube of a Trelumina probe (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore drainage film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over a length of 25 cm. The dOFD is endoscopically inserted into the tubular stomach intraoperatively after completion of the anastomosis. Continuous negative pressure is applied with an electronic pump (-125 mm Hg). The PR is continuously aspirated completely and the stomach and anastomotic region are decompressed. At the same time, nutrition is delivered via an integrated intestinal tube. Depending on the results of the endoscopic control after 5 days, PARD is either continued or terminated. RESULTS: During the observation period (2017-2023), PARD was used in all patients (n = 43) with ILE. The healing rate under PARD was 100% and healing was observed in all anastomoses. No additional endoscopic procedures or surgical revisions of the anastomoses were required. The median duration of PARD was 8 days (range 4-21). We observed problems in the healing of the anastomosis in 20 of 43 patients (47%) for whom we defined endoscopic criteria for at-risk anastomosis. CONCLUSIONS: Our results suggest that PARD has a strong protective effect on anastomotic healing and may reduce the risk of anastomotic insufficiency. The integrated feeding tube of the dOFD allows early postoperative enteral feeding while simultaneously applying negative pressure. PARD appears to prevent the negative consequences of impaired anastomotic healing.

The Angle of His as a Measurable Element of the Anti-reflux Mechanism.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux. OBJECTIVES: Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model. METHODS: The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented. RESULTS: Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively). CONCLUSIONS: In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.

The potential of a polyglycolic acid sheet for preventing intrathoracic sleeve migration.

INTRODUCTION: Postoperative gastroesophageal reflux disease (GERD) can be a consequence of laparoscopic sleeve gastrectomy (LSG). Intrathoracic sleeve migration (ITSM) is a factor contributing to its development. This study aimed to investigate whether the occurrence of ITSM can be prevented by applying a polyglycolic acid (PGA) sheet around the His angle. MATERIAL AND METHODS: In this retrospective analysis, 46 consecutive patients who underwent LSG were divided into two groups: Group A - our standard LSG in the first half (n = 23) and Group B - our standard LSG with PGA sheet covering the angle of His in the second half (n = 23). We compared the two groups for one-year postoperative GERD and the incidence of ITSM. RESULTS: No significant differences were found between the two groups in terms of patient background, operation time, and one-year postoperative total body weight loss, and no adverse effects related to the PGA sheet were observed. Group B had a significantly lower incidence of ITSM than Group A, and the rate of acid-reducing medicine usage was less pronounced in Group B during follow-up (p < .05). CONCLUSION: This study suggests that applying a PGA sheet can be safe and effective in reducing postoperative ITSM and preventing exacerbations of postoperative GERD.

Effect of the reverse Trendelenburg position on the incidence of gastroesophageal reflux in dogs anesthetized for elective stifle surgery.

OBJECTIVE: To determine if a 15° reverse Trendelenburg position decreases the incidence of gastroesophageal reflux (GER) compared with a horizontal position in dogs anesthetized for stifle surgery. STUDY DESIGN: Prospective, randomized parallel-arm study. ANIMALS: A total of 44 healthy client-owned dogs were enrolled and data from 36 dogs were analyzed. METHODS: Dogs requiring preoperative radiographs under anesthesia, or with a history of gastrointestinal signs or administered gastroprotectant therapy within 1 month of surgery were excluded. Anesthesia protocol was standardized to include hydromorphone, dexmedetomidine, ketamine, propofol and isoflurane. Dogs were randomly assigned at enrollment to be positioned in a 15° reverse Trendelenburg or a horizontal position for surgery. Continuous pH monitoring was documented throughout the procedure with a 6.4 Fr (2.13 mm) esophageal pH probe positioned in the distal esophagus via the oral cavity. GER was defined as pH < 4.0 (acidic) or > 7.5 (alkaline) for more than 30 seconds. The proportions of dogs developing GER were compared between groups using Fisher's exact test. Time to reflux was compared using survival curves and the Gehan-Breslow-Wilcoxon test. Statistical significance was set as p < 0.05. RESULTS: An episode of GER occurred in 11/36 (30%) dogs. Reflux was alkaline in two dogs and acidic in nine dogs. The proportion of dogs with GER was 5/18 (28%) and 6/18 (33%) for dogs in the reverse Trendelenburg position and horizontal position, respectively, and was not statistically significant (p > 0.99). Median (range) time until reflux was 44 (23-135) and 44.5 (9-56) minutes when dogs were positioned in reverse Trendelenburg position and horizontal position, respectively (p = 0.66; two-tailed Mann-Whitney U test). CONCLUSIONS AND CLINICAL RELEVANCE: Positioning the surgery table in a 15° rostral elevation for dogs anesthetized for elective stifle surgical procedures did not decrease the incidence of GER.

Mixed-methods feasibility study to inform a randomised controlled trial of proton pump inhibitors to reduce strictures following neonatal surgery for oesophageal atresia.

