Summary
Background
Until recently only two therapeutic options have been available to control symptoms and the esophagitis in chronic gastro‐oesophageal reflux disease (GERD), i.e. lifelong proton ...pump inhibitor (PPI) therapy or anti‐reflux surgery. Lately, transoral incisionless fundoplication (TIF) has been developed and found to offer a therapeutic alternative for these patients.
Aim
To perform a double‐blind sham‐controlled study in GERD patients who were chronic PPI users.
Methods
We studied patients with objectively confirmed GERD and persistent moderate to severe GERD symptoms without PPI therapy. Of 121 patients screened, we finally randomised 44 patients with 22 patients in each group. Those allocated to TIF had the TIF2 procedure completed during general anaesthesia by the EsophyX device with SerosaFuse fasteners. The sham procedure consisted of upper GI endoscopy under general anaesthesia. Neither the patient nor the assessor was aware of the patients' group affiliation. The primary effectiveness endpoint was the proportion of patients in clinical remission after 6‐month follow‐up. Secondary outcomes were: PPI consumption, oesophageal acid exposure, reduction in Quality of Life in Reflux and Dyspepsia and Gastrointestinal Symptom Rating Scale scores and healing of reflux esophagitis.
Results
The time (average days) in remission offered by the TIF2 procedure (197) was significantly longer compared to those submitted to the sham intervention (107), P < 0.001. After 6 months 13/22 (59%) of the chronic GERD patients remained in clinical remission after the active intervention. Likewise, the secondary outcome measures were all in favour of the TIF2 procedure. No safety issues were raised.
Conclusion
Transoral incisionless fundoplication (TIF2) is effective in chronic PPI‐dependent GERD patients when followed up for 6 months.
Clinicaltrials.gov: CT01110811
Reoperations for complications of bariatric surgery are associated with high morbidity and mortality. It is not known whether endoscopic treatment may reduce reoperation rates.
Twenty-one patients ...underwent endoscopic treatment for persisting large anastomotic leaks before considering redo surgery. Eight patients had a gastric bypass, eight had a sleeve gastrectomy combined with a duodenal switch (SDS), four had a sleeve gastrectomy alone, and one had a Scopinaro procedure (biliopancreatic diversion). Fistulas were gastrocutaneous in 15 patients, duodenocutaneous in 2, gastroperitoneal in 3, and gastrobronchial in 1. Partially covered self-expanding metal stents (SEMSs) were used, followed by additional endoscopic procedures if the SEMS failed. SEMSs were removed by traction alone or by insertion of a self-expanding plastic stent (SEPS) followed by extraction of both stents together.
SEMS insertion led to 62 % (13/21) primary closures. Complementary endoscopic treatment led to 4 secondary closures. Total success rate was 81 % (17/21). Three patients in whom SEMSs failed underwent reoperation but died during postoperative follow-up; one patient died from pulmonary embolism before SEMS extraction. The success rates of endotherapy were 100 % (8/8) in the gastric bypass group, 62.5 % (5/8) in the SDS group, 75 % (3/4) in the sleeve gastrectomy group, and 100 % (1/1) for the Scopinaro procedure. Gastrocutaneous fistulas on sleeve sutures were successfully treated in 60 % of cases (6/10), while other anastomotic fistulas were successfully treated in 100 % of cases (11/11) ( P = 0.0351).
Endoscopic treatment using SEMSs for complications of bariatric surgery is feasible. Healing of severe leaks was obtained in 81 % (17/21) of patients, avoiding high-risk reintervention. Gastrocutaneous fistulas on a sleeve suture are the most difficult condition to treat.
Objectives
Helicobacter pylori is a worldwide infection, but little is known about the efficacy of treatment for H. pylori infection in HIV‐positive patients. The goal of this work was to evaluate ...outcomes after first‐line H. pylori treatment and identify risk factors for failure in HIV‐positive patients.
Methods
This registry study of unmatched H. pylori‐infected HIV‐positive patients and HIV‐negative obese pre‐bariatric surgery controls was performed in a tertiary university hospital. Cases were enrolled from 2006 to 2017, controls from 2007 to 2014, and both received standard of care. An additional ‘optimal’ subgroup of cases was enrolled prospectively from 2017 to 2019 which was treated only on the basis of antibiogram, drug interaction search and additional support by one referent physician. Helicobacter pylori eradication failure rates were compared according to clinical, microbiological and pathological parameters and treatment.
