Balazs Kovacs

Thoracoabdominal pressure gradient and gastroesophageal reflux: insights from lung transplant candidates

Advanced lung disease is associated with gastroesophageal reflux disease (GERD). The thoracoabdominal pressure gradient (TAPG) facilitates gastroesophageal reflux, but the effects of TAPG on gastroesophageal reflux in patients with pulmonary disease have not been well defined. Patients diagnosed with end-stage lung disease are expected to have the most extreme derangement in respiratory mechanics. The aim of this study is to explore the relationship between TAPG and reflux in lung transplant (LTx) candidates. We reviewed LTx recipients who underwent pretransplant esophageal high-resolution manometry and a 24-hour pH study. Patients were excluded if they were undergoing redo LTx, had manometric hiatal hernia, or had previously undergone foregut surgery. TAPG was defined as the intra-abdominal pressure minus the intrathoracic pressure during inspiration. Adjusted TAPG was calculated by the TAPG minus the resting lower esophageal sphincter (LES) pressure (LESP). Twenty-two patients with normal esophageal function tests (i.e., normal esophageal motility with neither manometric hiatal hernia nor pathological reflux on 24-hour pH monitoring) were selected as the pulmonary disease-free control group. In total, 204 patients underwent LTx between January 2015 and December 2016. Of these, 77 patients met inclusion criteria. We compared patients with obstructive lung disease (OLD, nxa0=xa033; 42.9%) and those with restrictive lung disease (RLD, nxa0=xa042; 54.5%). 2/77 patients (2.6%) had pulmonary arterial hypertension. GERD was more common in the RLD group than in the OLD group (24.2% vs. 47.6%, Pxa0=xa00.038). TAPG was similar between the OLD group and the controls (14.2 vs. 15.3 mmHg, Pxa0=xa00.850); however, patients in the RLD group had significantly higher TAPG than the controls (24.4 vs. 15.3 mmHg, Pxa0=xa00.002). Although TAPG was not correlated with GERD, the adjusted TAPG correlated with reflux in all 77 patients with end-stage lung disease (DeMeester score, rsxa0=xa00.256, Pxa0=xa00.024; total reflux time, rsxa0=xa00.259, Pxa0=xa00.023; total number of reflux episodes, rsxa0=xa00.268, Pxa0=xa00.018). Additionally, pathological reflux was seen in 59.1% of lung transplant candidates with adjusted TAPG greater than 0 mmHg (i.e., TAPG exceeding LESP); GERD was seen in 30.9% of patients who had an adjusted TAPGxa0≤xa00 mmHg. In summary, TAPG varies based on the underlying cause of lung disease. Higher adjusted TAPG increases pathological reflux, even if patients have normal antireflux anatomy and physiology (i.e., no hiatal hernia and manometrically normal LES function). Adjusted TAPG may provide further insights into the pathophysiology of GERD.

Autologous Dermis Graft Implantation: A Novel Approach to Reinforcement in Giant Hiatal Hernias

Objectives Nonreinforced tensile repair of giant hiatal hernias is susceptible to recurrence, and the role of mesh graft implantation remains controversial. Creating a new and viable choice without the use of high-cost biological allografts is desirable. This study presents the application of dermis graft reinforcement, a cost-efficient, easily adaptable alternative, in graft reinforcement of giant hiatal hernia repairs. Methods A 62-year-old female patient with recurrent giant hiatal hernia (9u2009×u200911u2009cm) and upside down stomach, immediately following the Belsey repair done in another department, was selected for the pilot procedure. The standard three-stitch nonabsorbable reconstruction of diaphragmatic crura was undertaken via laparoscopic approach. A 12u2009×u20096u2009cm dermis autograft was harvested from the loose abdominal skin. “U” figure onlay reinforcement of diaphragm closure was secured with titanium staples. The procedure was completed with a standard Dor fundoplication. One- and seven-month follow-ups were conducted. Results No short-term postoperative complications were observed. One-month follow-up showed normal anatomical location of abdominal viscera on computed tomography imaging. High-resolution manometry showed normal lower esophageal sphincter pressure. Preoperative abdominal complaints were resolved. Procedural costs were lower than the average cost following mesh graft reinforcement. Conclusion Dermis graft reinforcement is a cheap, easily adaptable procedure in the repair of giant hiatal hernias, even in the setting of laparoscopic reoperative procedure.

Remedial bypass or antrectomy and Roux-en-Y after failed fundoplication

Excellent outcomes have been reported with primary antireflux surgery; however, some patients require reoperation. Of the patients who undergo reoperation, a select few are at higher risk for poor outcomes after redo fundoplication. The high-risk group includes patients who are morbidly obese; those with a short esophagus, poor esophageal motility, or patients who have undergone; multiple (i.e., more than 2) reoperative procedures; and those with delayed gastric emptying. These patients are better served with Roux-en-Y (RNY) gastrojejunostomy, with or without gastrectomy. In this article, we summarize our approach for reoperative intervention after antireflux surgery has failed, and discuss criteria for patient selection, operative technique, and outcomes of RNY reconstruction as a remedial antireflux procedure.