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Pescarus R.,Providence Portland Medical Center | Sharata A.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Providence Portland Medical Center | And 5 more authors.
Surgical Endoscopy and Other Interventional Techniques | Year: 2016

Background: Roux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB. Methods: After placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance. Results: No peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6 months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6 months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism. Conclusion: The Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population. © 2015, Springer Science+Business Media New York. Source

Robinson B.,Foundation for Surgical Innovation and Education | Dunst C.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Providence Cancer Center | Cassera M.A.,Providence Cancer Center | And 5 more authors.
Surgical Endoscopy and Other Interventional Techniques | Year: 2015

Background: Laparoscopic surgery for gastrointestinal reflux disease was introduced in 1991. Early safety, efficacy, and 5–10-year durability have been amply documented, but long-term patient outcomes have been criticized. This study presents 20-year outcomes after laparoscopic fundoplication (LF) in a consecutive patient cohort. Methods: Patients who underwent primary LF procedures for gastroesophageal reflux disease (GERD) were identified from a prospectively collected IRB-approved database (1991–1995). A phone symptom questionnaire was administered using a 5-point validated GERD scoring system (heartburn, regurgitation, and dysphagia). Symptomatic success was defined by a lack of surgical re-intervention and a low symptom score. Results: One-hundred and ninety-three patients were identified during the time period. Fifty-one patients completed the survey (100 lost to follow-up, 40 deceased, 2 declined to answer). Respondents had a median follow-up of 19.7 years. Overall, 38/51 (74.5 %) of patients reported complete control of heartburn and regurgitation. Ten patients reported only occasional heartburn. Eight of fifty-one (16 %) reported daily dysphagia, and 22/51 (43 %) of respondents were using proton pump inhibitors at the time of telephone interview. Nine of fifty-one (18 %) underwent revision of the original surgery which did not negatively impact the satisfaction rating, with 8/9 (89 %) of these patients reporting the highest satisfaction rating. Overall, 46/51 (90 %) were satisfied with their choice of surgery. Conclusion: Long-term results from the early experience with LF are excellent with 94 % of patients reporting only occasional or fewer reflux symptoms at 20-year follow-up. However, 18 % required surgical revision surgery to maintain their results. There is a relatively high rate of daily dysphagia but 90 % of patients are happy to have had LF. © 2014, Springer Science+Business Media New York. Source

Sharata A.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Providence Portland Medical Center | Pescarus R.,Providence Portland Medical Center | And 5 more authors.
Journal of Gastrointestinal Surgery | Year: 2014

Introduction Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for a myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice. Methods Comprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6-12 months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2 days. Results One hundred POEM patients were included in the final analysis. The mean age was 58 years (18-83 years). Primary presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16 months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES.The mean operative time was 128 min. The median hospital length of stay (LOS) was 1 day. The overall morbidity was 6 %; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvie's, and one required prolonged intubation for CO2 retention).The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90 % on TBS with 93 % patients demonstrating >90 % emptying at 1 min. Of the achalasia patients, 36 % (17/47) showed some return of normal peristalsis (≥70 % peristalsis) on post-op HRM.Abnormal acid exposure was present on postoperative testing in 38 % (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97 % with a complete resolution accomplished in 89 %. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8 %) vs. non-achalasia patients (17/24; 70.8 %). Of those with preoperative chest pain, 91.5 % reported complete relief.Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations. Conclusion This study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97 %) and chest pain (91.5 %) for patients with esophageal spastic disorders with acceptable procedural morbidity. © 2014 The Society for Surgery of the Alimentary Tract. Source

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