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Nguyen NT, Abu Dayyeh B, Chang K, Lipham J, Bell R, Buckley FP, Dunst CM, Mittal RK, Thosani N, Oelschlager BK, Hinojosa MW, Brunaldi V, Yadlapati R, Kahrilas PJ. American Foregut Society Cooperative White Paper on Mechanisms of Pathologic Reflux and Antireflux Surgery. FOREGUT: THE JOURNAL OF THE AMERICAN FOREGUT SOCIETY 2025; 5:16-26. [DOI: 10.1177/26345161241276454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2025]
Abstract
Background:
Within the spectrum of gastroesophageal reflux disease (GERD), pathologic reflux applies to the subset of patients with either erosive esophagitis or abnormal esophageal acid exposure on pH-metry, consequences of a dysfunctional antireflux barrier (ARB).
Methods:
The American Foregut Society (AFS) tasked a 13-member working group of expert foregut surgeons and esophagologists (The ARB Cooperative) to develop a white paper on ARB function, dysfunction, and mechanisms of action of antireflux surgery through discussion of relevant literature summarized herein.
Results:
The ARB Cooperative concluded that pathologic reflux is a consequence of the interplay between progressive anatomical distortion of the ARB and physiology. Factors contributing to ARB dysfunction include (1) separation of crural diaphragm from the lower esophageal sphincter with widening of the hiatus and diminished crural diaphragm sphincteric function; (2) loss of the intra-abdominal lower esophageal sphincter segment with complete disabling of the flap valve component of the ARB; (3) axial hiatal hernia leading to reflux during swallow-induced lower esophageal sphincter (LES) relaxation, LES hypotension, inspiration related reflux, a lowered threshold for eliciting transient LES relaxations, and increased compliance of the gastroesophageal junction leading to greater diameter of sphincter opening during transient LES relaxations. With regard to antireflux surgery, the objectives include: (1) reduction of hiatal hernia and restoration of the intra-abdominal esophageal segment; (2) repair of the dilated hiatus; (3) restoring flap valve function by modifying gastroesophageal anatomy; and (4) restricting gastroesophageal junction opening during periods of relaxation.
Conclusions:
This ARB Cooperative white paper supports the concept of there being 3 major inter-related mechanisms promoting ARB competence: the LES as an intrinsic sphincter, the crural diaphragm as an extrinsic sphincter, and the gastroesophageal valve, a mechanical 1-way valve. Pathological reflux occurs with progressive anatomical disruption of the ARB which in turn leads to physiological dysfunction, the severity of which parallels the extent of anatomical disruption. The corollary of this is that the primary mechanism of antireflux surgery is to restore the ARB by eliminating or compensating for its anatomical disruption. It is the hope of the cooperative that understanding the proposed framework will help clinicians and researchers in improving antireflux procedures.
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Affiliation(s)
- Ninh T. Nguyen
- University of California, Irvine Medical Center, Orange, CA, USA
| | | | - Kenneth Chang
- University of California, Irvine Medical Center, Orange, CA, USA
| | - John Lipham
- University of Southern California, Los Angeles, CA, USA
| | - Reginald Bell
- Institute of Esophageal and Reflux Surgery, Englewood, CO, USA
| | | | | | - Ravinder K. Mittal
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, Houston, TX, USA
| | | | | | | | - Rena Yadlapati
- University of California San Diego School of Medicine, La Jolla, CA, USA
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Smout AJ, Schijven MP, Bredenoord AJ. Antireflux surgery - choosing the right candidate. Expert Rev Gastroenterol Hepatol 2025; 19:27-38. [PMID: 39756007 DOI: 10.1080/17474124.2024.2449455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Accepted: 12/31/2024] [Indexed: 01/07/2025]
Abstract
INTRODUCTION Surgical gastric fundoplication is an effective treatment option for gastroesophageal reflux disease. In contrast to acid suppression, fundoplication nearly abolishes all types of reflux, acid and nonacid. However, in some cases, lasting side effects of the procedure may overshadow its positive effects. It has remained difficult to determine which patients are the most suitable candidates for fundoplication. AREAS COVERED This review aims to evaluate the available data on preoperative factors that are associated with the outcome of fundoplication and to determine which combination of patient characteristics and preoperative test results provides optimal selection. In addition, we assess the need for tailoring the procedure on the basis of the preoperative quality of esophageal peristalsis. EXPERT OPINION Surgical treatment of gastroesophageal reflux disease is underutilized as it may provide an excellent option for a subset of GERD patients. It is not sensible to restrict surgical treatment to patients who do not respond to acid suppression. However, meticulous patient selection is key. Most importantly, surgical treatment should not be considered in patients in whom there is no convincing evidence that the symptoms are caused by reflux. Impaired esophageal peristalsis should not be regarded as a contraindication against fundoplication.
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Affiliation(s)
- André J Smout
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
| | - Marlies P Schijven
- Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Digital Health, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
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Erol MF, Demir B, Kayaoglu HA. Comparative analysis of laparoscopic Nissen fundoplication and Rossetti modification in gastroesophageal reflux disease: A focus on life-quality enhancement. Asian J Surg 2024; 47:5096-5100. [PMID: 38945768 DOI: 10.1016/j.asjsur.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/09/2024] [Accepted: 06/13/2024] [Indexed: 07/02/2024] Open
Abstract
OBJECTIVE This study aims to investigate the focus of surgical treatment of gastroesophageal reflux disease (GERD) on enhancing life quality beyond symptom relief. The comparison involves laparoscopic Nissen fundoplication and Rossetti modification techniques. METHODS Patients intolerant to or experiencing relapse after medical therapy underwent either standard Nissen procedure (Group 1, n = 61) or Rossetti modification (Group 2, n = 42). A disease-specific quality of life questionnaire for GERD was utilized for evaluating life quality preoperatively and 2 years postoperatively. Symptom scores and patient satisfaction were also assessed. RESULTS Preoperatively, groups were similar in symptom duration, hiatal hernia presence, and DeMeester scores (p = 0.127, p = 0.427, and 0.584, respectively). Both groups exhibited a statistically significant increase in life quality postoperatively (p < 0.001), with no significant intergroup difference. Symptoms decreased after both surgeries, except for dysphagia and bloating. Bloating significantly increased in both groups after surgery (p = 0.018 and p = 0.017, respectively), and dysphagia increased significantly only in Group 2 (p = 0.007). The surgery refusal rate was significantly higher in Group 2 for similar preoperative symptoms (p = 0.040). CONCLUSION Despite increased life quality scores, the combination of increased dysphagia and bloating in patients undergoing Rossetti modification resulted in a decreased satisfaction rate.
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Affiliation(s)
- Mehmet Fatih Erol
- Yuksek Ihtisas Education and Training Hospital, Department of General Surgery, Bursa, Turkey.
| | - Berkay Demir
- Bilkent City Hospital, Department of Gastrointestinal Surgery, Ankara, Turkey
| | - Huseyin Ayhan Kayaoglu
- Private Hayat Hospital, Department of General Surgery, Obesity and Metabolic Surgery Center, Bursa, Turkey
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Lee J, Lee I, Oh Y, Kim JW, Kwon Y, Alromi A, Eledreesi M, Khalid A, Aljarbou W, Park S. Current Status of Anti-Reflux Surgery as a Treatment for GERD. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:518. [PMID: 38541244 PMCID: PMC10972421 DOI: 10.3390/medicina60030518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/01/2024] [Accepted: 03/20/2024] [Indexed: 06/29/2024]
Abstract
Anti-reflux surgery (ARS) is an efficient treatment option for gastroesophageal reflux disease (GERD). Despite growing evidence of the efficacy and safety of ARS, medications including proton pump inhibitors (PPIs) remain the most commonly administered treatments for GERD. Meanwhile, ARS can be an effective treatment option for patients who need medications continuously or for those who are refractory to PPI treatment, if proper candidates are selected. However, in practice, ARS is often regarded as a last resort for patients who are unresponsive to PPIs. Accumulating ARS-related studies indicate that surgery is equivalent to or better than medical treatment for controlling typical and atypical GERD symptoms. Furthermore, because of overall reduced medication expenses, ARS may be more cost-effective than PPI. Patients are selected for ARS based on endoscopic findings, esophageal acid exposure time, and PPI responsiveness. Although there is limited evidence, ARS may be expanded to include patients with normal acid exposure, such as those with reflux hypersensitivity. Additionally, other factors such as age, body mass index, and comorbidities are known to affect ARS outcomes; and such factors should be considered. Nissen fundoplication or partial fundoplication including Dor fundoplication and Toupet fundoplication can be chosen, depending on whether the patient prioritizes symptom improvement or minimizing postoperative symptoms such as dysphagia. Furthermore, efforts to reduce and manage postoperative complications and create awareness of the long-term efficacy and safety of the ARS are recommended, as well as adequate training programs for new surgeons.
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Affiliation(s)
- Jooyeon Lee
- Department of Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Inhyeok Lee
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Youjin Oh
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Jeong Woo Kim
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Yeongkeun Kwon
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Ahmad Alromi
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- The Jordanian Ministry of Health, Department of General Surgery, Princes Hamzh Hospital, Amman 11947, Jordan
| | - Mohannad Eledreesi
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- Taif Armed Forces Hospital, Taif 26792, Saudi Arabia
| | - Alkadam Khalid
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
| | - Wafa Aljarbou
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
- Dr. Sulaiman Al Habib Hospital, Riyadh 34423, Saudi Arabia
| | - Sungsoo Park
- Division of Foregut Surgery, Korea University College of Medicine, Seoul 02841, Republic of Korea; (I.L.); (Y.K.); (M.E.)