Results
We analysed 258 HIV‐positive patients and 204 HIV‐negative control patients. Helicobacter pylori eradication failure rates were markedly greater in cases (24.1%) than in controls (8.8%). The proportions of levofloxacin and metronidazole resistance were greater in cases than in controls (P < 0.05). Among cases treated with H. pylori triple therapy (S3T), the ‘optimal’ subgroup experienced a 9.5% failure rate vs. 28.6% with other strategies (P = 0.01). Risk factors for failure were H. pylori treatment strategy, exposure to antiretroviral treatment, and alcohol status. Overall, positive HIV status was a risk factor for S3T eradication failure.
Conclusions
Patients co‐infected with H. pylori and HIV frequently failed to eradicate H. pylori and this was related to treatment strategy, antiretroviral exposure and lifestyle.
Aim
Interest in transanal laparoscopy has increased in the last decade. This approach can allow primary procedures such as polypectomy, total mesorectal excision and the treatment of postoperative ...complications such as bleeding, leakage and fistula formation.
Method
Two patients treated by transanal repair for leakage of a colorectal anastomosis after laparoscopic anterior resection of the rectum are reported. The first developed leakage immediately during the surgery and in the second leakage presented at 4 weeks. A new transanal platform according to DAPRI (Karl Storz‐Endoskope, Tuttlingen, Germany), formed by a reusable port and reusable monocurved instruments was developed to permit manipulation of sutures introduced via the anus in a maximally ergonomic manner. Laparoscopic suturing was performed transanally and a protective ileostomy was added as well.
Results
The transanal procedures took 60 and 45 min and the patients were discharged after 5 days and 2 days. At 2 months both defects were found to be healed on contrast radiology and endoscopy; therefore the ileostomy was closed. Anal function was satisfactory with a frequency of two and one times per 24 h with no incontinence or evidence of sepsis.
Conclusion
Intra‐operative or late leakage of colorectal anastomosis can be safely treated by transanal laparoscopy. This new transanal platform offers the surgeon the possibility to work in ergonomic positions, without increasing the cost of the procedure thanks to the reusable nature of the material used.
Background
Endoscopic pre-peritoneal mesh repair (TEP) through single-incision laparoscopy (SIL) permits placement of a large mesh through a final millimetric umbilical scar. This prospective study ...evaluates the first 200 consecutive SILTEPs performed by a single surgeon.
Patients and methods
Between November 2011 and September 2015, 200 consecutive SILTEPs were performed in 161 patients. The mean age was 49.8 ± 16.3 years and the mean BMI was 24.5 ± 3.4 kg/m
2
. The technique involved one 11-mm trocar, one 10-mm 0° scope and curved reusable instruments. A supplementary 1.8-mm straight trocarless grasping forceps was percutaneously inserted for perioperative complications or difficulties.
Results
A unilateral hernia repair was performed in 122 patients, and a bilateral repair in 39 patients. The total operative time was 57.4 ± 22.3 min, and pure laparoscopic time was 46.6 ± 21.6 min. There was no need for insertion of a supplementary 5-mm trocar, and the need for insertion of 1.8-mm trocarless grasper was 32.9%. Perioperative complications occurred in 73 patients. The mean final scar length was 15.3 ± 2.6 mm. The mean hospital stay was 1.0 ± 0.3 days. Postoperative complications at the access site affected 15 patients and at the hernia site 31 patients. After a mean follow-up of 25.4 ± 12.3 months, there was one asymptomatic, small incisional hernia at the access site as well as one reoperation for recurrent inguinal hernia at 16 months. No other late complications were registered.
Conclusion
Transumbilical SILTEP permits placement of a large mesh through a final millimetric scar. Getting over the learning curve in conventional multitrocar TEP is mandatory. As per our institute’s algorithm, the contraindications continue to be giant inguino-scrotal, incarcerated and recurrent inguinal hernias.
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