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Background. The purpose was to develop indications for surgical treatment of patients with hiatal hernias and evaluate its results. Materials and methods. At the Department of Surgery of Digestive Organs of SI “Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine”, 45 patients with hiatal hernias were examined in 2017–2019. Long-term treatment results were studied within 6 months to 2 years in 19 (42.2 %) individuals. Results. In our studies, among 45 operated patients, 27 (60.0 %) had a diagnosis of axial hiatal hernia (type I), 9 (20.0 %) — paraesophageal hiatal hernia (type II), 8 (17.8 %) — combined hiatal hernia (type III), 1 (2.2 %) patient had hiatal hernia with a shortening of the esophagus (type IV). Grade I of hiatal hernia was noted in 25 (55.6 %) people, grade II occurred in 12 (26.7 %), and grade III, when body and even the antral part of the stomach prolapse into the posterior mediastinum, — in 8 (17.8 %) patients. Cruroplasty was performed in 100 % of cases: posterior — in 24 (53.3 %) individuals, anterior and posterior (сombined) — in 13 (28.9 %), alloplasty — in 8 (17.8 %). Laparoscopic fundoplication was carried out in all patients: Nissen fundoplication — in 36 (80.0 %), Toupet fundoplication — in 6 (13.3 %), Dor fundoplication — in 3 (6.7 %). There were no fatal cases. The average duration of surgery was (135 ± 24) min, the average time of transplant fixation — (24 ± 12) min. Conclusions. Therefore, laparoscopic antireflux operations are highly effective in the treatment of hiatal hernias, well tolerated and characterized by a low percentage of complications (6 (13.3 %) cases), rapid recovery of patients in the postoperative period, allowing them to be recognized as surgery of choice in the treatment of this pathology. The choice of surgical procedure for hiatal hernia is determined by the features of anatomical interrelations and the purpose of restoring the esophageal-gastric junction and diaphragm.

Objective. To analyze the effectiveness of various methods of laparoscopic antireflux operations in patients with gastroesophageal reflux disease. Materials and methods. The results of treatment of 177 patients with gastroesophageal reflux disease from 2015 to 2021 were analyzed. Patients were divided into three groups: 1st - 62 patients who underwent laparoscopic antireflux surgery of our own modification (Patent of Ukraine No 59772); 2nd - 91 patients who underwent laparoscopic Nissen fundoplication; 3rd - 24 patients who underwent laparoscopic Toupet fundoplication. Results. 36 months after surgery in the 1st group the recurrence rate of gastroesophageal disease was 1.6%, recurrence of hernia of the esophageal orifice - 1.6%, in the 2nd group - 7.7 and 3.3%, respectively; in the 3rd group - 12.5 and 8.3%, respectively. Conclusions. The application of a new integrated approach to the surgical treatment of gastroesophageal reflux disease reduces the number of postoperative complications (gas -bloat syndrome - 3 times, dysphagia - 5 times), the recurrence rate of gastroesophageal reflux disease - 5 times and recurrence of esophageal hernia - 2 times, improves the quality of life of patients 36 months after surgery in 2.6 times and increases the timeliness of diagnosis and facilitates the choice of differentiated treatment tactics.

Summary. The purpose was to study the features and results of redo laparoscopic antireflux surgery in our clinic. Materials and methods. For the period from 2008 to 2019, in our clinic, laparoscopic antireflux operations were performed in 1164 patients. 54 patients underwent laparoscopic reoperation during the study period based on the following indications: recurrence of hiatal hernia (n = 38), recurrent reflux (n = 4), dysphagia (n = 8), severe pain (n = 5). All patients underwent repeated examinations in our clinic, telephone interviews, mailing of special questionnaires. All complaints were recorded, the quality of life was determined according to the GERD-HRQL questionnaire. Results. All redo operations were performed laparoscopically without conversion to laparotomy. Intraoperative complications were observed in 11.11 % of patients. Long-term follow up from 6 months to 6 years was observed in 90.74 % of patients. The quality of life of patients according to the GERD-HRQL questionnaire significantly improved in long-term follow-up (p

Only a small percentage of patients fail laparoscopic fundoplications undertaken for gastroesophageal reflux disease. But because many laparoscopic fundoplications have been undertaken, surgeons frequently encounter patients in need of “redo” operations. This study was undertaken to evaluate the robotic approach versus laparoendoscopic single-site (LESS) approach for redo fundoplications. With an Institutional Review Board approval, 64 patients undergoing LESS (n = 32) or robotic (n = 32) redo antireflux operations were prospectively followed up. Data are presented as median (mean + SD). For LESS versus robotic redo operations, the operative duration was 145 (143 ± 33.5) versus 196 (208 ± 76.7) minutes ( P < 0.01), estimated blood loss was 50 (80 ± 92.1) versus 20 (43 ± 57.1) mL ( P = 0.07), and length of stay was 1 (3 ± 5.4) versus 1 (2 ± 1.9) day ( P = 0.57); 1 LESS operation was converted to “open.” Operative duration was longer for men ( P = 0.01). Postoperative complications were not more frequent after Nissen (n = 36) or Toupet (n = 28) fundoplication, regardless of the approach. When matched by BMI, operative duration was prolonged by a large Type I to IV hiatal hernia ( P = 0.01). Symptoms improved dramatically and were similar with both approaches, and patient satisfaction was high. Robotic redo antireflux operations take longer than LESS operations. LESS and robotic redo antireflux operations are both safe and offer significant and similar amelioration of symptoms after failed fundoplications.