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Michael S, Marom G, Brodie R, Salem SA, Fishman Y, Shein GS, Helou B, Pikarsky AJ, Mintz Y. The Angle of His as a Measurable Element of the Anti-reflux Mechanism. J Gastrointest Surg 2023; 27:2279-2286. [PMID: 37620664 DOI: 10.1007/s11605-023-05808-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/21/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a common condition, resulting from the loss of the anti-reflux barrier. Laparoscopic fundoplication is the surgical procedure of choice for treatment of GERD; however, there remains a debate on the exact mechanism through which it prevents reflux. OBJECTIVES Our aim was to understand the relationship between reflux, fundoplication, and the angle of His on an experimental model. METHODS The study was conducted on four groups of fresh explanted swine stomachs: control group, myotomy, myotomy with Nissen fundoplication, and myotomy with Toupet fundoplication. The stomachs were placed in a specially designated container on an inclinable platform which would increase the hydrostatic pressure on the esophago-gastric junction. Measurements of the angle of His using fluoroscopy and the esophago-gastric orifice area using endoscopy were performed, and the occurrence of reflux was documented. RESULTS Each group of the study contained nine swine stomachs. In the control and myotomy groups, the angle became wider as the incline level increased the pressure and was significantly different between the groups (p < .001). Both groups demonstrated an increase in the orifice area as the incline level increased the pressure. There was a significant correlation between the angle of His and the area of the esophago-gastric orifice (p < .001). In the control group, the reflux began at the 0°. In the myotomy group, it began at the + 15° incline (less pressure). Reflux rarely occurred in the Nissen and Toupet groups, with the breaking point being mostly defined as "beyond - 30°". A significant difference was noted in the occurrence of reflux between fundoplication and the non-fundoplication groups (p < 0.001), while there was no significant difference between the Toupet and Nissen groups (p = 0.134). Analysis showed a significant independent correlation between both the angle of His and the orifice area with the presence of reflux (p = .002 and p = .024 respectively). CONCLUSIONS In this study, we developed an experimental model to enable careful evaluation of the elements of the anti-reflux mechanism, of which, the angle of His has a measurable element. We demonstrated that as the angle of His becomes wider the esophago-gastric orifice area becomes larger. Additionally, a wider angle of His and a larger esophago-gastric orifice area were correlated independently with more reflux. This suggests that the fundoplication creates an acute angle of His which is correlated with a smaller area of the esophago-gastric orifice and eventually with a lower incidence of reflux.
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Affiliation(s)
- Samer Michael
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Gad Marom
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Samer Abu Salem
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gabriel Szydlo Shein
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Brigitte Helou
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Park S, Park SH, Kim MS, Kwak J, Lee I, Kwon Y, Lee CM, Choi HS, Keum B, Yang KS, Park JM, Park S. Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication. Int J Surg 2023; 109:1239-1248. [PMID: 37026848 PMCID: PMC10389471 DOI: 10.1097/js9.0000000000000274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/26/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Currently, the reported parameters that predict the resolution of symptoms after surgery are largely subjective and unreliable. Considering that fundoplication rebuilds the structural integrity of the lower esophageal sphincter (LES), the authors focused on searching for objective and quantitative predictors for the resolution of symptoms based on the anatomical issues and whether an antireflux barrier can be well established or not. MATERIALS AND METHODS The authors reviewed the prospectively collected data of 266 patients with gastroesophageal reflux disease (GERD) who had undergone laparoscopic Nissen fundoplication (LNF). All patients were diagnosed with GERD using preoperative esophagogastroduodenoscopy, 24-h ambulatory esophageal pH monitoring, and high-resolution esophageal manometry. The patients received GERD symptom surveys using the validated Korean Antireflux Surgery Group questionnaire twice: preoperatively and 3 months after the surgery. RESULTS After excluding patients with insufficient follow-up data, 152 patients were included in the analysis. Multivariate logistic regression analyses revealed that a longer length of the LES and lower BMI determined better resolution of typical symptoms after LNF (all P <0.05). Regarding atypical symptoms, higher resting pressure of LES and DeMeester score greater than or equal to 14.7 were associated with better resolution after the surgery (all P <0.05). After LNF, typical symptoms improved in 34 out of 37 patients (91.9%) with a length of LES >greater than .05 cm, BMI less than 23.67 kg/m 2 , and atypical symptoms were resolved in 16 out of 19 patients (84.2%) with resting pressure of LES greater than or equal to 19.65 mm Hg, DeMeester score greater than or equal to 14.7. CONCLUSION These results show that the preoperative length and resting pressure of LES is important in the objective prediction of symptom improvement after LNF.
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Affiliation(s)
- Sangjun Park
- Department of Surgery, Korea University College of Medicine
| | - Shin-Hoo Park
- Department of Surgery, Korea University College of Medicine
- Division of Foregut Surgery, Department of Surgery, Korea University Anam Hospital
| | - Min Seo Kim
- Genomics and Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul
| | - Jisoo Kwak
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital
| | - Inhyeok Lee
- Department of Surgery, Korea University College of Medicine
- Division of Foregut Surgery, Department of Surgery, Korea University Anam Hospital
| | - Yeongkeun Kwon
- Division of Foregut Surgery, Department of Surgery, Korea University Anam Hospital
| | - Chang Min Lee
- Division of Foregut Surgery, Department of Surgery, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital
| | - Bora Keum
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital
| | - Kyung-Sook Yang
- Department of Biostatistics, Korea University College of Medicine
| | - Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine
| | - Sungsoo Park
- Department of Surgery, Korea University College of Medicine
- Division of Foregut Surgery, Department of Surgery, Korea University Anam Hospital
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Briggs KB, Svetanoff WJ, Fraser JA, Aguayo P, Fraser JD, HolcombIII GW, St Peter SD. Fundoplication without esophagocrural sutures: Long-term follow-up of a randomized clinical trial. J Pediatr Surg 2022; 57:1499-1503. [PMID: 34980467 DOI: 10.1016/j.jpedsurg.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/14/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We previously conducted a randomized trial that showed a lack of need for esophagocrural (EC) sutures during fundoplication when no esophageal dissection was performed. There was no difference in wrap herniation or other complications in the group without EC sutures at a median 1.5 years of follow-up. In this follow-up study, we aim to evaluate long-term symptom control and complication profiles in these patients. METHODS 106 patients were randomized and participated in the original trial. We were primarily concerned with identification of late complications and persistence of symptoms. Presently, we conducted a retrospective chart review and a telephone follow-up survey at a minimum of 6.5 years after fundoplication. RESULTS 100 patients were alive at late follow-up and 70% of caregivers responded to the telephone survey. 53% of patients were male; 76% were Caucasian. Of these children, 39 (56%) received four EC sutures, while 31 (44%) did not. Follow-up was conducted at a median of 8.7 years [IQR 8.2,9.7] post-fundoplication. Late wrap herniation was not demonstrated radiographically on chart review or caregiver report in either group. The rate of residual reflux symptoms, post-operative hospitalizations for pneumonia, failure to thrive (FTT), and brief resolved unexplained event (BRUE) were also similar between groups. CONCLUSION Long-term follow-up in children who underwent fundoplication without esophagocrural sutures demonstrates no difference in symptom management or subsequent hospitalizations at a minimum of 6.5-year follow-up. LEVEL OF EVIDENCE II (follow-up of a randomized controlled trial).
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Affiliation(s)
- Kayla B Briggs
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - James A Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - George W HolcombIII
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States.
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Analatos A, Lindblad M, Ansorge C, Lundell L, Thorell A, Håkanson BS. OUP accepted manuscript. BJS Open 2022; 6:6576516. [PMID: 35511051 PMCID: PMC9070466 DOI: 10.1093/bjsopen/zrac034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 01/07/2022] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Fundoplication is an essential step in para-oesophageal hernia (POH) repair, but which type minimizes postoperative mechanical complications is controversial. Methods This was a randomized, double-blind clinical trial conducted between May 2009 and October 2018. Patients with symptomatic POH were allocated to either a total (Nissen) or a posterior partial (Toupet) fundoplication after hernia reduction and crural repair. The primary outcome was dysphagia (Ogilvie dysphagia scores) at 6 months postoperatively. Secondary outcomes were peri- and postoperative complications, swallowing difficulties assessed by the Dakkak dysphagia score, gastro-oesophageal reflux, quality of life (QoL), and radiologically confirmed hernia recurrence. Results A total of 70 patients were randomized to a Nissen (n = 32) or a Toupet (n = 38) fundoplication. Compared with baseline, Ogilvie dysphagia scores were stable at the 3- and 6-month follow-up in the Nissen group (P = 0.075 and 0.084 respectively) but significantly improved in the Toupet group (from baseline mean (s.d.): 1.4 (1.1) to 0.5 ( 0.8) at 3 months, and 0.5 (0.6) at 6 months; P = 0.003 and P = 0.001 respectively). At 6 months, Dakkak dysphagia scores were significantly higher in the Nissen group than in the Toupet group (mean (s.d.): 10.4 (7.9) versus 5.1 (7.2); P = 0.003). QoL scores improved throughout the follow-up. However, at 3 and 6 months postoperatively, the absolute median improvement (⍙) from preoperative values in the mental component scores of the Short Form-36 QoL questionnaire was significantly higher in the Toupet group (median (i.q.r.): 7.1 (−0.6 to 15.2) versus 1.0 (−5.4 to 3.3) at 3 months, and 11.2 (1.4 to 18.3) versus 0.4 (−9.4 to 7.5) at 6 months; (P = 0.010 and 0.003 respectively)). At 6 months, radiologically confirmed POH recurrence occurred in 11 of 24 patients (46 per cent) of the Nissen group and in 15 of 32 patients (47 per cent) of the Toupet group (P = 1.001). Conclusions A partial posterior wrap (Toupet fundoplication) showed reduced obstructive complications and improved QoL compared with a total (Nissen) fundoplication following POH repair. Registration number: NCT04436159 (http://www.clinicaltrials.gov)
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Affiliation(s)
- Apostolos Analatos
- Correspondence to: Apostolos Analatos, Department of Surgery, Nyköping Hospital, Olrogs väg 1, 61139, Nyköping, Sweden (e-mail: )
| | - Mats Lindblad
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Christoph Ansorge
