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Laparoscopic fundoplication is the current surgical gold standard for the treatment of refractory gastroesophageal reflux disease (GERD). Magnetic sphincter augmentation (MSA) is a less invasive, standardized, and reversible option to restore competency of the lower esophageal sphincter. A comparative cohort study was conducted at a tertiary-care referral center on patients with typical GERD symptoms treated with systematic crural repair combined with Toupet fundoplication or MSA. Primary study outcome was decrease of Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Between January 2014 and December 2021, a total of 199 patients (60.3% female, median [Q1–Q3] age: 51.0 [40.0–61.0]) underwent MSA (n = 130) or Toupet fundoplication (n = 69). Operative time and hospital stay were significantly shorter in MSA patients (P

Aim To compare quality of life in patients with large hiatus hernia undergoing laparoscopic Toupet fundoplication and magnetic sphincter augmentation. Background and Methods Laparoscopic Toupet fundoplication (LTF) and laparoscopic magnetic sphincter augmentation (MSA) have been compared in a previous retrospective study (Asti E et al, Medicine, 2016) in patients with small hiatal hernia ( This is an observational, retrospective, comparative cohort study. Patients with 5 cm hiatus hernia measured by endoscopy and barium swallow study and those with previous esophago-gastric surgery were excluded. The primary outcome was quality of life based on the Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire. Secondary outcomes were proton pump inhibitors (PPI) use, incidence of dysphagia and gas-related symptoms, and hiatus hernia recurrence rate. Results Between March 2007 and June 2018, 150 patients with GERD met the inclusion criteria; 88 underwent a LTF and 62 a MSA procedure. Both groups had similar preoperative features. The mean follow-up was 64 months and all patients were followed for at least one year after surgery. There was no statistically significant difference between LTF and MSA in GERD-HRQL scores (p=0.178), PPI use (p=0.327), gas-related symptoms (p=0.162), dysphagia (p=0.254), and reoperation rate (p=0.167). Conclusion Both LTF and MSA have similar safety profile and disease-specific quality of life in patients with large hiatal hernia.

Aim The aim of the study was to assess safety, quality of life and recurrence rate after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (PHASIX ST®). Background & Methods Safety and effectiveness of absorbable meshes for laparoscopic hiatus hernia repair are still debated, with several studies reporting conflicting outcomes. This may be due to patient selection, technique of repair, type of mesh, definition of recurrent hernia and length of follow up. An observational, single-center study was conducted in patients undergoing laparoscopic crural repair reinforced with PHASIX ST®, a monofilament resorbable mesh (poly-4-hydroxybuterate) with a hydrogel barrier on one side. Data were extracted from hospital charts and a prospectively updated research database. The quality of life was assessed by the GastroEsophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire. Clinical evaluation, upper gastrointestinal endoscopy and/or barium swallow study were performed at 6 – 24 months of follow up. Recurrent hernia was defined as the maximum vertical height of stomach > 2 cm above diaphragm at endoscopy and/or barium swallow study. Results 103 consecutive patients were implanted with PHASIX ST® mesh from January 2017 to May 2019. The overall postoperative morbidity rate was 2.9%. The average follow up was 13 months with 31 (30%) patients reaching 2-year. The mean postoperative GERD-HRQL score significantly improved compared to baseline (4.6 ± 3.9 vs 16.6 ± 4.1, p Conclusion The use of PHASIX ST® mesh to reinforce crural repair for large hiatus hernias is safe and seems to be effective in the short-term follow up.