The purpose of our study is to evaluate expediency of Platelet-Rich Plasma with self-fixated ProgripTMmesh use in hiatal hernia repair. The study was performed on 144 patients with gastroesophageal reflux with large hiatal hernias (the size of hernias 10-20 cm2), who underwent Nissen fundoplication and crurarrhaphia. All patients were divided into two groups: I group (71 patients) - we used non-absorbable self-fixating ProgripTMmesh for reinforcement of crurarrhaphia, II group (73 patients) – crurarrhaphia was done without mesh. In the patients of I group pieces of mesh were infiltrated by 2-4 ml of autologous PRP. Follow-up was completed in 128 (88,9%) patients with a mean follow-up duration of 39 months (range 12-60 months). There were no serious complications in the patients of both groups. During the 60 months of follow-up, 2 recurrences occurred in the mesh group and 14 recurrences appeared in the non-mesh group (p

Introduction. Laparoscopic techniques have been applied to ensure surgical treatment of the vesicoureteral reflux (VUR) in children during the last decades. We present the experience of using the laparoscopic extravesical antireflux standard and ureter-fixed modified surgery.Materials and methods. A multi-center prospective experimental clinical historical cohort two-group study of patients with III–V stage primary VUR. The basic group consisted of 48 children who had a unilateral laparoscopic extravesical surgery when the ureter was fixed according to the developed technique. 44 children who had a surgery according to the standard technique were included into the control group.Results. Complete VUR removal was noted in 100% of patients from the basic group and 81.2% of patients from the control group (р Conclusions. Laparoscopic extravesical antireflux is a safe and effective surgery. Distal ureter fixation reduces the rate of VUR recurrences.

Gastroesophageal reflux disease (GERD) is a highly prevalent disease with symptoms that have been described for centuries. The surgical therapy, however, has a brief history starting at the beginning of the twentieth century. The delay in the development of antireflux operations can be credited to the lack of knowledge of the pathophysiology of GERD and the limitation of diagnostic methods. Nissen should be remembered as a pioneer in the development of antireflux surgery. However, the procedure that Nissen first described in 1956 underwent several modifications over time, so that the term “Nissen Fundoplication” may have different meanings to different surgeons. The historical evolution of fundoplication can be demonstrated through a timeline that passes through the original Nissen technique and its most relevant modifications, such as those proposed by Rosseti, Toupet, Donahue, and DeMeester, which aimed to improve GERD symptoms and minimize side effects. The historical understanding of this evolution should stimulate further technical improvements to benefit GERD patients.

The observation is described the successful treatment of the child with VATER association. We made the correction of esophageal atresia with lower trachea-oesophageal fistula, anal atresia withrectourethral fistula. Performed surgical operations: retrosternal esophagoplasty the stomach, gastrooesophageal anastomosis in the neck with an antireflux mechanism, anosphincteroplasty.

Over the past two decades, as experience with advanced laparoscopy has increased, surgeons have increasingly adopted laparoscopic antireflux surgery as the gold standard approach to gastroesophageal reflux disease. However, with the expansive implementation of these techniques, a concomitant increased incidence of complications from antireflux surgery has also been observed. In this milieu, foregut surgeons are increasingly called upon to care for patients who have previously undergone an antireflux operation. This chapter addresses the epidemiology of reoperative surgery of the hiatus, the optimal clinical evaluation and management prior to operative intervention, and the technical approach to caring for these patients.

Background Open trigonoplasty antireflux operation has been associated with promising results. However, its success in controlling reflux has not been evaluated in the long term. Methods All patients who underwent trigonoplasty for vesicoureteral reflux by one surgeon from 2004 to 2014 were included. Pre-Operative evaluations included direct radionuclide cystography (DRNC) or voiding cystourethrography, urine analysis and culture and abdominal sonography. Urodynamic study and cystoscopy was performed in selected patients. Trigonoplasty was done by a modified Gil-Verent method. The latest available patients’ DRNCs were used to judge for reflux relapse. Results Ninety-one patients, 142 refluxing units; median (range) age, 10.5 (1-45) years; M/F, (11/80) were followed for 18 to 135 months. Reflux resolution rate was 73.6% for patients and 75.4% for refluxing units. Relapse was associated with reflux grade (67% in grade V), ureteral orifice appearance (40% in golf hole/stadium), and patients with a history of pyelonephritis. Multivariable model based on the above variables had less than 10% sensitivity in predicting relapse. Conclusions Trigonoplasty success rate can decrease with long-term follow-up.

Robot-assisted general surgery operations are being performed more frequently. This review investigates whether robotic assistance results in significant advantages or disadvantages for the operative treatment of gastro-oesophageal reflux disease and achalasia.

The topic of “when and what” for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the “when”) and on the right antireflux operation to perform once the ideal candidate is identified (the “what”). The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.

This paper includes commentaries on outcomes of esophageal surgery, including the mechanisms by which fundoduplication improves lower esophageal sphincter (LES) pressure; the efficacy of the Linx™ management system in improving LES function; the utility of radiologic characterization of antireflux valves following surgery; the correlation between endoscopic findings and reported symptoms following antireflux surgery; the links between laparoscopic sleeve gastrectomy and decreased LES pressure, endoscopic esophagitis, and gastroesophageal reflux disease (GERD); the less favorable outcomes following fundoduplication among obese patients; the application of bioprosthetic meshes to reinforce hiatal repair and decrease the incidence of paraesophageal hernia; the efficacy of endoluminal antireflux procedures, and the limited efficacy of revisional antireflux operations, underscoring the importance of good primary surgery and diligent work-up to prevent the necessity of revisional procedures.

A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD). Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis. This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.