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Nyköping Hospital, Nyköping, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Anders Thorell
- Karolinska Institutet, Department of Clinical Sciences, Danderyds Hospital and Department of Surgery and Anaesthesiology, Ersta Hospital Stockholm, Stockholm, Sweden
| | - Bengt S. Håkanson
- Karolinska Institutet, Department of Clinical Sciences, Danderyds Hospital and Department of Surgery and Anaesthesiology, Ersta Hospital Stockholm, Stockholm, Sweden
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Kopsaftis Z, Yap HS, Tin KS, Hnin K, Carson-Chahhoud KV. Pharmacological and surgical interventions for the treatment of gastro-oesophageal reflux in adults and children with asthma. Cochrane Database Syst Rev 2021; 5:CD001496. [PMID: 33998673 PMCID: PMC8127576 DOI: 10.1002/14651858.cd001496.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Asthma and gastro-oesophageal reflux disease (GORD) are common medical conditions that frequently co-exist. GORD has been postulated as a trigger for asthma; however, evidence remains conflicting. Proposed mechanisms by which GORD causes asthma include direct airway irritation from micro-aspiration and vagally mediated oesophagobronchial reflux. Furthermore, asthma might precipitate GORD. Thus a temporal association between the two does not establish that GORD triggers asthma. OBJECTIVES To evaluate the effectiveness of GORD treatment in adults and children with asthma, in terms of its benefits for asthma. SEARCH METHODS The Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, Embase, reference lists of articles, and online clinical trial databases were searched. The most recent search was conducted on 23 June 2020. SELECTION CRITERIA We included randomised controlled trials comparing treatment of GORD in adults and children with a diagnosis of both asthma and GORD versus no treatment or placebo. DATA COLLECTION AND ANALYSIS A combination of two independent review authors extracted study data and assessed trial quality. The primary outcome of interest for this review was acute asthma exacerbation as reported by trialists. MAIN RESULTS The systematic search yielded a total of 3354 citations; 23 studies (n = 2872 participants) were suitable for inclusion. Included studies reported data from participants in 25 different countries across Europe, North and South America, Asia, Australia, and the Middle East. Participants included in this review had moderate to severe asthma and a diagnosis of GORD and were predominantly adults presenting to a clinic for treatment. Only two studies assessed effects of intervention on children, and two assessed the impact of surgical intervention. The remainder were concerned with medical intervention using a variety of dosing protocols. There was an uncertain reduction in the number of participants experiencing one or more moderate/severe asthma exacerbations with medical treatment for GORD (odds ratio 0.53, 95% confidence interval (CI) 0.17 to 1.63; 1168 participants, 2 studies; low-certainty evidence). None of the included studies reported data related to the other primary outcomes for this review: hospital admissions, emergency department visits, and unscheduled doctor visits. Medical treatment for GORD probably improved forced expiratory volume in one second (FEV₁) by a small amount (mean difference (MD) 0.10 L, 95% CI 0.05 to 0.15; 1333 participants, 7 studies; moderate-certainty evidence) as well as use of rescue medications (MD -0.71 puffs per day, 95% CI -1.20 to -0.22; 239 participants, 2 studies; moderate-certainty evidence). However, the benefit of GORD treatment for morning peak expiratory flow rate was uncertain (MD 6.02 L/min, 95% CI 0.56 to 11.47; 1262 participants, 5 studies). It is important to note that these mean improvements did not reach clinical importance. The benefit of GORD treatment for outcomes synthesised narratively including benefits of treatment for asthma symptoms, quality of life, and treatment preference was likewise uncertain. Data related to adverse events with intervention were generally underreported by the included studies, and those that were available indicated similar rates regardless of allocation to treatment or placebo. AUTHORS' CONCLUSIONS Effects of GORD treatment on the primary outcomes of number of people experiencing one or more exacerbations and hospital utilisation remain uncertain. Medical treatment for GORD in people with asthma may provide small benefit for a number of secondary outcomes related to asthma management. This review determined with moderate certainty that with treatment, lung function measures improved slightly, and use of rescue medications for asthma control was reduced. Further, evidence is insufficient to assess results in children, or to compare surgery versus medical therapy.
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Affiliation(s)
- Zoe Kopsaftis
- Respiratory Medicine Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia
- School of Medicine, The University of Adelaide, Adelaide, Australia
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Hooi Shan Yap
- Department of Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Kyi Saw Tin
- Alice Springs Hospital, Alice Springs, Australia
| | - Khin Hnin
- Flinders University, Adelaide, Australia
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10
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McKinley SK, Dirks RC, Walsh D, Hollands C, Arthur LE, Rodriguez N, Jhang J, Abou-Setta A, Pryor A, Stefanidis D, Slater BJ. Surgical treatment of GERD: systematic review and meta-analysis. Surg Endosc 2021; 35:4095-4123. [PMID: 33651167 DOI: 10.1007/s00464-021-08358-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients. METHODS PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale. RESULTS From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference = - 0.51, 95%CI - 0.63, - 0.40, I2 = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I2 = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I2 = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I2 = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I2 = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67). CONCLUSIONS The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.
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Affiliation(s)
| | - Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Danielle Walsh
- Walsh - Department of Surgery, East Carolina University, Greenville, USA
| | - Celeste Hollands
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Lauren E Arthur
- Walsh - Department of Surgery, East Carolina University, Greenville, USA
| | - Noe Rodriguez
- Department of Surgery, Florida Atlantic University, Boca Raton, USA
| | - Joyce Jhang
- University of Nebraska Medical Center, Omaha, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Aurora Pryor
- Department of Surgery, Stony Brook University, Stony Brook, USA
| | | | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA.
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11
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Renzi A, Di Sarno G, d'Aniello F, Brillantino A, Minieri G, Coretti G, Barbato D, Barone G. Complete Fundus Mobilization Reduces Dysphagia After Nissen Procedure. Surg Innov 2020; 28:272-283. [PMID: 33236675 DOI: 10.1177/1553350620971174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Anti-reflux surgery is an effective treatment for gastroesophageal reflux disease (GERD). Nevertheless, surgery is still indicated with great caution in relation to the risk of complications, and in particular to postoperative dysphagia (PD). Objective. To compare the clinical outcomes, with particular focus on the incidence and severity of PD, of laparoscopic Nissen-Rossetti fundoplication (NRF) and floppy Nissen fundoplication (FNF) with complete fundus mobilization, in the surgical treatment of GERD. Methods. Ninety patients with GERD were enrolled. Forty-four patients (21[47.7%] men, 23[52.2%] women; mean age 42.4 ± 14.3 years) underwent NRF (Group A), and 46 patients (23[50%] men, 23[50%] women; mean age 43.3 ± 15.4 years) received laparoscopic FNF with complete fundus mobilization (Group B). Clinical assessment was performed using a structured questionnaire and SF-36 quality of life (QoL) score. PD was assessed using a validated classification, and an overall outcome was also determined by asking the patient to score it. Results. At 24-month follow-up, 38 (88.3%) patients in Group A vs 39 (86.6%) in Group B reported to be completely satisfied with reflux relief and free of protonic pump inhibitors (PPIs), while 3 (6.9%) in Group A vs 2(4.4%) in Group B reported occasional PPI intake and 2(4.6%) in Group A vs 4(8.8%) in Group B needed regular PPI use. Persistent PD was observed in 8(18.6%) patients in Group A and in 2(4.4%) in Group B (P = .03). No significant differences were found in the QoL score and in the overall outcome perceived by the patients. Conclusion. FNF, with complete fundus mobilization, appears to be associated with a lower rate of postoperative persistent dysphagia.
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Affiliation(s)
- Adolfo Renzi
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | | | | | | | - Gianluca Minieri
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Guido Coretti
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Domenico Barbato
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
| | - Gianni Barone
- Esophageal Diseases Center and GERD Unit, 18620Buon Consiglio Hospital - Fatebenefratelli, Naples, Italy
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12
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Tailoring Endoscopic and Surgical Treatments for Gastroesophageal Reflux Disease. Gastroenterol Clin North Am 2020; 49:467-480. [PMID: 32718565 DOI: 10.1016/j.gtc.2020.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The incidence of gastroesophageal reflux disease (GERD) remains on the rise. Pathophysiology of GERD is multifactorial, revolving around an incompetent esophagogastric junction as an antireflux barrier, with other comorbid conditions contributing to the disease. Proton pump inhibitors remain the most common treatment of GERD. Endoscopic therapy has gained popularity as a less invasive option. The presence of esophageal dysmotility complicates the choice of surgical fundoplication. Most literature demonstrates that fundoplication is safe in the setting of ineffective or weak peristalsis and that postoperative dysphagia cannot be predicted by preoperative manometry parameters. More data are needed on the merits of endoluminal approaches to GERD.
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13
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Zachariah RA, Goo T, Lee RH. Mechanism and Pathophysiology of Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:209-226. [PMID: 32146942 DOI: 10.1016/j.giec.2019.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroesophageal reflux (GER) describes a process in which gastric contents travel retrograde into the esophagus. GER can be either a physiologic phenomenon that occurs in asymptomatic individuals or can potentially cause symptoms. When the latter occurs, this represents GER disease (GERD). The process by which GER transforms into GERD begins at the esophagogastric junction. Impaired clearance of the refluxate also contributes to GERD. Reflux causes degradation of esophageal mucosal defense. The refluxate triggers sensory afferents leading to symptom generation.
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Affiliation(s)
- Robin A Zachariah
- H.H. Chao Comprehensive Digestive Disease Center, 333 City Boulevard West, Suite 400, Room 459, Orange, CA 92868, USA
| | - Tyralee Goo
- Tibor Rubin Veterans' Affairs Medical Center, 5901 E. Seventh Street, Long Beach, CA 90822, USA
| | - Robert H Lee
- H.H. Chao Comprehensive Digestive Disease Center, 333 City Boulevard West, Suite 400, Room 459, Orange, CA 92868, USA; Tibor Rubin Veterans' Affairs Medical Center, 5901 E. Seventh Street, Long Beach, CA 90822, USA.
