ABSTRACT

Abstract

This is an update of the WHO SSI guideline published in 2018, focussing on areas pertinent for gastrointestinal (GI) surgery and hepatobiliary and pancreatic (HBP) surgical procedures. Based on new information and appraisal of current evidence, the following recommendations can be suggested: During skin preparation, we suggest using alcohol-based chlorhexidine for clean, clean-contaminated, and contaminated GI and HBP surgical field preparation in the absence of a mucous membrane (e.g., stoma, genitalia, anus). Preoperatively, we suggest that corticosteroids and anti-TNF medication be discontinued. No recommendations could be made on the following comparisons, given the paucity of high-quality evidence and panel discussion not favouring one intervention over the other based on clinical experience: 2%-3% chlorhexidine gluconate versus aqueous povidone-iodine for surgical field preparation. 4%-5% chlorhexidine gluconate versus aqueous povidone-iodine for surgical field preparation. Aqueous chlorhexidine gluconate versus aqueous povidone-iodine for surgical field preparation Pre-operative dexamethasone in single-dose versus no pre-operative dexamethasone for patients undergoing GI surgery. Discontinuing Vedolizumab preoperatively versus continuing Vedolizumab preoperatively for patients undergoing GI surgery. Discontinuing Ustekinumab preoperatively versus continuing Ustekinumab preoperatively for patients undergoing GI surgery.

Main recommendations

MR1

ESGE recommends the following standards for Barrett esophagus (BE) surveillance:

• a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy
• photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions
• use of the Prague and (for visible lesions) Paris classification
• collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.

Strong recommendation, weak quality of evidence.

MR2

ESGE suggests varying surveillance intervals for dif ferent BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies.For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.
Weak recommendation, low quality of evidence.

MR3

ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient’s life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered.
Weak recommendation, very low quality of evidence.

MR4

ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.
Strong recommendation, high level of evidence

MR5

ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.
Strong recommendation, high level of evidence.

MR6

ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).
Strong recommendation, moderate quality of evidence.

MR7

ESGE recommends endoscopic resection as curative treatment for T1a Barrett’s cancer with well/moderate differentiation and no signs of lymphovascular invasion.
Strong recommendation, high level of evidence.

MR8

ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 μm AND no [lympho] vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.
Weak recommendation, low quality of evidence.

MR9

ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 μm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.
Strong recommendation, low quality of evidence

MR10a

ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.
Strong recommendation, very low quality of evidence.

MR10b

ESGE recommends careful inspection of the neosquamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.
Strong recommendation, very low level of evidence.

MR10c

ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.
Strong recommendation, low level of evidence

MR10d

ESGE suggests, after successful EET, obtaining fourquadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.
Weak recommendation, low level of evidence.

MR10e

ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.
Strong recommendation, very low level of evidence.

MR11

After successful EET, ESGE recommends the following surveillance intervals:

• For patients with a baseline diagnosis of HGD or EAC: at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.
• For patients with a baseline diagnosis of LGD: at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.

Strong recommendation, low quality of evidence.

Abstract

Background

New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.

Objective

To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.

Methods

We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.

Results

The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn.

Conclusion

An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.

Guideline registration number

PREPARE-2023CN018.

Keywords: Paraesophageal hernia, Hiatal hernia, Diaphragmatic hernia, Mesh, Guidelines

ABSTRACT

Introduction

Abdominal distension is an objective visible sign of increased abdominal girth. Bloating is a feeling of abdominal fullness and discomfort. Bloating may be associated or not with abdominal distension. Bloating and abdominal distension are among the most commonly reported gastrointestinal symptoms and may be associated with both organic and functional disorders. Nevertheless, specific consensus and recommendations on diagnosis, underlying mechanisms, assessment and management of functional bloating and abdominal distension are still lacking. The aim of this European consensus, then, is to provide expert opinions and recommendations on the epidemiology, diagnosis, pathophysiology and treatment of functional bloating and abdominal distension.

Methods

A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of this consensus. Relevant questions were formulated and addressed through a literature review and statements were developed and voted using a Delphi process.

Results

Functional bloating and abdominal distension are common and frequently overlap with other disorders of gut-brain interaction. Diagnosis is made according to the Rome IV criteria after the exclusion of organic disease, based on the physical examination and assessment of the patient's medical history and alarming signs. In the absence of alarming signs or any relevant finding, clinical laboratory, imaging or endoscopic tests are unnecessary. The pathophysiology of functional bloating and abdominal distension is multifactorial and involves visceral hypersensitivity, abdomino-phrenic dyssynergia, intestinal dysmotility and dysbiosis. Treatment may include dietary modifications (e.g. lactose-limiting diet and low FODMAP diet), probiotics, antispasmodics (e.g., otilonium bromide, peppermint oil), rifaximin, secretagogues (e.g., linaclotide), neuromodulators (e.g., serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, buspirone), and plethysmography-based biofeedback. Moreover, cognitive behaviour therapy and hypnotherapy can be used in case of functional bloating associated with irritable bowel syndrome.

Conclusion

This consensus provides an evidence-based framework for the evaluation and treatment of patients with functional bloating and abdominal distension.