The patient was a 35-year-old man who first underwent fundoplication due to hematemesis associated with reflux esophagitis 11 years earlier. Despite two subsequent antireflux operations, reflux-related symptoms persisted, and upper gastrointestinal endoscopy confirmed recurrent reflux esophagitis. After 24-h pH monitoring and Bilitec 2000 showing regurgitation of gastric and duodenal juice, distal gastrectomy with Roux-en-Y reconstruction was performed. The patient's postoperative course was uneventful, and recurrence has not appeared for 10 months after surgery. To our knowledge, this is the first report of successful surgery after three failed antireflux operations for recurrent reflux esophagitis. Distal gastrectomy should be considered after unsuccessful antireflux operations for intractable reflux esophagitis.

A thorough understanding of the anatomy and physiology of the components of the reflux barrier is essential to achieving success with any antireflux operation. The reflux barrier is a concept that has grown over the last century. Although there has always been an intuitive understanding of a valve-like mechanism between the esophagus and the stomach, the identification of the corresponding structures and understanding their individual role in creating a functional reflux barrier has been an ongoing effort.

Laparoscopic antireflux surgery (LARS) has assumed a major role in the treatment of gastroesophageal reflux disease (GERD). The advancement in laparoscopic techniques and instrumentation over the past two decades has led to an increase in the number of antireflux operations. Although the operation is fundamentally similar to open antireflux procedures, clear benefits to the laparoscopic approach have been described.

Background Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility diagnosis associated with a myriad of conditions. The frequency of EGJOO attributed to anatomic causes compared to idiopathic causes is uncertain. Our study aims to identify the frequency of EGJOO and to compare these two groups. Methods We conducted a case–control study of high-resolution manometry (HRM) studies with a diagnosis of EGJOO performed at a single academic center. EGJOO cases were classified as anatomic (if any potential anatomic cause was identified) or idiopathic. Clinical and manometric characteristics of idiopathic EGJOO were compared with anatomic EGJOO cases. Key Results Criteria for EGJOO were met in 11% of HRM studies. Ancillary studies revealed 21/32 EGJOO cases had potential anatomic causes with a hiatal hernia noted in 15/21 cases of anatomic EGJOO. Idiopathic EGJOO cases met Chicago Classification criteria for hypercontractile esophagus with greater frequency than anatomic cases (p = 0.01). The mean distal contractile integral was significantly greater for idiopathic cases compared to anatomic cases (p = 0.003). Treatments used for EGJOO were varied and usually successful in alleviating symptoms. Patients with anatomic EGJOO related to a hiatal hernia who underwent an antireflux operation did not develop dysphagia postoperatively. Conclusions & Inferences EGJOO is a frequently encountered manometric diagnosis, commonly associated with anatomic abnormalities potentially explaining the EGJOO. These findings support current recommendations to pursue ancillary diagnostics to investigate cases of unexplained EGJOO. Cases of idiopathic EGJOO are more likely to have hypercontractility on HRM, possibly suggesting a primary esophageal motility disorder.

OBJECTIVE. Gastroesophageal reflux disease is extremely common in the pediatric population, and antireflux procedures are performed with increasing frequency. The objective of this study was to determine whether pediatric antireflux procedures are associated with a decreased rate of reflux-related hospitalizations.METHODS. A study was conducted of pediatric patients who were undergoing antireflux procedures using data that were derived from the Washington State Comprehensive Hospital Abstract Reporting System and Vital Records. Patients were identified by a search of all records (1987–2001) for procedure codes that pertained to antireflux procedures in patients who were younger than 19 years. The number of hospitalizations for and rates of reflux-related events per patient-year before and after an antireflux procedure was calculated, and factors that were associated with higher antireflux procedure rates were examined.RESULTS. A total of 1142 patients underwent antireflux procedures. The rate of reflux-related events declined sharply with age both before and after an antireflux procedure. The cohort was divided into 3 groups on the basis of age at first antireflux procedure (CONCLUSIONS. The rate of reflux-related events was lower after an antireflux operation for children who underwent an antireflux procedure before age 4. Older children, however, were hospitalized at equal rates before and after an antireflux procedure, and older children with developmental delay were hospitalized at greater rates after an antireflux procedure. These findings highlight the need to clarify the subjective and objective indications for antireflux procedures in infants and children.

The purpose of this trial was to measure the health-related quality of life (HRQL) of gastroesophageal reflux disease (GERD) patients waiting for an antireflux operation.A total of 120 patients waiting for a laparoscopic fundoplication were sent questionnaires measuring their symptoms and quality of life.Ninety-five of the patients still needing an operation returned the questionaires and were included in the analysis. Thirty-one of 84 patients (37%) felt that the symptoms had worsened, and 51/90 (57%) were unsatisfied. Thirty percent suffered from throat or airway infections, 25% from swallowing difficulties, 48% from retrosternal pain, and 18% had asthma. The mean GERD HRQL score (0-45) was 21.7 (95% confidence interval, 19.7-23.7). Short Form-36 scores of this population were significantly worse when compared to patients with inguinal hernia or moderate asthma.Patients waiting for a fundoplication seem to have a significantly decreased health-related quality of life due to poor symptom control regardless of continuous medical treatment.

Increased recognition of the association between urinary tract infections and reflux, sibling screening, and the evaluation of antenatal hydronephrosis have resulted in an increase in the diagnosis of reflux early in life. Although many children would sustain no untoward affects of their condition if reflux were left untreated, the disease can be severe and even life threatening. Although antireflux operations have been refined and improved, it remains difficult to determine which individuals truly benefit from these operations. A large prospective randomized placebo-antibiotic-operation study with long-term follow-up is needed, as is the development of nomograms, to assess the individual child's risk of adverse outcomes.