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14
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Cullis PS, Siminas S, Losty PD. Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review. Br J Surg 2020; 107:636-646. [PMID: 32083325 DOI: 10.1002/bjs.11488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/30/2019] [Accepted: 12/02/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antireflux surgery is commonly performed in children, yet evidence for its efficacy is limited. The aim of this review was to determine the effect of antireflux surgery with regard to objective measures of quality of life (QoL) and value of upper gastrointestinal investigations in neurologically normal (NN) and neurologically impaired (NI) children. METHODS A systematic review was conducted of articles reporting children undergoing antireflux surgery in whom preoperative and postoperative objective testing was performed. Primarily, Embase, CINAHL, MEDLINE and PubMed were searched from inception to April 2019. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess article quality. RESULTS Of 789 articles, 14 met the eligibility criteria, 12 prospective observational and 2 retrospective studies. The median MINORS score was 59·4 (i.q.r. 39 to 62·5) per cent. Seven studies reported assessment of validated QoL measures before and after antireflux surgery in 148 children. Follow-up ranged from 1 to 180 months. All studies confirmed significant improvements in QoL measures among NN and NI children at all follow-up points. Eleven studies reported on preoperative and postoperative investigations in between 416 and 440 children children. Follow-up ranged from 0·5 to 180 months. Nine studies confirmed improvements in gastro-oesophageal reflux using 24-h oesophageal pH monitoring with or without manometry, but conflicting results were identified for four studies reporting gastric emptying. No studies reported fluoroscopy or endoscopy adequately. CONCLUSION Based on the results of studies of low-to-moderate quality, antireflux surgery improved QoL and reduced oesophageal acid exposure in NN and NI children in the short and medium term. Although antireflux surgery is a common elective operation, the lack of rigorous preoperative and postoperative evaluation(s) in the majority of patient-reported studies is striking.
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Affiliation(s)
- P S Cullis
- Department of Paediatric Surgery, Royal Hospital for Sick Children Edinburgh, Edinburgh, UK.,School of Medicine, University of Glasgow, Glasgow, UK
| | - S Siminas
- Department of Paediatric Surgery, Central Manchester Children's Hospital, Manchester, UK
| | - P D Losty
- Institute of Child Health, University of Liverpool, Liverpool, UK.,Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
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15
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Hu Y, Zhang B, Shi X, Ning B, Shi J, Zeng X, Liu F, Chen JD, Xie WF. Ameliorating Effects and Autonomic Mechanisms of Transcutaneous Electrical Acustimulation in Patients With Gastroesophageal Reflux Disease. Neuromodulation 2019; 23:1207-1214. [PMID: 31859433 DOI: 10.1111/ner.13082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 09/22/2019] [Accepted: 10/30/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND/AIM Gastric dysmotility is one of pathophysiologies of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) on gastric accommodation and gastric slow waves, and evaluate possible mechanisms in patients with GERD. METHODS Thirty patients were studied in two randomized sessions of sham-TEA and TEA with the measurements of esophageal high-resolution manometry (HRM), gastric accommodation assessed by a nutrient-drinking test, electrogastrogram (EGG), electrocardiogram (ECG), and postprandial dyspeptic symptoms. RESULTS Compared with sham-TEA, TEA improved nutrient drinking-induced fullness (42.0 ± 3.3 vs. 31.0 ± 3.5, P = 0.003) at 10 min after the drink, and belching right after the drink (22.0 ± 4.6 vs. 11.7 ± 3.1, P = 0.012) and at 10 min (16.0 ± 3.8 vs. 3.0 ± 1.5, P = 0.002) after the drink. TEA also improved gastric accommodation (954 ± 37 mL vs. 857 ± 47 mL, P = 0.001) and normalized maximal drink-induced impairment in gastric slow waves. Concurrently, TEA enhanced vagal activity assessed from spectral analysis of heart rate variability in the postprandial state (0.42 ± 0.03 vs. 0.49 ± 0.04, P = 0.039). The vagal activity was positively correlated with the percentage of normal slow waves (r = 0.528; P = 0.003) and negatively correlated with the regurgitation score (r = -0.408, P = 0.025). CONCLUSIONS Acute TEA increases gastric accommodation, improves gastric slow waves, and reduces postprandial fullness and belching, possibly mediated via the vagal mechanisms.
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Affiliation(s)
- Yedong Hu
- Department of Gastroenterology, Shanghai East Hospital Affiliated Tongji University, Shanghai, China
| | - Bo Zhang
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaodan Shi
- Department of Gastroenterology, Shanghai East Hospital Affiliated Tongji University, Shanghai, China
| | - Beifang Ning
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jian Shi
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xin Zeng
- Department of Gastroenterology, Shanghai East Hospital Affiliated Tongji University, Shanghai, China
| | - Fei Liu
- Department of Gastroenterology, Shanghai East Hospital Affiliated Tongji University, Shanghai, China
| | - Jiande Dz Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Wei-Fen Xie
- Department of Gastroenterology, Shanghai East Hospital Affiliated Tongji University, Shanghai, China.,Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
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16
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Battaglia E, Boano V, Ursino M, Elia C, Russo L, Sguazzini C, Gasparini M, Grassini M. Nissen fundoplication and dyspeptic symptoms: is the water load test useful? MINERVA GASTROENTERO 2019; 66:11-16. [PMID: 31760736 DOI: 10.23736/s1121-421x.19.02632-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The water load test is a simple, cheap and standardized method to evaluate gastric distension and gastric motility responses. We have previously shown that in patients with mild erosive or non-erosive esophagitis this test is frequently abnormal, suggesting an altered gastric function. The aim was to evaluate the water load test score before and after Nissen fundoplication in reflux patients. METHODS Thirty-one patients (16 men, 15 women, mean age 46.5 y) were studied before and 3 months after Nissen fundoplication by stationary esophageal manometry, wireless Bravo pH system monitoring (48 hours), and water load test. A dyspepsia symptom questionnaire was also completed before and after surgery. Data were compared with those of 35 controls. RESULTS All patients had pH-monitoring positive for pathological acid exposure and/or related-reflux symptoms in the absence of motility disorders. Basal symptoms scores were higher in patients compared to controls and improved after surgery, except than postprandial fullness, early satiation, and bloating, that were significantly increased. At baseline, all patients ingested significantly lower water volumes than controls, with a tendency to early onset of fullness and nausea, respectively. After surgery, the water volumes were significantly lower than presurgery. CONCLUSIONS In patients with reflux-related symptoms, with or without esophagitis, the water load test is frequently abnormal, suggesting an altered gastric function. Nissen fundoplication is associated with a relatively higher incidence of bloating, epigastric pain and fullness. These preliminary data could explain the incomplete resolution of symptoms after surgery in some patients, and suggest the use of additional studies to explore the gastric function in presurgical evaluation.
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Affiliation(s)
- Edda Battaglia
- Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy -
| | - Valentina Boano
- Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy
| | - Moreno Ursino
- Department of Mathematical Sciences, Polytechnical University of Turin, Turin, Italy.,Centre de Recherche des Cordeliers (CRC), University of Paris, Paris, France
| | - Chiara Elia
- Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy
| | - Luigi Russo
- Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy
| | - Carlo Sguazzini
- Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy
| | - Mauro Gasparini
- Department of Mathematical Sciences, Polytechnical University of Turin, Turin, Italy
| | - Mario Grassini
- Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy
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17
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Bakhos CT, Petrov RV, Parkman HP, Malik Z, Abbas AE. Role and safety of fundoplication in esophageal disease and dysmotility syndromes. J Thorac Dis 2019; 11:S1610-S1617. [PMID: 31489228 DOI: 10.21037/jtd.2019.06.62] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Gastroesophageal reflux disease (GERD) is quite prevalent worldwide, especially in the western hemisphere. The pathophysiology of GERD is complex, involving an incompetent esophagogastric junction (EGJ) as an anti-reflux barrier, as well as other co-morbid conditions such as gastroparesis, hiatal herniation or hyper acid secretion. Esophageal dysmotility is also frequently encountered in GERD, further contributing to the disease in the form of fragmented peristalsis, ineffective esophageal motility (IEM) or the more severe aperistalsis. The latter is quite common in systemic connective tissue disorders such as scleroderma. The main stay treatment of GERD is pharmacologic with proton pump inhibitors (PPI), with surgical fundoplication offered to patients who are not responsive to medications or would like to discontinue them for medical or other reasons. The presence of esophageal dysmotility that can worsen or create dysphagia can potentially influence the choice of fundoplication (partial or complete), or whether it is even possible. Most of the existing literature demonstrates that fundoplication may be safe in the setting of ineffective or weak peristalsis, and that post-operative dysphagia cannot be reliably predicted by pre-operative manometry parameters. In cases of complete aperistalsis (scleroderma-like esophagus), partial fundoplication can be offered in select patients who exhibit prominent reflux symptoms after a comprehensive multidisciplinary evaluation. Roux-en-Y gastric bypass is an alternative to fundoplication in patients with this extreme form of esophageal dysmotility, after careful consideration of the nutritional status.
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Affiliation(s)
- Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Roman V Petrov
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Henry P Parkman
- Department of Medicine, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Zubair Malik
- Department of Medicine, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
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18
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Arnoldner MA, Kristo I, Paireder M, Cosentini EP, Schima W, Weber M, Schoppmann SF, Kulinna-Cosentini C. Swallowing MRI-a reliable method for the evaluation of the postoperative gastroesophageal situs after Nissen fundoplication. Eur Radiol 2018; 29:4400-4407. [PMID: 30421012 PMCID: PMC6610269 DOI: 10.1007/s00330-018-5779-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 08/27/2018] [Accepted: 09/19/2018] [Indexed: 01/11/2023]
Abstract
Purpose To evaluate the diagnostic performance of swallowing MRI of the gastroesophageal junction (GEJ) in the postoperative care of patients after laparoscopic antireflux surgery (LARS) Material and methods In this institutional review board-approved prospective study, 79 symptomatic patients (mean age, 52.3 years; range, 26–80 years) were evaluated after laparoscopic Nissen fundoplication. MRI findings were correlated with revision surgery, endoscopy, and high-resolution manometry (HRM) as standard of reference. MRI was performed on a 3.0-T unit using T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences for anatomical assessment of the GEJ followed by dynamic MR swallowing (fast low-angle shot sequences). Four independent readers (two radiologists, two surgeons) rated 83 MR scans according to defined criteria, such as wrap disruption, slipping, recurrent hiatal hernia, and esophageal motility disorder. Results Wrap disruption was correctly diagnosed concordantly with the standard of reference in 87.8%, slipping in 81.5%, and recurrent hiatal hernia in 84.9% of the cases. For esophageal motility disorder, MRI interpretation was consistent with manometry in 66.2% of the subjects. Interobserver analysis showed substantial agreement for recurrent hiatal hernia (k = 0.703), moderate agreement for wrap disruption (k = 0.585), and fair agreement for motility disorder and slipping (k = 0.234 and k = 0.200, respectively). Conclusion MR swallowing readily depicts the major failure mechanisms of LARS and has good reliability even in non-experienced readers. Key Points • MR swallowing accurately readily depicts the major failure mechanisms of laparoscopic antireflux surgery and has good reliability even in non-experienced readers. • It should be included in the preoperative workup for revision surgery after fundoplication. • It will be of great benefit to surgeons in considering and planning a reoperation.
