Top

Surgical Endoscopy

Published in:

01-03-2019

Minimal versus obligatory dissection of the diaphragmatic hiatus during magnetic sphincter augmentation surgery

Authors: James M. Tatum, Evan Alicuben, Nikolai Bildzukewicz, Kamran Samakar, Caitlin C. Houghton, John C. Lipham

Published in: Surgical Endoscopy | Issue 3/2019

Abstract

Background

The magnetic sphincter augmentation (MSA) device was initially implanted with minimal hiatal dissection (MHD) at the diaphragmatic hiatus. Due to concern of possible MSA device dysfunction if herniated into an occult or small hiatal hernia, and increased understanding to the role of defective crura in reflux disease, the operative procedure was changed to planned obligatory dissection (OD) of the hiatus at the time of all implantations.

Methods

Between December 2012 and September 2016, 182 patients underwent MSA implant at a single medical center and have complete records available for review through September 2017. The MHD dissection period extended from December 2012 to September 2015, from September 2015 to 2016 all patients underwent OD.

Results

MHD occurred 53% (96/182) versus OD in 47% (86/182), mean follow-up time in days for MHD and OD was 554 (SD 427) versus 374 (298) days. Intraoperative measurement of hernia size for the MHD versus OD was 0.77 (1.1) versus 3.95 (2.4) cm, p < 0.001. At first visit follow-up, there was no difference in any dysphagia (p = 0.11). Recurrent GERD (defined as resumption of PPI after successful initial post-operative wean) was less frequent after OD than after MHD, 3.6 versus 16.3%, p = 0.006. Delayed onset dysphagia was 1.2% in the OD group versus 8.6% in the MHD group, p = 0.04. Recurrent hiatal hernia of 2 cm or greater occurred in 0.0% of the OD and 11.5% of the MHD, p = 0.03. Repeat surgery for hiatal hernia repair has occurred in 0% of the OD and 6.6% of the MHD, p = 0.02.

Conclusion

OD of the hiatus with crural closure resulted in less recurrence of reflux symptoms and hiatal hernia, despite an increased proportion of patients with larger hiatal hernia and more complex anatomic disease at the time of operation.

Bonavina L, DeMeester T, Fockens P et al (2010) Laparoscopic sphincter augmentation device eliminates reflux symptoms and normalizes esophageal acid exposure: one- and 2-year results of a feasibility trial. Ann Surg 252:857–862CrossRefPubMed

Lipham JC, DeMeester TR, Ganz RA et al (2012) The LINX® reflux management system: confirmed safety and efficacy now at 4 years. Surg Endosc 26:2944–2949CrossRefPubMed

Lipham JC, Taiganides PA, Louie BE et al (2015) Safety analysis of first 1000 patients treated with magnetic sphincter augmentation for gastroesophageal reflux disease. Dis Esophagus 28(4):305–311CrossRefPubMed

Ganz RA, Edmundowicz SA, Taiganides PA et al (2016) Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol 14(5):671–677CrossRefPubMed

Louie BE, Farivar AS, Schultz D et al (2014) Short-term outcomes using magnetic sphincter augmentation versus Nissen fundoplication for medically resistant gastroesophageal reflux disease. Ann Thorac Surg 98:498–505CrossRefPubMed

Ganz RA, Peters JH, Horgan S et al (2013) Esophageal sphincter device for gastroesophageal reflux disease. N Engl J Med 368:719–727CrossRefPubMed

Rona KA, Reynolds J, Schwameis K et al (2016) Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias. Surg Endosc. https://doi.org/10.1007/s00464-016-5204-3 CrossRefPubMed

Rona KA, Tatum JM, Zehetner J et al (2018) Hiatal hernia recurrence following magnetic sphincter augmentation and posterior cruroplasty: Intermediate-term outcomes. Surg Endosc. https://doi.org/10.1007/s00464-018-6059-6 (Epub ahead of print)CrossRefPubMed

Kahrilas PJ, Lee TJ (2005) Pathophysiology of gastroesophageal reflux disease. Thorac Surg Clin 15(3):323–333CrossRefPubMed

10.

Shafik A, Shafik I, El Sibai O et al (2006) The effect of esophageal and gastric distension on the crural diaphragm. World J Surg 30(2):199–204CrossRefPubMed

11.

Mittal RK, Fisher MJ, McCallum RW et al (1990) Human lower esophageal sphincter pressure response increased intra-abdominal pressure. Am J Physiol 258:G624–G630PubMed

12.

Lin S, Brassseur J, Pouderoux P et al (1995) The phrenic ampulla: distal esophagus or potential hiatal hernia? Am J Physiol 268:130–135

13.

Souza M, Nobre R, Bezerra P et al (2017) Anatomical functional deficiencies of the crural diaphragm in patients with esophagitis. Neurogastroenterol Motil 29(1):1365–1369CrossRef

14.

Fei L, del Genio G, Rossetti G et al (2009) Hiatal hernia recurrence: surgical complication or disease? Electron microscope findings of the diaphragmatic pillars. J Gastrointest Surg 13(3):159–164CrossRef

15.

Fei L, de Genio G, Brusciano L et al (2007) Crura ultrastructural alterations in patients with hiatl hernia: a pilot study. Surg Endosc 21(6):907–911CrossRefPubMed

16.

Dodds WJ, Dent J, Hogan WJ et al (1982) Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N Engl J Med 307:1547–1552CrossRefPubMed

17.

Louie BE, Kapur S, Blitz M et al (2013) Length and pressure of the reconstructed lower esophageal sphincter is determined by both crural closure and Nissen fundoplication. J Gastrointest Surg 17(2):236–243CrossRefPubMed

18.

Patti MG, Goldberg HI, Arcerito M et al (1996) Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure and the degree of mucosal injury. Am J Surg 171(1):182–186CrossRefPubMed

19.

Fein M, Ritter MP, DeMeester TR et al (1999) Role of the lower esophageal sphincter and hiatal hernia in the pathogenesis of gastroesophageal reflux disease. J Gastrointest Surg 3(4):405–410CrossRefPubMed

20.

Buckley FP, Bell RCW, Freeman K et al (2017) Favorable results from a prospective evaluation of 200 patients with large hiatal hernias undergoing LINX magnetic sphincter augmentation. Surg Endosc. https://doi.org/10.1007/s00464-017-5859-4 (Epub ahead of print)CrossRefPubMedPubMedCentral

Title: Minimal versus obligatory dissection of the diaphragmatic hiatus during magnetic sphincter augmentation surgery
Authors: James M. Tatum
Evan Alicuben
Nikolai Bildzukewicz
Kamran Samakar
Caitlin C. Houghton
John C. Lipham
Publication date: 01-03-2019
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 3/2019
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-018-6343-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Minimal versus obligatory dissection of the diaphragmatic hiatus during magnetic sphincter augmentation surgery

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 3/2019

Concomitant ventral hernia repair and bariatric surgery: a retrospective analysis from a UK-based bariatric center

Clinical response after laparoscopic fenestration of symptomatic hepatic cysts: a systematic review and meta-analysis

Comparison of early experience of robotic and transanal total mesorectal excision using propensity score matching

White paper: technology for surgical telementoring—SAGES Project 6 Technology Working Group

Complications of percutaneous endoscopic and radiologic gastrostomy tube insertion: a KASID (Korean Association for the Study of Intestinal Diseases) study

Comparison of impacts of intraperitoneal saline instillation with and without pulmonary recruitment maneuver on post-laparoscopic shoulder pain prevention: a randomized controlled trial