In most patients who have Barrett's esophagus and who are undergoing open or laparoscopic antireflux surgery, there is a significant improvement in symptom control that is equivalent to that in patients who have uncomplicated gastroesophageal reflux disease. The requirement for reoperation in patients with Barrett's esophagus may be slightly higher, although in the two laparoscopic series published to date, the rate is still only approximately 6%. How much this will increase with longer follow-up, time alone will tell, but given the good results in approximately 95% of patients operated to date, the authors do not believe that the diagnosis of Barrett's esophagus should be considered a blanket contraindication for laparoscopic antireflux surgery. Clearly, in most patients with Barrett's esophagus, an antireflux operation will not result in regression of Barrett's mucosa. It is still unclear whether antireflux surgery provides any protection against subsequent development of esophageal adenocarcinoma. What is clear, however, is that after antireflux surgery, patients who have Barrett's esophagus are still at risk for developing adenocarcinoma and should remain in surveillance programs. The authors believe that laparoscopic antireflux surgery is a safe and effective approach for the cure of reflux-related symptoms in patients who have Barrett's esophagus.

Background . Antireflux surgery can reduce respiratory symptoms associated with gastroesophageal reflux. However, there is a paucity of data on the durability of this benefit. To evaluate the long-term effects of antireflux surgery on respiratory complaints associated with gastroesophageal reflux, we reviewed our experience. Methods . Retrospective review of 2,123 antireflux procedures completed between 1986 and 1998 identified 65 patients (3.1%) with associated respiratory symptoms. There were 32 men and 33 women, ranging in age from 20 to 80 years (median 59 years). Respiratory symptoms included wheezing in 43 patients, sputum production in 37, cough in 30, choking episodes in 24, and hoarseness in 17. Preoperative medication use included steroids in 23 patients and bronchodilators in 18. Results . Antireflux operations included the uncut Collis-Nissen fundoplication in 29 patients, Belsy Mark IV repair in 13, open Nissen fundoplication in 13, and laparoscopic Nissen fundoplication in 10. Perioperative complications occurred in 19 patients who underwent open procedures and in none who had laparoscopic procedures. There was one death in the open-operation group and none in the laparoscopic group. Median follow-up was 65 months (range 1 to 174 months) and was complete in 62 patients (96.9%). Improvement in respiratory symptoms (83%) and reduction in respiratory medication use (78%) were significant as compared to a calculated 33% placebo-effect improvement ( p Conclusions . Antireflux operations significantly reduce respiratory complaints associated with gastroesophageal reflux. This benefit appears to be long term.

Despite documented success of antireflux surgery in controlling GERD in select patients, there remains a persistent incidence of failure requiring reoperation. Broadly speaking, the need for reoperation can be broken into three general categories, errors in diagnosis or patient selection, intraoperative errors, or the natural history of the antireflux operation itself or the condition being treated. When evaluating a patient for possible reoperative antireflux surgery, there are a variety of ways to approach the management, both determining whether to undertake a redo, and what operation to perform. These decisions depend on the timing of the development of recurrent symptoms or problems and the pattern of failure. Patterns of failure include, fundoplication disruption, recurrent or development of new hiatal hernia, tight fundoplication or crural stenosis, slipped fundoplication, and a fundoplication that is either too loose or misplaced at the time of initial surgery. Failure of antireflux surgery and the pattern of failure can usually be suspected based on presenting symptoms, either recurrent or new. A directed work-up including anatomic and functional studies should identify the failure pattern and guide decision-making about reoperation. Careful technique at the time of reoperation can result in a high rate of success of both resolving presenting symptoms and providing durable control of GERD. Understanding the patterns of failure can help guide improvements in technique to minimize future failure.

The impetus to identify and counsel patients with progressive disease regarding the need for surgical therapy is critical. This goes largely unheeded by gastroenterologists due to their lack of confidence in the durability of a fundoplication and concern over the side effects of the operation. Consequently, early referral of a patient with symptoms and signs of progressive disease for surgical therapy is resisted. Further, there is widespread concern that not all surgeons are sufficiently experienced in evaluating esophageal patients, many are not knowledgeable enough to select the proper antireflux procedure, and some are not sufficiently trained to properly perform the procedure. 4,5 Over the last 5 decades, 5 principles of the surgical treatment of GERD have emerged and when followed, lead to a successful outcome in nearly all patients. These principles are: documentation of the diagnosis of GERD; determination of the status of the lower esophageal sphincter (LES) and esophageal body; identification of the patient who is a proper candidate for surgical therapy; selection of the proper surgical procedure; and surgeon awareness of the technical nuances of the procedure. Application of these principles requires surgeons to hone their cognitive, diagnostic, clinical, and surgical skills regarding reflux disease. Errors can lead to surgical failure and the need for repetitive reoperations with the inherent risk of vagal injury and ischemic damage to esophageal and gastric tissues. The last 5 decades of experience have taught that a successful therapeutic outcome is unlikely after 3 failed antireflux operations. 6-8 Consequently, it is imperative that the first operation be performed for the right diagnosis, on the right patient, and by a knowledgeable and capable surgeon. The objective of this review is to describe the current state of surgical treatment for GERD, to expand on how new knowledge about disease progression and LES function has improved our ability to select the appropriate patient for surgical therapy, and to offer a more personalized surgical approach to these patients.