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Affiliation(s)
- Michael A Arnoldner
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Paireder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Wolfgang Schima
- Department of Radiology, Göttlicher Heiland Krankenhaus, Barmherzige Schwestern Krankenhaus, and Sankt Josef Krankenhaus, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | | | - Christiane Kulinna-Cosentini
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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19
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DEL GRANDE LM, HERBELLA FAM, KATAYAMA RC, SCHLOTTMANN F, PATTI MG. THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55Suppl 1:13-17. [DOI: 10.1590/s0004-2803.201800000-39] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.
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20
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Luk SWY, Chiu PWY. Surgical Treatment for Gastroesophageal Reflux Disease (GERD) in Asia. THE RISE OF ACID REFLUX IN ASIA 2018:113-122. [DOI: 10.1007/978-81-322-0846-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Emken BEG, Lundell LR, Wallin L, Myrvold HE, Engström C, Montgomery M, Malm AR, Lind T, Hatlebakk JG. Effects of omeprazole or anti-reflux surgery on lower oesophageal sphincter characteristics and oesophageal acid exposure over 10 years. Scand J Gastroenterol 2017; 52:11-17. [PMID: 27593706 DOI: 10.1080/00365521.2016.1224378] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the effect of anti-reflux surgery (ARS) versus proton pump inhibitor therapy on lower oesophageal sphincter (LOS) function and oesophageal acid exposure in patients with chronic gastro-oesophageal reflux disease (GORD) over a decade of follow-up. MATERIAL AND METHODS In this randomised, prospective, multicentre study we compared LOS pressure profiles, as well as oesophageal exposure to acid, at baseline and at 1 and 10 years after randomisation to either open ARS (n = 137) or long-term treatment with omeprazole (OME) 20-60 mg daily (n = 108). RESULTS Median LOS resting pressure and abdominal length increased significantly and remained elevated in patients operated on with ARS, as opposed to those on OME. The proportion of total time (%) with oesophageal pH <4.0 decreased significantly in both the surgical and medical groups, and was significantly lower after 1 year in patients treated with ARS versus OME. After 10 years, oesophageal acid exposure was normalised in both groups, with no significant differences, and bilirubin exposure was within normal limits. After 10 years, patients with or without Barrett's oesophagus did not differ in acid reflux control between the two treatment options. CONCLUSIONS Open ARS and OME were both effective in normalising acid reflux into the oesophagus even when studied over a period of 10 years. Anatomically and functionally the LOS was repaired durably by surgery, with increased resting pressure and abdominal length.
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Affiliation(s)
| | - Lars R Lundell
- b Department of Surgery , Centre for Digestive Diseases, Karolinska University Hospital, CLINTEC, Karolinska Institutet , Stockholm , Sweden
| | - Lene Wallin
- c Department of Surgery , Glostrup University Hospital , Copenhagen , Denmark
| | - Helge E Myrvold
- d Department of Cancer Research and Molecular Medicine , Norwegian University of Science and Technology , Trondheim , Norway
| | - Cecilia Engström
- e Department of Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | | | - Anders R Malm
- g Formerly of AstraZeneca Gothenburg , Mölndal , Sweden
| | - Tore Lind
- g Formerly of AstraZeneca Gothenburg , Mölndal , Sweden
| | - Jan G Hatlebakk
- a Department of Medicine , Haukeland University Hospital , Bergen , Norway
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Mauritz FA, Conchillo JM, van Heurn LWE, Siersema PD, Sloots CEJ, Houwen RHJ, van der Zee DC, van Herwaarden-Lindeboom MYA. Effects and efficacy of laparoscopic fundoplication in children with GERD: a prospective, multicenter study. Surg Endosc 2016; 31:1101-1110. [PMID: 27369283 PMCID: PMC5315717 DOI: 10.1007/s00464-016-5070-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/21/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Laparoscopic antireflux surgery (LARS) in children primarily aims to decrease reflux events and reduce reflux symptoms in children with therapy-resistant gastroesophageal reflux disease (GERD). The aim was to objectively assess the effect and efficacy of LARS in pediatric GERD patients and to identify parameters associated with failure of LARS. METHODS Twenty-five children with GERD [12 males, median age 6 (2-18) years] were included prospectively. Reflux-specific questionnaires, stationary manometry, 24-h multichannel intraluminal impedance pH monitoring (MII-pH monitoring) and a 13C-labeled Na-octanoate breath test were used for clinical assessment before and 3 months after LARS. RESULTS After LARS, three of 25 patients had persisting/recurrent reflux symptoms (one also had persistent pathological acid exposure on MII-pH monitoring). New-onset dysphagia was present in three patients after LARS. Total acid exposure time (AET) (8.5-0.8 %; p < 0.0001) and total number of reflux episodes (p < 0.001) significantly decreased and lower esophageal sphincter (LES) resting pressure significantly increased (10-24 mmHg, p < 0.0001) after LARS. LES relaxation, peristaltic contractions and gastric emptying time did not change. The total number of reflux episodes on MII-pH monitoring before LARS was a significant predictor for the effect of the procedure on reflux reduction (p < 0.0001). CONCLUSIONS In children with therapy-resistant GERD, LARS significantly reduces reflux symptoms, total acid exposure time (AET) and number of acidic as well as weakly acidic reflux episodes. LES resting pressure increases after LARS, but esophageal function and gastric emptying are not affected. LARS showed better reflux reduction in children with a higher number of reflux episodes on preoperative MII-pH monitoring.
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Affiliation(s)
- Femke A Mauritz
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands. .,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J M Conchillo
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L W E van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - R H J Houwen
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - D C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
| | - M Y A van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Room: KE.04.140.5, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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Hiatal hernia and gastroesophageal reflux: Study of collagen in the phrenoesophageal ligament. Surg Endosc 2016; 30:5091-5098. [DOI: 10.1007/s00464-016-4858-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/03/2016] [Indexed: 01/11/2023]
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Moore M, Afaneh C, Benhuri D, Antonacci C, Abelson J, Zarnegar R. Gastroesophageal reflux disease: A review of surgical decision making. World J Gastrointest Surg 2016; 8:77-83. [PMID: 26843915 PMCID: PMC4724590 DOI: 10.4240/wjgs.v8.i1.77] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/22/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a very common disorder with increasing prevalence. It is estimated that up to 20%-25% of Americans experience symptoms of GERD weekly. Excessive reflux of acidic often with alkaline bile salt gastric and duodenal contents results in a multitude of symptoms for the patient including heartburn, regurgitation, cough, and dysphagia. There are also associated complications of GERD including erosive esophagitis, Barrett’s esophagus, stricture and adenocarcinoma of the esophagus. While first line treatments for GERD involve mainly lifestyle and non-surgical therapies, surgical interventions have proven to be effective in appropriate circumstances. Anti-reflux operations are aimed at creating an effective barrier to reflux at the gastroesophageal junction and thus attempt to improve physiologic and mechanical issues that may be involved in the pathogenesis of GERD. The decision for surgical intervention in the treatment of GERD, moreover, requires an objective confirmation of the diagnosis. Confirmation is achieved using various preoperative evaluations including: ambulatory pH monitoring, esophageal manometry, upper endoscopy (esophagogastroduodenoscopy) and barium swallow. Upon confirmation of the diagnosis and with appropriate patient criteria met, an anti-reflux operation is a good alternative to prolonged medical therapy. Currently, minimally invasive gastro-esophageal fundoplication is the gold standard for surgical intervention of GERD. Our review outlines the many factors that are involved in surgical decision-making. We will review the prominent features that reflect appropriate anti-reflux surgery and present suggestions that are pertinent to surgical practices, based on evidence-based studies.
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MORAIS DJ, LOPES LR, ANDREOLLO NA. Dysphagia after antireflux fundoplication: endoscopic, radiological and manometric evaluation. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2014; 27:251-5. [PMID: 25626933 PMCID: PMC4743216 DOI: 10.1590/s0102-67202014000400006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The transient dysphagia after fundoplication is common and most often disappears until six weeks postoperatively. AIM Analyze a group of patients who presented late and persistent dysphagia postoperatively. METHODS Forty-one patients after Nissen fundoplication, 14 male and 27 female, mean age 48 year, were evaluated based on medical history, esophagogastroduodenoscopy, contrast radiographic examination and esophageal manometry. The results were compared with another 19 asymptomatic individuals. RESULTS Contrast radiographic examination of the esophagus revealed in six cases delayed emptying, characterizing that four patients had achalasia and two diffuse spasm of the esophagus. Esophageal manometry showed that maximal expiratory pressure of the lower sphincter ranged from 10 to 38 mmHg and mean respiratory pressure from 14 to 47 mmHg, values similar to controls. Residual pressure ranged from 5 to 31 mmHg, and 17 patients had the same values as the control group. CONCLUSION The residual pressure of the lower sphincter was higher and statistically significant in patients with dysphagia compared with those operated without dysphagia. Future studies individualizing and categorizing each motility disorder, employing other techniques of manometry, and the analysis of the residual pressure may contribute to understand of persistent dysphagia in the postoperative fundoplication.
