Renato V. Soares

High-Resolution Manometry in Evaluation of Factors Responsible for Fundoplication Failure

BACKGROUND From 10% to 25% of patients undergoing antireflux procedures eventually redevelop symptoms as a result of anatomic failure of the hiatal repair or fundoplication. High-resolution manometry (HRM) allows for reliable evaluation of the lower esophageal sphincter (LES) in detail, including subtle evidence of a hiatus hernia. The aim of this study was to characterize the dynamics and function of the LES postoperatively using HRM to determine which elements may contribute to recurrent symptoms after antireflux surgery. STUDY DESIGN Twenty-three patients with recurrent symptoms and/or abnormal 24-hour pH monitoring after Nissen fundoplication (Unsuccessful group) and 11 asymptomatic post-Nissen patients tested as routine follow-up (Successful group) underwent HRM. Tracings were analyzed for percentage of peristalsis, LES pressure, length of the high-pressure zone (HPZ), LES residual pressure, and the presence of a dual HPZ (indicating a recurrent hiatus hernia). Results were compared between the 2 groups. RESULTS Mean LES pressure tended to be greater in the Successful group compared with the Unsuccessful group (p = 0.068). There were no differences in length of the HPZ, residual pressures, and peristalsis. A dual HPZ was identified in 13 Unsuccessful group patients (56%), and 1 (9%) of the Successful group patients (p < 0.05). Abnormal DeMeester scores were observed in 79% of patients with a dual HPZ, compared with 35% of patients without a dual HPZ (p < 0.05). CONCLUSIONS The presence of a dual HPZ on HRM in patients after fundoplication appears to be a strong predictor of recurrent gastroesophageal reflux disease. In patients with recurrent symptoms after antireflux surgery, HRM also provides valuable information about peristalsis and LES characteristics that help guide appropriate management.

Prevalence of respiratory symptoms in patients with achalasia

Achalasia is a primary esophageal motor disorder that results in poor clearance of the esophagus. Although an esophagus filled with debris and undigested food should put these patients at risk for aspiration, the frequency with which the latter occurs has never been documented. In this study, we sought to determine the incidence of respiratory symptoms and complaints in patients with achalasia. A comprehensive symptom questionnaire was administered to 110 patients with achalasia presenting to the Swallowing Center at the University of Washington between 1994 and 2008 as part of their preoperative work-up. Questionnaires were analyzed for the frequency of respiratory complaints in addition to the more typical symptoms of dysphagia, regurgitation, and chest pain. Twenty-two achalasia patients with respiratory symptoms who had also undergone Heller myotomy and completed a post-op follow-up questionnaire were analyzed as a subset. Ninety-five patients (86%) complained of at least daily dysphagia. Fifty-one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%), aspiration (the sensation of inhaling regurgitated esophagogastric material) in 34 patients (31%), hoarseness in 23 patients (21%), wheezing in 17 patients (15%), shortness of breath in 11 patients (10%), and sore throat in 13 patients (12%). Neither age nor gender differed between those with and those without respiratory symptoms. In the subset of patients with respiratory symptoms who had undergone Heller myotomy, respiratory symptoms improved in the majority after the procedure. Patients with achalasia experience respiratory symptoms with much greater frequency than the approximately 10% that was previously believed. Awareness of this association may be important in the workup and ultimate treatment of patients with this uncommon esophageal disorder.