Peptic esophageal stricture with dysphagia is a late manifestation of severe gastroesophageal reflux disease (GERD). Although laparoscopic fundoplication is an effective antireflux operation, its efficacy for persons with peptic esophageal stricture and dysphagia has not been well defined. The aim of this study was to evaluate outcomes after fundoplication in this subgroup of GERD patients. Forty GERD patients with moderate, severe, or incapacitating dysphagia and peptic esophageal stricture were compared to a control group of 121 GERD patients without significant dysphagia or stricture. Reflux symptom severity was scored by each patient preoperatively and at most recent follow-up postoperatively (mean 1.5 years) using a scale ranging from 0 to 4 (0 = symptoms absent; 4 = symptoms incapacitating). Symptom scores were compared by the Wilcoxon rank-sum test. Postoperative redilation and fundoplication failure rates were also determined. At a mean follow-up of 1.5 years after fundoplication, the median dysphagia score had improved from 3 to 0 (P

Background: Primary antireflux surgery provides excellent symptom relief in most patients. Unfortunately, the results of redo surgery are less predictable. In these patients, esophageal injury from long-standing reflux of gastric contents and operative trauma from previous failed antireflux procedures results in progressive deterioration in esophageal propulsion, poor clearance of reflux episodes, mucosal damage, and, in some cases, stricture formation. For the past 16 years, we have selectively used esophageal resection and replacement instead of another reoperation in these challenging patients. Methods: Seventeen patients with end-stage esophageal body dysfunction and one or more previously unsuccessful antireflux procedures underwent esophagectomy and reconstruction by colon interposition in 15 patients and jejunum interposition in 2 patients. The indications for esophagectomy rather than a redo antireflux procedure were a global loss of effective esophageal motility in 13 and a nondilatable stricture in four. Their outcome was compared with that of 32 patients with adequate motility and 18 with a similar global loss of motility who had a redo antireflux procedure. Perioperative complications after esophagectomy were recorded, and long-term outcome was assessed by means of a standardized questionnaire at a median of 7 years after the operation. Results: Patients with profound esophageal body dysfunction who underwent esophageal resection had outcomes similar to those with normal motility who underwent a redo antireflux procedure. Those with profound esophageal motility dysfunction who underwent a redo antireflux procedure had a worse outcome than those who underwent resection. Esophageal resection and replacement was performed without mortality or graft failure. All patients who underwent resection stated that their preoperative symptoms were relieved completely ( n = 6) or improved ( n = 10). Thirteen patients (81%) were able to eat three meals a day, and 12 patients (75%) enjoyed an unrestricted diet. Two thirds of the patients were at or above their ideal body weight, and 88% were fully satisfied with the outcome of the procedure. Conclusion: Patients with end-stage esophageal body dysfunction who have had a previous unsuccessful antireflux procedure can be treated by esophageal resection with a high expectation of success. (J Thorac Cardiovasc Surg 1998;115:296-302)

Background Minimally invasive procedures have become common, and more reoperations for failed antireflux procedures are performed laparoscopically. We wanted to study the outcomes of laparoscopic reoperations for reflux. Methods Medical records of all patients who underwent reoperation without esophageal resection after previous antireflux procedures between January 2000 and October 2012 were reviewed. Results Seventy-five patients were included in this report: 56 (77%) women and 19 (23%) men. Median age was 58 years. The previous operation was laparoscopic antireflux procedures in 65 (87%) patients. The median interval between the last antireflux procedure and laparoscopic reoperation was 42 months. The median body mass index (BMI) was 28.7. All patients were symptomatic. Intraoperative findings included recurrent hiatal hernia in 47 (63%) patients, incompetent fundoplication in 14 (19%) patients, tight fundoplication in 8 (11%) patients, and tight crura in 2 (3%) patients. Laparoscopic Nissen fundoplication was performed in 57 (76%) patients, partial posterior fundoplication was performed in 12 (16%) patients, partial anterior fundoplication was performed in 3 (4%) patients, removal of crural stitches was performed in 2 patients, and a combination of partial posterior fundoplication and removal of crural stiches was performed in 1 patient. Complications occurred in 13 (15%) patients. Improvement in symptoms was observed in 70 (93%) patients in early postoperative follow-up and in 59 (78%) patients in long-term follow-up. Functional results were classified as excellent in 59 (78%) patients, good in 6 (7%) patients, fair in 7 (8%) patients, and poor in 3 (4%) patients. Conclusions Laparoscopic reoperation for failed antireflux operations is a complex procedure, but it is safe and effective in selected patients. Reoperation after a failed antireflux repair results in excellent or good functional status in a majority of patients, but these results may deteriorate over time.

Modern upper GI function studies allow for the detection of several pathophysiological factors that contribute to gastroesophageal reflux disease. The information obtained can lead to therapeutic consequences in patients with an indication for a surgical intervention, i.e., an individualized choice of antireflux procedure according to the existing pathophysiologic defect.In an experimental study on mini-pigs the mechanical effect of four standardized antireflux operations (anterior and posterior 180 degrees hemifundoplication, Nissen-DeMeester and Nissen-Rossetti 360 degrees fundoplication) on the lower esophageal sphincter (LES) was investigated. It was the aim of the study to objectively determine the extent of changes in pressure and length parameters at the LES according to the performed antireflux procedure.It could be demonstrated that different degrees of fundic wrap formation lead to a proportional mechanical effect at the LES according to the size of this wrap.Choosing a distinct type of fundoplication will allow for a tailored augmentation of the LES according to the individual functional defect.

Even though the technical elements for a successful laparoscopic fundoplication have been clearly identified, 10–15 % of patients will eventually experience recurrence of their symptoms and between 3 and 6 % will need a second antireflux operation.