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Affiliation(s)
- Drausio Jeferson MORAIS
- From the Disciplina de Moléstias do Aparelho Digestivo e Gastrocentro,
Departamento de Cirurgia, Faculdade de Ciências Médicas da Unicamp
(Digestive Diseases and Surgical Unit and Gastrocenter, Department of Surgery, School
of Medical Sciences, State University of Campinas, Unicamp), Campinas, SP,
Brazil
| | - Luiz Roberto LOPES
- From the Disciplina de Moléstias do Aparelho Digestivo e Gastrocentro,
Departamento de Cirurgia, Faculdade de Ciências Médicas da Unicamp
(Digestive Diseases and Surgical Unit and Gastrocenter, Department of Surgery, School
of Medical Sciences, State University of Campinas, Unicamp), Campinas, SP,
Brazil
| | - Nelson Adami ANDREOLLO
- From the Disciplina de Moléstias do Aparelho Digestivo e Gastrocentro,
Departamento de Cirurgia, Faculdade de Ciências Médicas da Unicamp
(Digestive Diseases and Surgical Unit and Gastrocenter, Department of Surgery, School
of Medical Sciences, State University of Campinas, Unicamp), Campinas, SP,
Brazil
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Abstract
PURPOSE OF REVIEW In the last decade, with the advent of new oesophageal testing [i.e. 24-h impedance-pH monitoring, combined impedance-manometry, high-resolution manometry (HRM)], relevant progress in understanding the mechanisms contributing to the development of gastro-oesophageal reflux disease (GORD) has been made, allowing a better management of patients with this disorder. The aim of our review is to report the state-of-the-art about oesophageal motor disorders in patients with reflux disease and to stimulate new research in this field. RECENT FINDINGS Hypotensive lower oesophageal sphincter (LOS), transient LOS relaxations, impairment of oesophagogastric junction including hiatal hernia, oesophageal bolus transit abnormalities and presence of ineffective oesophageal motility have been strongly implicated in GORD development. In particular, the majority of recent studies carried out with HRM and impedance-pH testing reported that these motor abnormalities are increasingly prevalent with increasing severity of GORD, from nonerosive reflux disease and erosive oesophagitis to Barrett's oesophagus. SUMMARY Defining and characterizing oesophageal dysmotility in patients with reflux disease is of maximum importance in order to properly diagnose these patients and to treat them with the best management of care. New studies are needed in order to better understand the physiomechanic basis of oesophageal dysmotility in GORD patients.
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Kulinna-Cosentini C, Schima W, Ba-Ssalamah A, Cosentini EP. MRI patterns of Nissen fundoplication: normal appearance and mechanisms of failure. Eur Radiol 2014; 24:2137-45. [PMID: 24965508 DOI: 10.1007/s00330-014-3267-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 05/18/2014] [Accepted: 05/27/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of the study was to assess the role of MR fluoroscopy in the evaluation of post-surgical conditions of Nissen fundoplication due to gastro-oesophageal reflux disease (GERD). METHODS A total of 29 patients (21 patients with recurrent/persistent symptoms and eight asymptomatic patients as the control group) underwent MRI of the oesophagus and gastro-oesophageal junction (GEJ) at 1.5 T. Bolus transit of a buttermilk-spiked gadolinium mixture was evaluated with T2-weighted half-Fourier acquisition single-shot turbo spin-echo (HASTE) and dynamic gradient echo sequences (B-FFE) in three planes. The results of MRI were compared with intraoperative findings, or, if the patients were treated conservatively, with endoscopy, manometry, pH-metry and barium swallow. RESULTS MRI was able to determine the position of fundoplication wrap in 27/29 cases (93% overall accuracy) and to correctly identify 4/6 malpositions (67%), as well as all four wrap disruptions. All five stenoses in the GEJ were identified and could be confirmed intraoperatively or during dilatation. MRI correctly visualized three cases with motility disorders, which were manometrically confirmed as secondary achalasia. Three patients showed signs of recurrent reflux without anatomical failure. CONCLUSION MRI is a promising diagnostic method to evaluate morphologic integrity of Nissen fundoplication and functional disorders after surgery. KEY POINTS MRI offers simultaneous morphological and functional imaging in one diagnostic method. MR fluoroscopy offers the possibility to identify the wrap position. MRI enables a non-invasive diagnosis, providing detailed information for the surgeon.
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Affiliation(s)
- Christiane Kulinna-Cosentini
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria,
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Effect of transoral incisionless fundoplication on reflux mechanisms. Surg Endosc 2013; 28:941-9. [PMID: 24149854 DOI: 10.1007/s00464-013-3250-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 09/30/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Transoral incisionless fundoplication (TIF) is a new endoscopic treatment option for gastroesophageal reflux disease (GERD). The mechanisms underlying the anti-reflux effect of this new procedure have not been studied. We therefore conducted this explorative study to evaluate the effect of TIF on reflux mechanisms, focusing on transient lower esophageal sphincter relaxations (TLESRs) and esophagogastric junction (EGJ) distensibility. METHODS GERD patients (N = 15; 11 males, mean age 41 years, range 23-66), dissatisfied with medical treatment were studied before and 6 months after TIF. We performed 90-min postprandial combined high-resolution manometry and impedance-pH monitoring and an ambulatory 24-h pH-impedance monitoring. EGJ distensibility was evaluated using an endoscopic functional luminal imaging probe before and directly after the procedure. RESULTS TIF reduced the number of postprandial TLESRs (16.8 ± 1.5 vs. 9.2 ± 1.3; p < 0.01) and the number of postprandial TLESRs associated with reflux (11.1 ± 1.6 vs. 5.6 ± 0.6; p < 0.01), but the proportion of TLESRs associated with reflux was unaltered (67.6 ± 6.9 vs. 69.9 ± 6.3 %). TIF also led to a decrease in the number and proximal extent of reflux episodes and an improvement of acid exposure in the upright position; conversely, TIF had no effect on the number of gas reflux episodes. EGJ distensibility was reduced after the procedure (2.4 ± 0.3 vs. 1.6 ± 0.2 mm(2)/mmHg; p < 0.05). CONCLUSIONS TIF reduced the number of postprandial TLESRs, the number of TLESRs associated with reflux and EGJ distensibility. This resulted in a reduction of the number and proximal extent of reflux episodes and improvement of acid exposure in the upright position. The anti-reflux effect of TIF showed to be selective for liquid-containing reflux only, thereby preserving the ability of venting gastric air.
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30
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Bonavina L, Siboni S, Saino GI, Cavadas D, Braghetto I, Csendes A, Korn O, Figueredo EJ, Swanstrom LL, Wassenaar E. Outcomes of esophageal surgery, especially of the lower esophageal sphincter. Ann N Y Acad Sci 2013; 1300:29-42. [PMID: 24117632 DOI: 10.1111/nyas.12232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This paper includes commentaries on outcomes of esophageal surgery, including the mechanisms by which fundoduplication improves lower esophageal sphincter (LES) pressure; the efficacy of the Linx™ management system in improving LES function; the utility of radiologic characterization of antireflux valves following surgery; the correlation between endoscopic findings and reported symptoms following antireflux surgery; the links between laparoscopic sleeve gastrectomy and decreased LES pressure, endoscopic esophagitis, and gastroesophageal reflux disease (GERD); the less favorable outcomes following fundoduplication among obese patients; the application of bioprosthetic meshes to reinforce hiatal repair and decrease the incidence of paraesophageal hernia; the efficacy of endoluminal antireflux procedures, and the limited efficacy of revisional antireflux operations, underscoring the importance of good primary surgery and diligent work-up to prevent the necessity of revisional procedures.
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Affiliation(s)
- Luigi Bonavina
- General Surgery, IRCCS, University of Milano, Milano, Italy
| | - Stefano Siboni
- General Surgery, IRCCS, University of Milano, Milano, Italy
| | - Greta I Saino
- General Surgery, IRCCS, University of Milano, Milano, Italy
| | - Demetrio Cavadas
- Department of Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Italo Braghetto
- Department of Surgery, University Hospital, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Attila Csendes
- Department of Surgery, University Hospital, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Owen Korn
- Department of Surgery, University Hospital, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Edgar J Figueredo
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - Eelco Wassenaar
- Department of Surgery, University of Washington, Seattle, Washington
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Ilczyszyn A, Botha AJ. Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication. Dis Esophagus 2013; 27:637-44. [PMID: 24033477 DOI: 10.1111/dote.12130] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti-reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF-325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross-sectional area and distensibility within a balloon-tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty-second median cross-sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre-extubation. Postoperatively, patients continued on protocol and were discharged after a two-night stay tolerating a sloppy diet. Patients with a hiatus hernia on high-resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm(2) /mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm(2) /mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm(2) /mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270° wrap resulting in a change in the DI from 0.65 to 0.89 mm(2) /mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long-term follow up would be beneficial to develop a target range of distensibility associated with good outcome.
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Affiliation(s)
- A Ilczyszyn
- Department of Upper GI Surgery, Guys' and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
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Kellokumpu I, Voutilainen M, Haglund C, Färkkilä M, Roberts PJ, Kautiainen H. Quality of life following laparoscopic Nissen fundoplication: Assessing short-term and long-term outcomes. World J Gastroenterol 2013; 19:3810-3818. [PMID: 23840119 PMCID: PMC3699043 DOI: 10.3748/wjg.v19.i24.3810] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/22/2013] [Accepted: 04/10/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the quality of life following laparoscopic Nissen fundoplication by assessing short-term and long-term outcomes.
METHODS: From 1992 to 2005, 249 patients underwent laparoscopic Nissen fundoplication. Short-term outcome data including symptom response, side effects of surgery, endoscopy, and patient’s perception of overall success were collected prospectively. Long-term outcomes were investigated retrospectively in patients with a median follow-up of 10 years by assessment of reflux symptoms, side effects of surgery, durability of antireflux surgery, need for additional treatment, patient’s perception of success, and quality of life. Antireflux surgery was considered a failure based on the following criteria: moderate to severe heartburn or regurgitation; moderate to severe dysphagia reported in combination with heartburn or regurgitation; regular proton pump inhibitor medication use; endoscopic evidence of erosive esophagitis Savary-Miller grade 1-4; pathological 24-h pH monitoring; or necessity to undergo an additional surgery. The main outcome measures were short- and long-term cure rates and quality of life, with patient satisfaction as a secondary outcome measure.