OBJECTIVES: This mixed-methods feasibility study aimed to explore parents' and medical practitioners' views on the acceptability and design of a clinical trial to determine whether routine prophylactic proton pump inhibitors (PPI) reduce the incidence of anastomotic stricture in infants with oesophageal atresia (OA). DESIGN: Semi-structured interviews with UK parents of an infant with OA and an online survey, telephone interviews and focus groups with clinicians. Data were analysed using reflexive thematic analysis and descriptive statistics. PARTICIPANTS AND SETTING: We interviewed 18 parents of infants with OA. Fifty-one clinicians (49 surgeons, 2 neonatologists) from 20/25 (80%) units involved in OA repair completed an online survey and 10 took part in 1 of 2 focus groups. Interviews were conducted with two clinicians whose survey responses indicated they had concerns about the trial. OUTCOME MEASURES: Parents and clinicians ranked the same top four outcomes ('Severity of anastomotic stricture', 'Incidence of anastomotic stricture', 'Need for treatment of reflux' and 'Presence of symptoms of reflux') as important to measure for the proposed trial. RESULTS: All parents and most clinicians found the use, dose and duration of omeprazole as the intervention medication, and the placebo control, as acceptable. Parents stated they would hypothetically consent to their child's participation in the trial. Concerns of a few parents and clinicians about infants suffering with symptomatic reflux, and the impact of this for study retention, appeared to be alleviated through the symptomatic reflux treatment pathway. Hesitant clinician views appeared to change through discussion of parental support for the study and by highlighting existing research that questions current practice of PPI treatment. CONCLUSIONS: Our findings indicate that parents and most clinicians view the proposed Treating Oesophageal Atresia with prophylactic proton pump inhibitors to prevent STricture (TOAST) trial to be feasible and acceptable so long as infants can be given PPI if clinicians deem it clinically necessary. This insight into parent and clinician views and concerns will inform pilot phase trial monitoring, staff training and the development of the trial protocol.

Conversion to Roux-En-Y Gastric Bypass: a successful means of mitigating reflux after laparoscopic sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric procedure due to the technical ease and weight loss success of the operation. However, there has been concern that LSG contributes to gastroesophageal reflux disease (GERD) postoperatively with a proportion of patients requiring conversion to a Roux-En-Y Gastric Bypass (RYGB). The objective of this study was to characterize the patients who underwent revision in our hospital system and to better understand pre-operative predictors of GERD and revision. METHODS: After IRB approval, a retrospective review was conducted assessing for patients who had conversion of LSG to RYGB at three hospitals within the University of Pennsylvania Health System from January 2015 to December 2021. The patients' charts were then reviewed to evaluate for demographics, BMI, operative findings, imaging and endoscopic reports, and post-operative outcomes. RESULTS: 97 patients were identified who underwent conversion of LSG to RYGB between January 2015 and December 2021. The cohort was predominantly female (n = 89, 91.7%) with an average age of 42.7 ± 10.6 years at the time of conversion. The most common indications for revision were GERD (72.2%) and obesity/insufficient weight loss (24.7%). Patients lost an average of 11.1 ± 12.9 kg after revision to RYGB. Of the patients who underwent revision for GERD, 80.2% noted global symptomatic improvement after revision and 19.4% were able to stop their proton pump inhibitor (PPI) postoperatively, with most patients decreasing the frequency of the PPI use postoperatively. CONCLUSION: The majority of patients who underwent conversion from LSG to RYGB due to GERD and saw marked improvements in GERD symptoms and outcomes. These findings illuminate the real-world practices and outcomes of bariatric revisional procedures for reflux and the need for more research on standardized practice.

Dietary approaches to stop hypertension (DASH)-style diet in association with gastroesophageal reflux disease in adolescents.

BACKGROUND: Dietary patterns and food items have been associated with gastroesophageal reflux disease (GERD) risk and they have led to conflicting findings. The aim of this study was to determine the association between a dietary approach to stop hypertension (DASH)-style diet with the risk of GERD and its symptoms in adolescents. STUDY DESIGN: Cross-sectional. METHODS: This study was performed on 5,141 adolescents aged between 13 and 14 years. Dietary intake was evaluated using a food frequency method. The diagnosis of GERD was done by using a six-item GERD questionnaire that asked about GERD symptoms. A binary logistic regression was used to assess the association between the DASH-style diet score and GERD and its symptoms in crude and multivariable-adjusted models. RESULTS: Our findings revealed that after adjustment for all confounding variables, the adolescents with the highest adherence to the DASH-style diet had a lower chance of developing GERD [odds ratio (OR) = 0.50; 95%CI 0.33-0.75, Ptrend< 0.001)], reflux (OR = 0.42; 95%CI 0.25-0.71, Ptrend=0.001), nausea (OR = 0.59; 95% CI:0.32-1.08, Ptrend=0.05) and stomach pain (OR = 0.69; 95%CI 0.49-0.98, P trend=0.03) compared to those with the lowest adherence. Similar results were found for odds of GERD among boys, and the total population (OR = 0.37; 95%CI: 0.18-0.73, Ptrend=0.002, OR = 0.51; 95%CI: 0.34-0.77, P trend<0.0, respectively). CONCLUSION: The current study revealed that adherence to a DASH-style diet might protect against GERD and its symptoms including, reflux, nausea, and stomach pain in adolescents. Further prospective research is needed to confirm these findings.

