Quantitative assessment of crural closure for laparoscopic anti-reflux surgeries

Abstract

Background: Long-term dysphagia is a known complication of laparoscopic anti-reflux surgery (LARS). Of the several factors, inadequate hiatal closure is one of the major reasons for its occurrence. The aim of this study is to develop a technique for the quantitative assessment of crural closure during LARS to reduce dysphagia. Materials and Methods: It is an analysis of prospectively collected data of 109 patients who underwent LARS at a tertiary healthcare centre in India. To identify the adequacy of hiatal closure intraoperatively, a 7 French Fogarty catheter was used, and its balloon was inflated with 1 cc air at the repaired hiatus. This inflated balloon in the repaired hiatus following cruroplasty gives an accurate quantitative assessment of the adequate closure and adequate space for food bolus to pass without causing mechanical obstruction after hiatus repair. Pre- and post-operative 12 months’ DeMeester scores and lower oesophageal sphincter (LES) pressures were calculated. Results: The patients had a significant reduction in DeMeester scores postoperatively from a mean of 68.5–12.3 ( P < 0.0001). None of the patients had long-term dysphagia or the need for long-term proton-pump inhibitors. The mean LES pressures on post-operative manometry showed increase to 15.1 mmHg from a mean of 6.4 mmHg, which was statistically significant ( P = 0.0001). None of the patients had a recurrence of hiatus hernia. Conclusion: Quantitative assessment of adequacy for crural closure during LARS using a 7 French Fogarty catheter balloon is a novel technique which may decrease the incidence of post-operative dysphagia or intrathoracic wrap migration or recurrence of hiatus hernia.

Treatment strategy for laparoscopic hiatal hernia repair

“…However, FLIP is not a general inspection tool because it has not yet obtained regulatory approval in Japan and is introduced only in a limited number of facilities. Various attempts have been reported to reduce postoperative dysphagia 11,12 . Aiolfi et al reported that the crura should not be excessively tight to leave a small 5 mm window from the highest stitch to the posterior esophageal wall, 12 but we have experienced severe postoperative dysphagia after LF, so we decided to make an about 1 cm window in Toupet fundoplication.…”