RESULTS: Conversion from laparoscopy to open surgery was necessary in 2.4% of patients. Mortality was zero and the 30-d morbidity was 7.6% (95%CI: 4.7%-11.7%). The median postoperative hospital stay was 2 d [interquartile range (IQR) 2-3 d]. Two hundred and forty-seven patients were interviewed for short-term analysis following endoscopy. Gastroesophageal reflux disease was cured in 98.4% (95%CI: 95.9%-99.6%) of patients three months after surgery. New-onset dysphagia was encountered postoperatively in 13 patients (6.7%); 95% reported that the outcome was better after antireflux surgery than with preoperative medical treatment. One hundred and thirty-nine patients with a median follow-up of 10.2 years (IQR 7.2-11.6 years) were available for a long-term evaluation. Cumulative long-term cure rates were 87.7% (81.0%-92.2%) at 5 years and 72.9% (64.0%-79.9%) at 10 years. Gastrointestinal symptom rating scores and RAND-36 quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. Of the patients available for long-term follow-up, 83% rated their operation a success.
CONCLUSION: For the long-term, our results indicate decreasing effectiveness of laparoscopic antireflux surgery, although most of the patients seem to have an overall quality of life similar to that of the general population.
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Shaheen NJ, Kim HP, Bulsiewicz WJ, Lyday WD, Triadafilopoulos G, Wolfsen HC, Komanduri S, Chmielewski GW, Ertan A, Corbett FS, Camara DS, Rothstein RI, Overholt BF. Prior fundoplication does not improve safety or efficacy outcomes of radiofrequency ablation: results from the U.S. RFA Registry. J Gastrointest Surg 2013; 17:21-p.29. [PMID: 22965650 DOI: 10.1007/s11605-012-2001-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 08/06/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ongoing gastroesophageal reflux may impair healing and re-epithelialization after radiofrequency ablation (RFA) of Barrett's esophagus (BE). Because prior fundoplication may improve reflux control, our aim was to assess the relationship between prior fundoplication and the safety/efficacy of RFA. METHODS We assessed the U.S. RFA Registry, a nationwide registry of BE patients receiving RFA at 148 institutions, to compare the safety and efficacy of ablation between those with prior fundoplication and those with medical management (proton pump inhibition). RESULTS Among 5,537 patients receiving RFA, 301 (5.4 %) had prior fundoplication. Of fundoplication subjects, 1.0 % developed stricture and 1.0 % were hospitalized after RFA. Rates of stricture, bleeding, and hospitalization were not statistically different (p = ns) between patients with and without prior fundoplication. Complete eradication of intestinal metaplasia and complete eradication of dysplasia were achieved in 71 % and 87 % of fundoplication patients, and 73 % and 87 % of patients without fundoplication, respectively (p = ns for both). Patients with prior fundoplication needed similar numbers of RFA sessions for eradication compared with those without fundoplication. CONCLUSIONS Radiofrequency ablation, with or without prior fundoplication, is safe and effective in eradicating BE. Prior fundoplication was associated with similar adverse event and efficacy rates when compared with medical management.
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Affiliation(s)
- Nicholas J Shaheen
- University of North Carolina School of Medicine, 130 Mason Farm Rd, CB#7080, Chapel Hill, NC 27599-7080, USA.
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Dysphagia and gastroesophageal junction resistance to flow following partial and total fundoplication. J Gastrointest Surg 2012; 16:475-85. [PMID: 21913039 DOI: 10.1007/s11605-011-1675-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 08/12/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Esophageal peristalsis and basal gastroesophageal junction (GEJ) pressure correlate poorly with dysphagia. AIM To determine intraluminal pressures that reflect GEJ function and to determine manometric correlates for dysphagia before and after fundoplication. METHODS The relationships between maximal intrabolus pressure, residual GEJ relaxation pressure and peak peristaltic pressure for water swallows were determined in normal volunteers and patients with reflux disease before and after fundoplication. GEJ anatomy was assessed by radiological, endoscopic and surgical criteria, whilst dysphagia was measured with a validated composite dysphagia score. RESULTS Dysphagia was significantly associated with lower peak peristaltic pressure in the distal esophagus and the presence of a hiatus hernia preoperatively, as well as higher residual pressure on GEJ relaxation postoperatively. Peak distal peristaltic pressure and residual GEJ relaxation pressure were predictors of intrabolus pressure after total fundoplication (p<0.002). Residual GEJ relaxation pressure was four times higher after 360° fundoplication (N=19) compared to 90° fundoplication (N=14, p<0.0001). Similarly, intrabolus pressure was elevated 2.5 times after 360° fundoplication and nearly doubled after 90° fundoplication and both were significantly different from controls (N=22) and reflux disease patients (N=53, p<0.0001). CONCLUSIONS Gastroesophageal junction impedance to flow imposed by fundoplication is associated with dysphagia when there is suboptimal distal esophageal contraction strength and relatively high residual GEJ relaxation pressure.
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Mittal RK, Karstens A, Leslie E, Babaei A, Bhargava V. Ambulatory high-resolution manometry, lower esophageal sphincter lift and transient lower esophageal sphincter relaxation. Neurogastroenterol Motil 2012; 24:40-6, e2. [PMID: 22074595 PMCID: PMC3746064 DOI: 10.1111/j.1365-2982.2011.01816.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Lower esophageal sphincter (LES) lift seen on high-resolution manometry (HRM) is a possible surrogate marker of the longitudinal muscle contraction of the esophagus. Recent studies suggest that longitudinal muscle contraction of the esophagus induces LES relaxation. AIM Our goal was to determine: (i) the feasibility of prolonged ambulatory HRM and (ii) to detect LES lift with LES relaxation using ambulatory HRM color isobaric contour plots. METHODS In vitro validation studies were performed to determine the accuracy of HRM technique in detecting axial movement of the LES. Eight healthy normal volunteers were studied using a custom designed HRM catheter and a 16 channel data recorder, in the ambulatory setting of subject's home environment. Color HRM plots were analyzed to determine the LES lift during swallow-induced LES relaxation as well as during complete and incomplete transient LES relaxations (TLESR). KEY RESULTS Satisfactory recordings were obtained for 16 h in all subjects. LES lift was small (2 mm) in association with swallow-induced LES relaxation. LES lift could not be measured during complete TLESR as the LES is not identified on the HRM color isobaric contour plot once it is fully relaxed. On the other hand, LES lift, mean 8.4 ± 0.6 mm, range: 4-18 mm was seen with incomplete TLESRs (n = 80). CONCLUSIONS & INFERENCES Our study demonstrates the feasibility of prolonged ambulatory HRM recordings. Similar to a complete TLESR, longitudinal muscle contraction of the distal esophagus occurs during incomplete TLESRs, which can be detected by the HRM. Using prolonged ambulatory HRM, future studies may investigate the temporal correlation between abnormal longitudinal muscle contraction and esophageal symptoms.
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Affiliation(s)
- R K Mittal
- Division of Gastroenterology, San Diego VA Health Care System and University of California, San Diego, CA, USA.
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Ma S, Qian B, Shang L, Shi R, Zhang G. A meta-analysis comparing laparoscopic partial versus Nissen fundoplication. ANZ J Surg 2012; 82:17-22. [PMID: 22507490 DOI: 10.1111/j.1445-2197.2010.05637.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND For proven gastro-oesophageal reflux disease, partial fundoplication is considered as effective as Nissen, but with fewer side effects. The aim of this meta-analysis was to compare the effect of laparoscopic partial fundoplication (LPF) with laparoscopic Nissen fundoplication (LNF). METHODS Extensive medical literature searches of the PubMed, Medline and Embase databases were performed up to April 2010 for all randomized clinical trials that compared LPF versus LNF. The effect variables analysed were the incidence of post-operative dysphagia, heartburn, inability to belch, outcome or satisfaction and Visick score. Meta-analyses were carried out using odds ratios (ORs) with 95% confidence interval. RESULTS Thirteen randomized trials were considered suitable for the meta-analysis. A total of 1374 patients underwent LPF or LNF. There was a significant reduction of the incidence of post-operative dysphagia (OR = 0.44, P < 0.0001) and inability to belch (OR = 0.41, P < 0.005) for the LPF compared to that of the LNF group. Compared with LPF, LNF resulted in a significant reduction of the incidence of post-operative heartburn (OR = 1.94, P < 0.01). The outcome or satisfaction of patients and Visick I and II scores were comparable between the two groups. CONCLUSION Both LPF and LNF are effective for the treatment of proven gastro-oesophageal reflux disease. LPF enables a decreased post-operative dysphagia and gas-related side effects, while LNF is more successful in controlling reflux symptoms, particularly heartburn, than LPF. A balance should be found between anti-reflux and side effects.
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Affiliation(s)
- Shijie Ma
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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SSAT maintenance of certification: literature review on gastroesophageal reflux disease and hiatal hernia. J Gastrointest Surg 2011; 15:1472-6. [PMID: 21594701 DOI: 10.1007/s11605-011-1556-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 04/15/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND This article reviews the current literature pertaining to the diagnosis and management of gastroesophageal reflux disease (GERD) and hiatal hernia. DISCUSSION GERD is one of the most common gastrointestinal disorders in the USA. For effective management, a conclusive diagnosis must be made. Most patients are effectively managed by acid suppression therapy, whereas others require procedural treatment. Endoluminal treatment of GERD is an option, but long-term results of this therapy are unknown. The "gold standard" surgical treatment of GERD is laparoscopic Nissen fundoplication. Large hiatal hernias are difficult to manage with a relatively high rate of recurrent hiatal hernia. CONCLUSION Whether or not to use mesh at the hiatus to decrease this occurrence is currently debatable.