Aim Aim of this comparative study was to analyze very long-term safety, symptomatic outcomes and rate of recurrence in a cohort of patients who underwent large hiatus hernia repair with or without synthetic mesh. Background & Methods The use of a permanent mesh to reinforce the hiatus could reduce the rate of radiological and symptomatic recurrences after laparoscopic paraesophageal hernia repair. However, strictures and even erosions into the esophageal lumen have been reported. Aim of this comparative study was to analyze very long-term safety, symptomatic outcomes and rate of recurrence in a cohort of patients who underwent large hiatus hernia repair with or without synthetic mesh. Observational cohort study using a prospectively maintained database. From November 2001 to September 2005, 39 consecutive patients underwent laparoscopic repair and fundoplication for large hiatus hernia (> 5 cm). Thirteen patients (Group M) received crural reinforcement with non-absorbable mesh, while 26 patients (Group S) underwent standard cruroplasty. Mesh-related complications, postoperative symptoms and hernia recurrence at very long-term follow-up through upper gastrointestinal endoscopy, GERD-HRQL and FOREGUT questionnaires. Results There were 23 women and 16 men, with a median age of 60 years (range 28-81). The hernia size was similar in both groups. Postoperative complications occurred in 2 patients (5.1%) and there was no mortality. The median long-term follow-up was 168 months (range 139-197 months, IQR: 23.5). At last follow-up visit, occasional (once a month) dysphagia occurred in 23% of Group M patients, but none required endoscopic dilatation. The hernia recurrence rate was 0. No short or long-term complications related to the use of the mesh were recorded. In group S, non of patients, complained of dysphagia, whereas 2 (7.7%) patients complained of occasional reflux symptoms and other 2 (7.7%) of dyspepsia. In 4 patients (15.4%), a small hiatus hernia recurrence or a partially slipped fundoplication was noted, but all patients were asymptomatic. GERD-HRQL scores significantly decrease in both groups (p Conclusion Laparoscopic antireflux surgery with permanent prosthetic mesh is an effective and safe procedure in carefully selected patients with large hiatal hernia.

Background Total minimally-invasive transthoracic esophagectomy (ttMIE) faces increasing application in surgical treatment of esophageal cancer. For esophago-gastric reconstruction, different anastomotic techniques are currently used, but their impact on postoperative anastomotic leakage and morbidity has not been investigated. The aim of this retrospective multicenter analysis was to describe anastomotic techniques used for ttMIE and to analyze the associated morbidity. Patients and Methods Patients were selected from a basic dataset, collected over a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the CD classification and the Comprehensive Complication Index® (CCI). Results Five anastomotic techniques were identified in 966 patients after ttMIE: Intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n=90, purse-string n=337), intrathoracic (n=109) or cervical (n=255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n=175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs. 17.2%, P=0.601), but overall complications (56.7%% vs. 63.7%, P=0.029) and median 90-day CCI (21 (IQR 0-36) vs. 29 (IQR 0-40), P=0.019) favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%) and cervical side-to-side linear-stapled esophago-gastrostomies (11.8%) (P Conclusion Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.

Aim The aim of this study was to evaluate esophageal motility before and after Magnetic Sphincter Augmentation (MSA) for medically refractory Gastro-Esophageal Reflux Disease (GERD). Background and Methods MSA (LINX® Reflux Management System) is intended for patients with chronic GERD with incomplete symptom relief from proton-pump inhibitors (PPI) and abnormal acid exposure. A prospectively collected database of patients who underwent MSA between 2007 and 2019 was queried. All patients who completed pre- and post-operative high-resolution manometry (HRM) were included in the study. Additional investigations included Health-Related Quality of Life (GERD-HRQL) questionnaire, Functional Outcome Swallowing Scale (FOSS), upper gastrointestinal endoscopy, barium swallow, and 24-96 hours pH-study. Data were analyzed using Wilcoxon signed rank test and McNemar test. Results Forty-five patients met the inclusion criteria. The median follow-up was 10 months (IQR 6). Compared to baseline, there was a statistically significant reduction in PPI use (p=0.000), rate of heartburn (p=0.000), regurgitation (p=0.008), and extra-esophageal symptoms (p=0.000). Only three (6.7%) patients required dietary changes. The GERD-HRQL score significantly improved (p=0.000). There was a significant increase in the Lower Esophageal Sphincter (LES) competency, including LES length (p=0.004) and Esophago-gastric Contractile Integral ((EGJ-CI) (p=0.000). A significant increase in integrated relaxation pressure (IRP) (p=0.000), mean Distal Contractile Integral (DCI) (p=0.008) and intrabolus pressure (p=0.000) was also found. Thirteen (28.9%) patients presented pre-operative Ineffective Esophageal Motility (IEM) and five of them resolved postoperatively. Two patients (4.4%) developed IEM after surgery: both had IRP and DCI values within normal limits, and one of them complained of dysphagia. However, the GERD-HRQL score recovered in both patients. Conclusion MSA was clinically effective in relieving both typical and atypical GERD symptoms. LES competency increased after MSA. EGJ outflow obstruction was uncommon and not associated with symptoms. Finally, ineffective esophageal motility may reverse to normal after MSA.

