BACKGROUND:
Transoral incisionless fundoplication (TIF) is an endoscopic alternative for the treatment of GERD. However, TIF does not address the hiatal hernia (HH). We present a novel approach with a laparoscopic HH repair followed by same-session TIF, coined concomitant transoral incisionless fundoplication (cTIF). The aim of this study was to assess the efficacy, safety, and feasibility of cTIF in a collaborative approach between Gastroenterology and surgery.
STUDY DESIGN:
Patients with confirmed GERD and >2 cm HH who underwent cTIF between 2018 and 2020 were included. Symptoms were assessed using the Reflux Disease Questionnaire, GERD Health-Related Quality of Life Index, and the Reflux Symptom Index pre and post cTIF. One-way ANOVA and paired samples t-test were used for statistical analysis.
RESULTS:
Sixty patients underwent cTIF (53% were men, mean age was 59.3 years) with 100% technical success. Mean ± SD HH measurement on endoscopy was 2.9 ± 1.5 cm. Scores on Reflux Disease Questionnaire for symptom frequency and symptom severity improved significantly from before to 6 months after cTIF (17.4 to 4.72; p < 0.01 and 16.7 to 4.56; p < 0.05, respectively). According to the GERD Health-Related Quality of Life Index, significant decreases were seen post cTIF in heartburn (23.26 to 7.37; p < 0.01) and regurgitation (14.26 to 0; p = 0.05). Reflux Symptom Index similarly decreased after cTIF (17.7 to 8.1 post cTIF; p < 0.01). Mean DeMeester score decreased from 43.7 to 4.9 and acid exposure time decreased from 12.7% to 1.28% post cTIF (p = 0.06).
CONCLUSIONS:
We present a novel multidisciplinary approach to GERD using a combined endoscopic and surgical approach with close collaboration between Gastroenterology and surgery. Our results suggest that cTIF is safe and effective in reducing reflux symptoms in a large spectrum of GERD patients.
INTRODUCTION:
Liquid nitrogen spray cryotherapy (SCT) was developed for endoscopic treatment of Esophageal Cancer and Barrett’s Esophagus. It has been shown to be a safe and effective therapy. Pulmonologists and thoracic surgeons have used SCT for treatment of benign tracheal strictures and stenoses with reduced severity of airway narrowing and symptomatic improvement. We describe the successful use of SCT in a recurrent, benign esophago-gastric anastomotic stricture, highlighting its potential as a new alternative treatment modality.
CASE DESCRIPTION/METHODS:
A 52-year-old female with stage T1 esophageal adenocarcinoma status-post laparoscopic thoracoscopic Ivor-Lewis esophagectomy presented to clinic 3 months following surgery for dysphagia. An esophagogastroduodenoscopy (EGD) revealed an esophago-gastric anastomotic stricture. Over the next 4 years, the stricture recurred despite monthly EGDs with dilations, steroid injections, and stent placement. Her course was complicated by dysphagia, food impactions, and severe protein-calorie malnutrition requiring total parenteral nutrition (TPN). The decision was made to perform Cryodilation. The patient then underwent seven EGDs with cryodilation over seven months. During the procedure, liquid nitrogen spray was administered for 20 seconds, followed by 60 seconds of thaw time, for a total of three freeze-thaw cycles and stricture then dilated up to 18mm. Prior to the first EGD with cryoablation, she recorded her lowest weight within 5 years at 49.4 kg (BMI 16.4). After initiating these procedures, the patient experienced marked functional and clinical improvement. After only three cycles, she began eating soft foods again. After five cycles, her weight peaked at 58.9 kg (BMI 19.7), which she maintained for 8 months. After six cycles of therapy she was able to discontinue TPN. Since cryodilation, she has had no further weight loss nor episodes of food impaction and the time between endoscopic dilation procedures has lengthened considerably.
DISCUSSION:
This case demonstrates a severe recurrent esophago-gastric anastomotic stricture which was unresponsive to aggressive, frequent traditional management. This novel and previously unreported method of serial cryotherapy with dilation greatly improved this patient’s symptoms and functional status. This method is a potential safe and effective primary treatment or adjunct modality for refractory benign esophageal strictures.
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