Background: Nissen fundoplication reduces gastro-oesophageal reflux effectively, but the mechanisms through which this effect is brought about have remained rather obscure. Methods: In this study the effect of fundoplication on oesophageal acid exposure, oesophageal body motility, and lower oesophageal sphincter pressure (LOSP) was assessed prospectively. Eleven patients were studied before and 3 months after a floppy Nissen fundoplication. A Dent sleeve was used to measure LOSP, and ambulatory pH and pressure monitoring were used to evaluate oesophageal motor function. Results: Gastro-oesophageal reflux was significantly decreased after fundoplication without an increase in LOSP. The motor function of the oesophageal body was not affected by the antireflux procedure. Conclusions: Nissen fundoplication is an effective antireflux operation, even though the procedure does not increase LOSP, and the motility pattern of the oesophageal body is not affected by the construction of a floppy fundic wrap.

A retrospective review of gastroesophageal leaks complicating antireflux operations was conducted to determine the incidence, predisposing factors, optimal treatment, and outcome in such patients. Twelve postoperative gastroesophageal leaks occurred in a series of 1,005 antireflux procedures (1.2%). Four of the 12 patients had undergone a previous hiatal operation, and this was a significant risk factor for postoperative leak (p0.001). Ten of the 12 patients had undergone "incomplete" wraps that involved suturing of the gastric fundus to the esophagus, and this was a significant risk factor for postoperative leak (p0.04). Five patients had peritoneal contamination and 7 had mediastinal or pleural soilage. Patients with peritoneal perforations were less likely to require intensive care unit admission than were patients with thoracic perforations (p0.05). Six of the 12 perforations were either well contained or well drained at the time of the diagnostic contrast study. All 6 of these patients responded to conservative treatment. The remaining 6 perforations were not contained at the time of diagnosis. Two of the affected patients initially received conservative treatment (1 death and 1 late empyema) and 4 were treated by operation (1 death). The mortality associated with gastroesophageal perforation was 17%. Contained perforations can be treated conservatively but noncontained perforations require early and aggressive surgical intervention.

Background Laparoscopic Nissen fundoplication is a common operation performed for reflux disease, generally with good results. A small percentage of patients experience transthoracic migration of the wrap, causing recurrent symptoms and eventually requiring transthoracic repair. Methods A retrospective chart review was performed for all patients who underwent a transthoracic repair of a slipped Nissen fundoplication at our institution from 2006 to 2010. Data included demographics, previous antireflux operations, symptoms at presentation, findings at operation, and overall outcome. Results Sixteen patients with a mean age of 61 years (range, 51–76 years) were identified who fit inclusion criteria. The most common presenting symptom was pain. Intraoperative findings included hiatal breakdown in all patients, shortened esophagus in 10 (62%) patients, and foreign body/mesh in 4 (25%) patients. Nine (56%) patients underwent a Collis gastroplasty along with a Nissen fundoplication. Nissen fundoplication alone was performed in 6 (38%) patients and a Belsey fundoplication with a Collis gastroplasty was performed in 1 (6%) patient. Minor complications occurred in 4 (25%) patients and major complications were seen in 2 (13%) patients. The median length of stay was 9 days (range, 6–30 days). There were no postoperative deaths. Overall, 12 (75%) of the patients were judged to have a good outcome, 3 (19%) a fair outcome, and 1 (6%) a poor outcome over a median 9-month follow-up. Conclusions Transthoracic repair in patients who have had transthoracic migration of a previous Nissen fundoplication has acceptable surgical outcome and affords symptomatic relief to the majority of patients.

Esophageal diverticular disease is an uncommon entity for which appropriate treatment remains somewhat controversial. The acquired diverticulum is typically classified by its location (upper, middle, epiphrenic) and pathogenesis (traction, pulsion). Traction diverticula have been ascribed to inflammation and adhesions from periesophageal lymph nodes arising from, for example, pulmonary tuberculosis or histoplasmosis. Pulsion diverticula arise from a number of factors, most notably esophageal dysmotility, functional or mechanical distal esophageal obstruction, and focal weakness of the esophageal wall.

An understanding of gastroesophageal reflux disease in infants and children by the clinician requires a working knowledge of 18- to 24-hour esophageal pH monitoring and the motility disorders of the esophagus and stomach that may be associated with gastroesophageal reflux disease. The results of surgical therapy for childhood gastroesophageal reflux disease cannot be assessed accurately without this knowledge. Antireflux operations can be tailored to the child's situation, which includes a combination of clinical symptoms and findings on objective tests for reflux and associated alimentary-tract motility disorders. The presence of severe complications from gastroesophageal reflux disease in "asymptomatic" infants and children is a troublesome and not yet fully defined problem. Special areas include the documentation of gastroesophageal reflux disease as a cause of SIDS, the increased reporting of Barrett's esophagus and adenocarcinoma of the esophagus in childhood, and the effect of associated alimentary-tract motility disorders in children with CNS disease who have gastroesophageal reflux disease requiring surgical intervention.

Between 1976 and 1989 an antireflux operation (193 Nissen; 5 Thal) was performed in 198 children with profound neurological impairment (NI). Etiology of the NI was a syndrome in 24%, congenital in 30%, and acquired in 46%. The most frequent symptoms of gastroesophageal reflux (GER), vomiting and pneumonia, were significantly reduced (P less than .05) after the antireflux operation. Postoperatively, 141 children (71%) developed return of one or more symptoms that had been preoperatively associated with GER, whereas 57 patients (29%) remained asymptomatic. Of the children with symptoms, 86 (61%) underwent diagnostic testing to exclude recurrent GER and 55 (39%) had no diagnostic evaluation. Recurrent GER was documented in 31 patients and a mechanical problem with the fundoplication in 18 children, an operative failure rate of 25%. The symptom-free interval following the antireflux operation averaged 11 months postoperatively; return of symptoms showed no statistical relationship to the etiology of NI, presence of seizures, or degree of muscle tone. The majority of children required multiple outpatient or emergency department visits for evaluation of these symptoms or assessment of gastrostomy tube problems. Survival of all children was 71% at an average postoperative follow-up of 3.5 years.