Background Background and hypothesis Conversion into a 60 cm Roux-en-Y jejunal loop is the most common remedial procedure in patients with gastroesophageal reflux after Billroth II gastrectomy. While this allows diversion of bilio-pancreatic secretions, symptomatic acid reflux may persist in the presence of a mechanically incompetent lower esophageal sphincter. We hypothesized that magnetic sphincter augmentation (MSA) may relieve symptoms and control esophagitis by reducing both acid and biliary reflux. Methods Methods A 70 year-old male patient presented with intractable reflux symptoms and grade B esophagitis 46 years after partial gastrectomy and Billroth II reconstruction for perforated gastric ulcer. The patient underwent extensive diagnostic evaluation. There was a 3 cm hiatus hernia, grade B esophagitis, and hyperemia of the gastrojejunal anastomosis. Biopsies were negative for malignancy and Helicobacter Pylori. pH-impedance testing showed combined acid and non-acid reflux; esophageal peristalsis was normal on high-resolution manometry. After informed consent, the patient preferred the option of laparoscopic MSA versus open laparotomy and Roux-en-Y conversion. Pneumoperitoneum was established with a Hasson trocar. After adhesiolysis, a hiatus hernia with retroesophageal lipoma was identified. The gastroesophageal junction was completely reduced in the abdominal cavity and a posterior crural repair was performed. A tunnel was made between the esophageal wall and the posterior vagus nerve and a no. 16 MSA (Linx®) device was applied. Results Results The postoperative course was uneventful and the patient was discharged home on postoperative day one. At 1- and 6-month follow-up visit the patient was off-medication, tolerated a free diet, and did not complain of any reflux symptom. The mean GERD-HRQL score decreased from 26 to 2 compared to baseline. A barium swallow confirmed the complete reduction of the hiatal hernia and the absence of reflux in the Trendelenburg position. Esophagitis was completely healed. Conclusion Conclusions To the best of our knowledge, this is the first case of MSA implant for refractory gastroesophageal reflux disease after Billroth II gastrectomy. This simple laparoscopic procedure allowed correction of both acid and biliary reflux. Disclosure All authors have declared no conflicts of interest.

Background In a previous proof of concept study, transhiatal pleural drain has been shown to be safe and effective after hybrid Ivor Lewis esophagectomy. Aim of the present study was to compare short-term outcomes of trans-hiatal and intercostal pleural drainage. We hypothesized that a trans-hiatal pleural drain introduced through the sub-xyphoid port site incision at laparoscopy could reduce postoperative pain and enhance patient recovery. Methods This was an observational retrospective cohort study. Two methods of pleural drainage were compared in patients undergoing hybrid Ivor Lewis esophagectomy. Patients treated with a transhiatal drain connected to a vacuum bag were compared to an historical cohort of patients treated with the conventional intercostal drain connected to under-water seal and suction. Postoperative morbidity, total and daily drainage output, serum albumin levels, and total dose of paracetamol and ketorolac administered on-demand were recorded. Postoperative complications were scored according to the Dindo-Clavien classification. Results Over a 2-year period, 50 patients with transhiatal drain and 50 with intercostal drains met the criteria for inclusion in the study. Demographic and clinico-pathological variables were similar in the two groups. No conversions from the portable vacuum system to underwater seal and suction occurred. There was no mortality nor statistical significant difference in the rate of grade ≥ 3 postoperative complications. The total volume of drain output and the serum albumin levels were similar in the two groups. The total dose of ketorolac was significantly reduced in patients with transhiatal drain (P Conclusion Transhiatal pleural drainage connected to a portable vacuum system can safely replace the intercostal drain after hybrid Ivor-Lewis esophagectomy in selected patients. It has the potential to reduce postoperative pain and use of nonsteroidal antinflammatory drugs, and to enhance recovery from surgery. Disclosure All authors have declared no conflicts of interest.