Perioperative Interventions to Prevent Gastroesophageal Reflux Disease and Marginal Ulcers After Bariatric Surgery - an International Experts' Survey.

OBJECTIVE: This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate perioperative interventions to prevent gastroesophageal reflux disease (GERD) and marginal ulcers (MU) after MBS. BACKGROUND: Very important long-term complications after MBS include GERD, Barrett's esophagus, and MU. Prevention might be fundamental to reduce the incidence, severe complications, and the increasing number of revisional bariatric surgeries. METHODS: An international scientific team designed an online confidential questionnaire with 45 multiple-choice questions. The survey was sent to 110 invited experts and 96 of them (from 41 different countries) participated from 21 July 2022 to 4 September 2022. RESULTS: Most experts (≥ 90%) prescribe postoperative acid suppression agents after MBS. Life-long proton pump inhibitors prophylaxis in smokers with avoidance of non-steroidal anti-inflammatory drugs are recommended by most of the experts (66%, 73%) after any type of gastric bypass. Two-thirds of experts (69%) perform Helicobacter pylori eradication prior to MBS. Two-thirds of experts (68%) routinely perform EGD and biopsy before MBS. Follow-up esophagogastroduodenoscopy (EGD) and timing threshold for revisional and conversional MBS were variable among experts. CONCLUSION: This expert survey underlines important perioperative interventions that reached a two-thirds consensus among MBS international experts. Variability in follow-up EGD, approach to complication management, and thresholds for revisional and conversional MBS emphasize the need for further researches and consensus guidelines.

Reconstruction of the phreno-esophageal ligament (R-PEL) prevents the intrathoracic migration (ITM) after concomitant sleeve gastrectomy and hiatal hernia repair.

BACKGROUND: Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and "de novo" GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure's metabolic and GERD-related outcomes. PATIENTS AND METHOD: Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients' evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed. RESULTS: Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m2. The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ's position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and "de novo" severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett's esophagus and no complication were recorded in any of the patients. CONCLUSION: Concurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.

Comparison of changes in body-fat mass and reflux esophagitis among reconstruction methods for proximal gastrectomy.

BACKGROUND: Although proximal gastrectomy (PG) is a function-preserving surgical option, it remains unclear as to which reconstruction method can prevent reflux and maintain body composition. METHODS: Patients who underwent PG at Keio University between April 2011 and November 2018 were analyzed. Changes in the subcutaneous and visceral adipose tissues were comparatively assessed before and after a year of surgery for three common reconstruction methods. We also compared the endoscopic findings of reflux esophagitis and the number of patients prescribed with proton-pump inhibitor after a year of surgery. RESULTS: This study included 76 patients, of which 33 patients underwent esophagogastrostomy with a circular stapler (CS), 35 under double flap (DF) reconstruction, and 8 underwent double tract (DT) reconstruction. Comparing esophagogastrostomy (CS and DF) and DT showed that esophagogastrostomy could significantly preserve both subcutaneous and visceral adipose tissues (P < 0.001 and P = 0.04, respectively). However, the change in the subcutaneous and visceral adipose tissues was comparable between CS and DF. As for reflux esophagitis, DF showed the lowest incidence rate for esophagitis and the least number of patients who were prescribed a proton-pump inhibitor. CONCLUSION: DF is a relatively better reconstruction method for preserving fat mass and preventing reflux among the three common reconstruction methods.

Ligamentum Teres Cardiopexy Might Not Prevent Gastro-esophageal Reflux After Laparoscopic Sleeve Gastrectomy: Case Series.

Roux-en-Y gastric bypass (RYGB) is considered the gold standard procedure in patients with obesity and gastroesophageal reflux (GERD), but in patients with preoperative hiatal hernia (HH) or GERD, who are unfit for RYGB, there are no clear guidelines. Ligamentum teres cardiopexy (LTC) has been proposed as an effective alternative. The purpose of this study was to analyze medium-term results of LTC procedure associated with laparoscopic sleeve gastrectomy (LSG) in patients with GERD or HH, according to the absence of pathologic acid reflux in esophageal 24 h pH monitoring test, symptom release, or PPI reduction. Five patients underwent LSG-LTC between March 2018 and October 2019. In one patient, the effectiveness of LTC as an anti-reflux procedure could not be assessed because of conversion to RYGB was required. After a follow-up period of 30 [24-42] months and excessive BMI loss of 62.74 ± 18.18%, GERD recurrence was observed in 75% of patients. The study was discontinued due to unsatisfactory preliminary results with LTC. Our results suggest that LTC might not prevent GERD after LSG in patients with preoperative GERD or HH.