A broad assessment of clinical outcomes after laparoscopic antireflux surgery

Objectives: There is considerable discussion regarding “success” rates for laparoscopic antireflux surgery (LARS). We hypothesized that, in part, this was a reflection of the outcome variables used. We, therefore, defined 8 specific variables (within 3 categories) and assessed outcomes for each in a large cohort of patients. Methods: Four hundred patients (208 women; median age 52 years old) who underwent LARS at the University of Washington from 1993 to 2008 were given a comprehensive questionnaire to assess various aspects of their outcomes from LARS. In addition, we analyzed all functional studies and all endoscopies performed in these patients in our institution, whether the patients had symptoms or not, and compared the findings to all available preoperative values. Results: The median follow-up was 92 (6–175) months. Symptoms Effect on presenting symptoms: Heartburn (N = 376) improved in 326 (87%), regurgitation (N = 365) improved in 331 (91%), and chest pain (N = 265) improved in 207 (78%) patients, measured by patients perception. Durability: The percentage of patients with successful control of gastroesophageal reflux disease (GERD) symptoms: 88% at 1 year, 83% at 2 years, 77% at 5 years, and 74% after 10 years. Development of new symptoms (side-effects): The following side-effects developed (ie, were new) or worsened (ie, were present before surgery): dysphagia in 72 (18%), bloating in 96 (24%), and diarrhea in 61 (15%) patients. The severities (0–10 scale) of these symptoms were: dysphagia 5.1 ± 2.6, bloating 6.5 ± 2.2, diarrhea 6.5 ± 2.9. Patient perception of overall success: Currently, 279 (70%) patients rate their operation as a complete success, 86 (22%) as partially successful, and 35 (8%) as unsuccessful. Those with partial or no success cited recurrent reflux (n = 70), a side-effect (n = 37), or both (n = 14) as the reason. Effects on esophageal function and mucosal integrity Esophageal acid exposure: The average preoperative DeMeester (DM) score was 56.8 ± 48.1 (n = 320), which decreased to 16.0 ± 31 in patients who underwent postoperative testing between 1 month and 1 year (n = 149). Among 129 patients who had both preoperative and postoperative values available, 92 (71%) had normalization of a previous abnormal DM score whereas 114 (88%) had at least some improvement. Mucosal integrity: Progression of Barretts esophagus: Of the 58 patients with Barretts esophagus before LARS, 2 developed high-grade dysplasia/cancer (or 1 per 258 patient years). Of 342 patients in our study without Barretts esophagus before LARS, 9 developed Barretts esophagus at a rate of 1 per 275 patient years (0.36% per year). Need for additional Therapy Medication use: 236 (59%) patients remain completely off medications for GERD, 164 (41%) are using antireflux medications. Of these, 73 (45%) patients are taking less medication than before LARS. The most common reasons for continuing GERD medication after LARS were heartburn (n = 100) 60%, regurgitation (n = 13) 8%, and Barretts esophagus (n = 13) 8%. Reoperations: Fifteen (3.7%) patients required reoperations, 9 for recurrent reflux and 6 for side-effects. Conclusions: The success or failure of LARS cannot be defined in a single domain. A comprehensive analysis of outcomes requires categorization that includes symptom response, side-effects, patients perception and objective measurement of acid exposure, mucosal integrity, and the need for additional medical or surgical treatment. Only then can patients and physicians better understand the role of LARS and make informed decisions.

Handling Topological Changes during Elastic Registration: Application to Augmented Reality in Laparoscopic Surgery

PurposeLocating the internal structures of an organ is a critical aspect of many surgical procedures. Minimally invasive surgery, associated with augmented reality techniques, offers the potential to visualize inner structures, allowing for improved analysis, depth perception or for supporting planning and decision systems.MethodsMost of the current methods dealing with rigid or non-rigid augmented reality make the assumption that the topology of the organ is not modified. As surgery relies essentially on cutting and dissection of anatomical structures, such methods are limited to the early stages of the surgery.We solve this shortcoming with the introduction of a method for physics-based elastic registration using a single view from a monocular camera. Singularities caused by topological changes are detected and propagated to the preoperative model. This significantly improves the coherence between the actual laparoscopic view and the model and provides added value in terms of navigation and decision-making, e.g., by overlaying the internal structures of an organ on the laparoscopic view.ResultsOur real-time augmentation method is assessed on several scenarios, using synthetic objects and real organs. In all cases, the impact of our approach is demonstrated, both qualitatively and quantitatively (http://www.open-cas.org/?q=PaulusIJCARS16).ConclusionThe presented approach tackles the challenge of localizing internal structures throughout a complete surgical procedure, even after surgical cuts. This information is crucial for surgeons to improve the outcome for their surgical procedure and avoid complications.

Transgastric hybrid surgery for the flexible endoscopist: early experience with the TAGSS system

perform intragastric procedures. We describe 3 ifferent procedures performed in a series of acute wine experiments: a hybrid endoscopic submucosal issection, an endoluminal stapled pyloroplasty, and an ndoluminal reinforcement of the cardia. The system llowed safe and rapid insertion of the ports, successful ompletion of the procedures, and safe removal and losure of the gastric wall. eath. D, External bolster. E, Valve. F, Luer lock.

Future Applications of Submucosal Surgery: NOTES, Full-Thickness Resections and Beyond

Navigation in the submucosal (SM) space is a common element in several emerging procedures in interventional endoscopy, including endoscopic submucosal dissection (ESD), POEM (peroral endoscopic myotomy), POP (peroral pyloromyotomy), and POET (peroral enucleation tumors). The use of a submucosal endoscopic mucosal flap (SEMF) technique as a valve in natural orifice translumenal surgery (NOTES) procedures has also proven to be useful. Submucosal endoscopy has an evolving role in diagnosis of neuromuscular disorders of the gastrointestinal tract (Fig. 16.1).