Vesicoureteral reflux (VUR) is a common problem in childhood, affecting approximately 1% to 2% of the pediatric population. Mild cases of VUR are likely to resolve spontaneously, but high-grade VUR may require surgical correction. Pediatric urologists are familiar with open antireflux operations, which can be accomplished with minimal operative morbidity. Minimally invasive endoscopic and laparoscopic techniques that now exist may serve to reduce morbidity further. This article reviews the endoscopic materials, techniques, and outcomes in the treatment of VUR in addition to the techniques and outcomes of laparoscopic and robotic ureteroneocystotomy.

Laparoscopic antireflux surgery (LARS) has assumed a major role in the treatment of gastroesophageal reflux disease (GERD). The advancement in laparoscopic techniques and instrumentation over the past decade has led to an increase in the number of antireflux operations. Although the operation is fundamentally similar to open antireflux procedures, clear benefits to the laparoscopic approach have been described.

The progress of laparoscopic surgery and a more profound understanding of the pathophysiological conditions leading to gastroesophageal reflux disease have resulted in a revival of antireflux surgery. Since 1991 [1] the laparoscopic Nissen and Toupet fundoplication and their modifications have emerged as the surgical alternative for treatment of GERD. The reduced morbidity and an approximately cero per cent mortality rate in combination with excellent outcomes following laparoscopic approaches have encouraged surgeons to a more liberal indication to surgery and have also raised patient’s expectations for a perfect outcome. Success and failure rates depend on a precise indication to surgery and on the frequency how often the procedure is performed in the institution and by a single surgeon [2]. As the “learning curve” for laparoscopic antireflux procedures even in centers is low, redo procedures require surgeons experienced in GERD and in laparoscopy, too. With the increase in laparoscopic antireflux procedures the debate has ceased whether redo fundoplications should be done open or laparoscopically. There is no doubt, that the standard for redo procedures after failed antireflux surgery is the minimal invasive technique for both, primary open and primary laparoscopic surgery, even if there are usually more adheasions and technical difficulties following a previous open procedure.

Gastroesophageal reflux disease is a common disorder, and patients diagnosed with GERD face a lifelong treatment requirement. A surgical antireflux procedure may be offered as an alternative to lifelong treatment with proton-pump inhibitors. Many investigations have been performed to help discover the best surgical alternative to medical management. An ideal antireflux procedure should be safe, effective, durable, and result in minimal complications. Total fundoplication in the form of Nissen fundoplication is the most widely used antireflux operation worldwide. Although its efficacy is well documented, the clinical success rate in terms of reflux control is occasionally compromised by troublesome mechanical side effects. Because of these unsatisfactory symptoms and continued hindered quality of life, the Nissen fundoplication has undergone many modifications. The current standard appears to be the 2 cm floppy Nissen; however, the alternative approach has been the use of a partial fundoplication, most frequently the Toupet procedure. Both the Nissen and Toupet fundoplications have proven to provide relief in the majority of patients, but each has its own drawback. Patients undergoing Nissen fundoplication have a higher incidence of dysphagia early after operation, although this appears to resolve in most. The Toupet, on the other hand, may not be as durable, and may lead to the early re-emergence of symptoms. The problem of post-Nissen dysphagia led many surgeons to believe that the Nissen night be contraindicated in patients who have dysmotility,because it would cause even greater dysphagia; however, recent articles have not demonstrated this to be the case. It seems that the floppy Nissen performed over a large bougie (56-60 Fr) with division of short gastrics and crural closure is an acceptable operation for reflux in both those who have normal motility and those who have mild to moderate dysmotility. Thus, for most patients who have GERD and normal motility, either procedure appears effective in the majority of patients; however, those patients who have severe dysmotilty disorders and who require an antireflux procedure(ie, scleroderma, postmyotomy achalasia) are likely best served with a partial fundoplication.

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.

Objective: To report the feasibility and efficacy of posterior partial fundoplication for patients with recurrent reflux after previous antireflux operations. Design: Prospective non-randomised single hospital study. Setting: University hospital, Sweden. Patients: 32 consecutive patients who required reoperation after failure of previous operations for gastro-oesophageal reflux disease. Main outcome measures: Control of symptoms, oesophageal acid reflux. Results: Most patients were referred for reoperation because of recurrent reflux, but six patients had a symptomatic intrahoracic herniation of the wrap with a life-threatening perforation in one patient. Three patients had recurrent reflux within 6 months of the operation and another two were classified as failures. The remaining 27 (84%) were classified as having a successful outcome during a mean follow-up period of 20 months. Conclusion: A posterior partial fundoplication can be done safely in a repeat operation for patients whose antireflux operation...

