Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA.
Grupo de Investigación Clínica, Universidad del Rosario. Escuela de Medicina y Ciencias de La Salud, Bogotá, DC, Colombia.
Surg Endosc. 2024 Nov;38(11):6839-6845. doi: 10.1007/s00464-024-11107-z. Epub 2024 Aug 21.
Despite excellent long-term outcomes, a small proportion of patients who undergo fundoplication with hiatal hernia repair (laparoscopic antireflux surgery [ARS]) for treatment of gastroesophageal reflux disease (GERD) may require reoperation. Esophagogastroduodenoscopy (EGD) assessment in patients presenting with symptom recurrence plays a critical role in surgical planning of redo-ARS by confirming failure of the fundoplication and revealing the pattern of failure. We aimed to compare the findings documented by external endoscopists (i.e., outside physicians) to those documented by internal endoscopists (i.e., operating foregut or thoracic surgeons) before redo-ARS.
After IRB approval, we conducted a retrospective chart review of patients who underwent redo-ARS at a tertiary surgical center between November 2016 and March 2023. Patients with both external and internal EGD reports were included, and findings from the two reports were compared.
Of 197 patients who underwent redo-ARS, both preoperative EGD reports were available for 181 (136 [75.1%] women; median age, 61 years [IQR 53-69]; median BMI, 27.9 kg/m2 [IQR 24.9-31.3]). The median time between primary and redo-ARS was 89 months (IQR 38-153), and the median time between external and internal endoscopic evaluation was 5 months (IQR 2-12). Only 38.9% of external reports mentioned a prior fundoplication. Compared to the operating surgeons, external physicians reported a significantly lower proportion of Barrett's esophagus (52.4%, p < .001), slipped fundoplications (28.8%, p < .001), paraesophageal hernias (20.5%, p < .001), disrupted fundoplications (20%, p < .001), intrathoracic fundoplications (0%, p < .001), and twisted fundoplications (0%, p < .001).
External endoscopists' reports of failed fundoplications are often incomplete and lack relevant details. Discrepancies between nonsurgical endoscopists and experienced surgeons are likely explained by a lack of training and experience to discern and document fundoplication changes accurately. To reduce this gap, we strongly recommend the adoption of standard definitions describing post-fundoplication endoscopic changes and the inclusion of relevant training within educational programs.
尽管腹腔镜抗反流手术（ARS）治疗胃食管反流病（GERD）的长期效果非常出色，但仍有一小部分接受胃底折叠术和食管裂孔疝修补术（fundoplication with hiatal hernia repair，FHHR）的患者需要再次手术。对于出现症状复发的患者，再次进行食管胃十二指肠镜检查（esophagogastroduodenoscopy，EGD）评估在手术规划 redo-ARS 中起着至关重要的作用，可通过确认抗反流手术失败并揭示失败模式来实现。我们旨在比较外部内镜医生（即外部医生）记录的结果与内部内镜医生（即操作前肠或胸外科医生）记录的结果，这些结果是在 redo-ARS 之前获得的。
在获得机构审查委员会批准后，我们对 2016 年 11 月至 2023 年 3 月期间在一家三级外科中心接受 redo-ARS 的患者进行了回顾性图表审查。纳入了同时具有外部和内部 EGD 报告的患者，并比较了两份报告中的结果。
在接受 redo-ARS 的 197 名患者中，有 181 名患者的术前 EGD 报告均可用（136 名女性[75.1%]；中位年龄为 61 岁[IQR 53-69]；中位 BMI 为 27.9kg/m2[IQR 24.9-31.3]）。初次手术与 redo-ARS 之间的中位时间为 89 个月（IQR 38-153），外部和内部内镜评估之间的中位时间为 5 个月（IQR 2-12）。仅有 38.9%的外部报告提到了先前的胃底折叠术。与手术医生相比，外部医生报告的 Barrett 食管比例明显较低（52.4%，p<0.001），滑疝（28.8%，p<0.001），食管旁疝（20.5%，p<0.001），抗反流手术失败（20%，p<0.001），胸腔内胃底折叠术（0%，p<0.001）和扭曲的胃底折叠术（0%，p<0.001）。
外部内镜医生报告的抗反流手术失败通常不完整，缺乏相关细节。非外科内镜医生和经验丰富的外科医生之间的差异可能是由于缺乏训练和经验，无法准确识别和记录抗反流手术的变化所致。为了减少这种差距，我们强烈建议采用描述抗反流手术后内镜变化的标准定义，并在教育计划中纳入相关培训。