Background Minimally invasive enucleation of esophageal leiomyoma may induce or aggravate gastroesophageal reflux disease, but scarce data are available in literature. Methods We conducted a retrospective, cross-sectional single-center study investigating long-term outcomes of laparoscopic, thoracoscopic, and endoscopic enucleation with focus on quality of life and gastroesophageal reflux. Postoperative clinical and endoscopic data were compared to baseline. All patients underwent barium swallow study, endoscopy and completed the GERD-HRQL questionnaire after a minimum 1-year follow-up. Results Thirty patients were included in the study. There were 19 females and 11 males, median age 48 years (range 28–67). Thirteen (43.3%) patients underwent laparoscopic enucleation plus fundoplication (9 Toupet, 3 Nissen, 1 Dor), 12 (40%) patients thoracoscopic enucleation, and 5 (16.7%) patients endoscopic enucleation. Mean operative time was 149.1 ± 62.6 min. Mean tumor diameter was 5.4 ± 3.2 cm. There was no operative mortality. Overall morbidity rate was 16.6%, and no mucosal perforations occurred. Mean hospital stay was 4.0 ± 1.8 days. The mean baseline GERD-HRQL score was 4.25 (range 0–21) in the laparoscopic group, 3.4 (range 0–12) in the thoracoscopic group, and 5.7 (range 0–13) in the endoscopic group. Preoperatively, hiatal hernia was present in 6 patients (46.1%) in the laparoscopic group, in 4 patients (33.3%) in the thoracoscopic group, and in 2 patients (40%) in the endoscopic group. The mean follow-up was 58 months (range 3–192) (Table 1). Conclusion GERD symptoms were more common in patients after endoscopic enucleation. Primary laparoscopic enucleation combined with fundoplication allows effective long-term reflux control. Disclosure All authors have declared no conflicts of interest.

Description Minimally invasive esophagectomy has the potential to reduce the incidence of pulmonary complications and postoperative pain. This video shows two safe and reproducible technical variants for thoracoscopic stapled anastomosis. The patient is placed in a left semi-prone position after induction of anesthesia with a single lumen orotracheal tube. Triportal access and low-pressure pneumothorax (8 mmHg) are used for the procedure. Once circumferential mobilization of the esophagus is completed, intraoperative ultrasonography is performed to identify a previously placed endoscopic metal clip marking the upper tumor level. The esophagus is safely transected above this level. An end-to-side intra-corporeal esophagogastric anastomosis is performed. Technique A. The esophagus is stapled with a 60 mm cartridge (EndoGIA™ Tri-Staple™ purple). The anvil of a 25 mm circular stapler (OrVil™) is inserted transorally and retrieved through a small hole in the esophageal stump. Technique B. The 25 mm anvil is inserted through a transverse esophagotomy with a 7 cm long 2–0 polypropylene suture attached to the sharp tip. The suture is passed from inside to outside of the esophageal lumen. The esophagus is then divided distal to the anvil with an linear stapler. At this point, the anvil is pulled out with a gentle traction close to the stapled line. In both techniques, the circular stapler is introduced into the chest cavity through a mini-thoracotomy at the level of lowermost trocar and a wound retractor (Alexis™) is used. The head of the circular stapler, sealed with a surgical glove cutted at the middle finger, is then introduced into the gastric tube through a small gastrotomy on the lesser curvature. The tip of the gastric tube is perforated close to the greater curvature and engage the esophageal anvil. After checking the doughnut, transection of the remnant gastric tube is completed with a linear stapler and the specimen is retrieved through the mini-thoracotomy. Disclosure All authors have declared no conflicts of interest.