The number of antireflux procedures performed for gastroesophageal reflux disease in the United States has increased in the past decade. In a sampling of US hospitals by the National Center for Health Statistics, the number of patients discharged with the International Classification of Disease (ICD-9-CM) classification 44.66 (“Other procedures for creation of esophagogastric sphincteric competence,” ie, fundoplication) in the years 1988, 1993, and 1998 was 13,000, 22,000, and 40,000, respectively. It would be safe to say that the majority of these antireflux procedures are now minimally invasive. The trend for more laparoscopic antireflux procedures also has been seen in Europe. The current approach of choice for surgical treatment of gastroesophageal reflux disease is a minimally invasive transabdominal antireflux procedure. During this evolution of operational approach there have been untoward events associated with the minimally invasive antireflux operation. There is a growing need to audit the results of minimally invasive antireflux procedures because there has been (in the medical literature) a question of its efficacy, and also because of the development of novel endoscopic procedures to reproduce a sphincter mechanism in the lower esophagus, which potentially could compete with laparoscopic antireflux surgery. In this review the results of primary laparoscopic antireflux procedures will be examined (international experience, English-language literature) with an emphasis placed on the description of perioperative complications and primary procedure failures. Data on redo procedures also will be analyzed to determine the causes for failure of primary minimally invasive procedures. Recommendations for avoiding the complications and failure of the primary minimally invasive antireflux procedure will be described.

BACKGROUND: Antireflux operations restore lower esophageal sphincter (LES) function and hiatal anatomy; however, the relative contributions are unclear. METHODS: We measured the competency of fundoplications, exclusive of in vivo variables, in gastroesophageal explants from 8 cadavers. Using a multichannel manometer, esophageal, LES, and intragastric pressures were recorded during transpyloric distension. Data were compared at baseline, and after Nissen (360°) and Toupet (270°) fundoplications. RESULTS: Before fundoplication, stomachs refluxed immediately upon distension. Nissen fundoplications never refluxed before gastric rupture (46.8 ± 15.0 mm Hg). LES pressure averaged 2.0 ± 0.5 times intragastric pressure during distension. Toupet fundoplications refluxed at intragastric pressure

A new technique for the correction of reflux is presented. The technique is simple, rapidly accomplished without mobilization of the ureter and virtually free of complications. The procedure has been done successfully on 85 (92%) of 92 ureters in the first 55 patients. The most important contribution of this procedure is the decrease in manipulation of the ureter, resulting in minimal disturbance of the blood supply and in a straight course of the ureter without the risk of kinking or obstruction.

Fourteen patients with scleroderma underwent antireflux operations (10 short Nissen, 2 Collis-Nissen, 1 Collis-Belsey, and 1 vagotomy and antrectomy with Roux-en-Y). Esophageal function was assessed preoperatively and postoperatively with a follow-up range of 8 to 181 months (mean, 65 months). Reflux symptoms were relieved in 10 of the 14 patients (p0.01), as shown by a decrease in their 24-hour acid exposure of from 15% to 7.5% (p0.05). However, the lower esophageal sphincter pressure gradient created by the operations did not increase significantly (3.7 +/- 3.4 mm Hg to 5.5 +/- 3.5 mm Hg). The esophageal acid exposure decreased sufficiently to promote some alleviation of the esophagitis. Radiologic signs of stenosis regressed in 6 of 7 patients. Postoperative endoscopic assessment revealed complete or partial healing of erosions seen preoperatively in 6 of the 7 patients so studied, and healing of all ulcers in 3 patients. Twelve patients continued to have columnar metaplasia. Manometric studies disclosed no significant changes in propulsion and contractility. Distal esophageal resting pressures rose significantly from 6.2 to 9.4 mm Hg (p0.05 mm Hg), suggestive of stasis. Radionuclide transit studies, however, showed no significant decrease in the esophageal emptying capacity after operation. It is concluded that conventional antireflux operations in patients with scleroderma can palliate reflux damage without jeopardizing esophageal function.

Over a 14-year period, 12 patients with documented scleroderma had an antireflux operation: eight short total fundoplication, two Collis-Nissen, one Collis-Belsey, and one Roux-en-Y. They were assessed before and after their operation with a follow-up range of 14–169 months (mean, 71 months) (Table 1). The functional abnormalities of scleroderma remained unchanged following antireflux surgery. Despite a decrease in total acid exposure, 6/12 patients still show significant episodes of acid pH in their esophagus, causing symptoms in 5. The esophageal mucosa reverted to normal in two patients. Ten of 12 still show extensive columnar lined mucosa. Despite a total fundoplication in 10/12 patients, significant acid exposure persists in 50% of operated scleroderma patients.

In the best series published, antireflux surgery will give an excellent to good result in about 90% of cases [1], and these results are sustained for up to 10 years. There are series reported, however, where the results have not been long-lasting, and reflux returns. Recurrent reflux is not the only cause of unsatisfactory results. Side effects of the operations such as dysphagia, bloating, diarrhea and persistent pain are also described [2].

Despite the absence of definitive explanations regarding either the physiologic or surgical factors which curtail gastro-esophageal reflux, effective antireflux operations exist. This article explores the theoretical factors relevant to the surgical control of reflux. These theoretical features include: (1) the pressure, length, and location of the manometrically defined lower esophageal sphincter (LES); (2) the gastro-esophageal valve as defined by the angle of His and a mucosal flap valve; and (3) the mechanical effects of a fundoplication which serve to increase the opening pressure of the cardia and optimize the physical relationships described by the law of La Place. Finally, the relation of these theoretical factors to actual operations is discussed.

In 1957 J. Leigh Collis published his innovative operation for treating the difficult problem of the irreducible hiatal hernia, esophagitis, and stricture. The design of the operation was based on the relatively primitive understanding of hiatal hernia and the newly emerging concept of reflux esophagitis. A variety of antireflux operations by different surgeons emerged over the years to follow. The original Collis gastroplasty has been subsequently modified with the addition of both partial and complete fundoplication procedures. The place of the modified Collis gastroplasty-fundoplication operations in today's approach to the problems of hiatal hernia and gastroesophageal reflux disease remains unsettled.