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Kessing BF, Conchillo JM, Bredenoord AJ, Smout AJPM, Masclee AAM. Review article: the clinical relevance of transient lower oesophageal sphincter relaxations in gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2011; 33:650-61. [PMID: 21219371 DOI: 10.1111/j.1365-2036.2010.04565.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Transient lower oesophageal sphincter relaxations (TLOSR) are considered the physiological mechanism that enables venting of gas from the stomach and appear as sphincter relaxations that are not induced by swallowing. It has become increasingly clear that most reflux episodes occur during TLOSRs and therefore play a key role in gastro-oesophageal reflux disease (GERD). AIM To describe the current knowledge about TLOSRs and its clinical implications. METHODS Search of the literature published in English using the PubMed database and relevant abstracts presented at international conventions. RESULTS Several factors influence the rate of TLOSRs including anti-reflux surgery, meal, body position, nutrition, lifestyle and a wide array of neurotransmitters. Ongoing insights in the neurotransmitters responsible for the modulation of TLOSRs, as well as the neural pathways involved in TLOSR induction, have lead to novel therapeutic targets. These therapeutic targets can serve as an add-on therapy in patients with an unsatisfactory response to proton pump inhibitor by inhibiting TLOSRs and its associated reflux events. However, the TLOSR-inhibiting drugs that are currently available still have significant side effects. CONCLUSION It is likely that in the future, selected GERD patients may benefit from transient lower oesophageal sphincter relaxation inhibition when compounds are found without significant side effects.
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Affiliation(s)
- B F Kessing
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
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Jiang Y, Sandler B, Bhargava V, Mittal RK. Antireflux action of Nissen fundoplication and stretch-sensitive mechanism of lower esophageal sphincter relaxation. Gastroenterology 2011; 140:442-9. [PMID: 20955702 DOI: 10.1053/j.gastro.2010.10.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 10/04/2010] [Accepted: 10/04/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Surgical fundoplication is an effective treatment for gastroesophageal reflux disease. One of the proposed mechanisms for its antireflux action is that it reduces lower esophageal sphincter (LES) relaxation. We investigated whether fundoplication works through a stretch-sensitive mechanism of LES relaxation. METHODS Studies were performed in rats. Intravenous and arterial lines were placed and tracheal intubation was performed. A midline laprotomy was performed to place sutures through the esophagus to exert axial stretch on the LES, and the vagus nerve was isolated in the neck for electrical stimulation. The LES pressure was monitored with a 2F solid-state pressure transducer placed through a gastrostomy. Cranial displacement of the LES was recorded using piezoelectric crystals. Data were recorded before and after 360-degree Nissen fundoplication. RESULTS Axial stretch and vagus nerve stimulation induced cranial displacement of the LES as well as LES relaxation in a dose-dependent manner. LES relaxation and axial stretch were each significantly reduced after fundoplication (P < .01). Nitric-oxide-induced LES relaxation was not affected by fundoplication. Removal of fundoplication restored axial stretch- and vagus nerve-stimulated LES relaxation as well as LES cranial displacement. CONCLUSIONS Fundoplication reduces LES relaxation by interfering with axial stretch on the LES. Based on this mechanism of the antireflux actions of fundoplication, it might be possible to design new surgical strategies to treat reflux disease and reduce complications of fundoplication surgery.
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Affiliation(s)
- Yanfen Jiang
- Department of Medicine and Surgery, San Diego VA Health Care System, California 92161, USA
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Medical treatment of GORD. Emerging therapeutic targets and concepts. Best Pract Res Clin Gastroenterol 2010; 24:937-46. [PMID: 21126705 DOI: 10.1016/j.bpg.2010.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 08/25/2010] [Accepted: 08/27/2010] [Indexed: 01/31/2023]
Abstract
Approximately 20-30% of patients with gastro-oesophageal reflux symptoms report inadequate symptom relief while on PPI therapy. Persisting acid or non-acid reflux can be demonstrated in 40-50% of them suggesting that there is room for anti-reflux therapy in these patients. New anti-reflux compounds aim at decreasing the occurrence of transient lower oesophageal sphincter relaxations (TLOSRs) which represent the main mechanism of all types of reflux. The most promising classes of compounds are GABA(B) agonists and mGluR5 antagonists which have been shown to reduce both reflux episodes and symptoms and are currently under evaluation in phase II and III clinical trials. Compounds that target TLOSR activity represent a promising new therapeutic option for patients who suffer from GORD symptoms. These drugs will probably be developed as add-on therapy in combination with PPIs provided the tolerability and safety issues are resolved.
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Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:2647-2669. [PMID: 20725747 DOI: 10.1007/s00464-010-1267-8] [Citation(s) in RCA: 240] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Watson DI, Immanuel A. Endoscopic and laparoscopic treatment of gastroesophageal reflux. Expert Rev Gastroenterol Hepatol 2010; 4:235-243. [PMID: 20350269 DOI: 10.1586/egh.10.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastroesophageal reflux is extremely common in Western countries. For selected patients, there is an established role for the surgical treatment of reflux, and possibly an emerging role for endoscopic antireflux procedures. Randomized trials have compared medical versus surgical management, laparoscopic versus open surgery and partial versus total fundoplications. However, the evidence base for endoscopic procedures is limited to some small sham-controlled studies, and cohort studies with short-term follow-up. Laparoscopic fundoplication has been shown to be an effective antireflux operation. It facilitates quicker convalescence and is associated with fewer complications, but has a similar longer term outcome compared with open antireflux surgery. In most randomized trials, antireflux surgery achieves at least as good control of reflux as medical therapy, and these studies support a wider application of surgery for the treatment of moderate-to-severe reflux. Laparoscopic partial fundoplication is an effective surgical procedure with fewer side effects, and it may achieve high rates of patient satisfaction at late follow-up. Many of the early endoscopic antireflux procedures have failed to achieve effective reflux control, and they have been withdrawn from the market. Newer procedures have the potential to fashion a surgical fundoplication. However, at present there is insufficient evidence to establish the safety and efficacy of endoscopic procedures for the treatment of gastroesophageal reflux, and no endoscopic procedure has achieved equivalent reflux control to that achieved by surgical fundoplication.
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Affiliation(s)
- David I Watson
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia.
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Richter JE, Friedenberg FK. Gastroesophageal Reflux Disease. SLEISENGER AND FORDTRAN'S GASTROINTESTINAL AND LIVER DISEASE 2010:705-726.e6. [DOI: 10.1016/b978-1-4160-6189-2.00043-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Nissen Fundoplication and Gastrointestinal-Related Complications: A Guide for the Primary Care Physician. South Med J 2009; 102:1041-5. [DOI: 10.1097/smj.0b013e3181b672eb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
The last 50 years have seen a transformation in the understanding and treatment of reflux disease. The development and wide use of flexible endoscopy and progressively more sophisticated approaches to measurement of pathophysiological factors have been major drivers of advances. The recognition and progressive elucidation of the mechanical events that comprise the transient lower esophageal sphincter relaxation and how they lead to reflux provide a novel and firm foundation for tailoring therapies that act directly to reduce occurrence of reflux episodes, either surgically or pharmacologically. Novel GABA(B) agonist drugs have been shown to inhibit transient relaxations and are currently being evaluated in clinical trials on patients with reflux disease. Better understanding has extended to recognition of the extraordinarily high prevalence of reflux disease and of the ability of proton pump inhibitor drugs to deliver major benefits to a high proportion of patients with reflux disease. The life of the Gastroenterological Society of Australia has spanned the period of these major advances. A large number of the members of the Society and their associates have contributed substantially to these advances.
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Affiliation(s)
- John Dent
- Department of Gastroenterology & Hepatology, Royal Adelaide Hospital & University of Adelaide, Adelaide, South Australia, Australia.
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Boiron M, Benchellal Z, Huten N. Study of swallowing sound at the esophagogastric junction before and after fundoplication. J Gastrointest Surg 2009; 13:1570-6. [PMID: 19495892 DOI: 10.1007/s11605-009-0937-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 05/20/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Swallowing sounds can be heard in the lower esophagus by xiphoid auscultation. We hypothesize that the xiphoid sound analysis could provide information concerning the integrity of the esophagogastric junction (EGJ), i.e., superposition of the lower esophageal sphincter (LES) and the diaphragm to assess clinical diagnosis of gastroesophageal reflux disease (GERD) and results of Nissen fundoplication (NF). The aim was to evaluate the changes in sound parameters using our acoustic technique after reorganization of the EGJ after NF. METHODS For 21 patients with GERD and hiatus hernia, two microphones were placed below the cricoid and on the xiphoid cartilages. The frequency and duration of xiphoid sounds, esophageal transit time were calculated. We defined the xiphoid sound as composed of vibration groups separated by periods >100 ms. The number of vibration groups, number of vibrations per group, and interval between groups were also calculated. RESULTS The xiphoid sound frequency was increased after NF, and the esophageal transit time and xiphoid sound duration were significantly decreased. A significant correlation was found between xiphoid sound duration and LES-diaphragm displacement. The number of vibration groups and interval between groups were reduced after NF. CONCLUSION The acoustic technique for swallowing revealed the effects of NF upon the dynamic profile of the EGJ. The organization of vibration groups at the EGJ suggested that the passage of the bolus was modified by hiatus hernia, i.e., dissociation between the LES and the diaphragm and regularized by NF. Concomitant acoustic and radiologic study should contribute to better understanding of sound related to EGJ structure and boli.
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Affiliation(s)
- Michèle Boiron
- Physiology and Digestive Motility Laboratory, School of Medicine, University François-Rabelais of Tours, Tours, France.
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Jiang Y, Bhargava V, Mittal RK. Mechanism of stretch-activated excitatory and inhibitory responses in the lower esophageal sphincter. Am J Physiol Gastrointest Liver Physiol 2009; 297:G397-405. [PMID: 19520741 PMCID: PMC2724084 DOI: 10.1152/ajpgi.00108.2009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We recently found that an orally directed stretch of the esophagus activates a neurally mediated relaxation of the lower esophageal sphincter (LES). Goals of our study were to characterize the neural mechanisms responsible for axial and transverse stretch-activated responses in the LES. LES pressure was monitored in anesthetized and artificially ventilated mice. Sutures were placed in the esophagus to exert graded stretch in the longitudinal and transverse directions. Effects of bilateral vagotomy and pharmacological agents on the stretch-activated LES responses were investigated. The relationship between vagally stimulated axial stretch and LES relaxation was also studied. Stretch in the longitudinal and transverse directions caused a dose-dependent LES relaxation and contraction, respectively, that were not affected by bilateral vagotomy and sympathectomy but were blocked by tetrodotoxin. In bilateral vagotomized animals, hexamethonium, atropine, pyridoxalphosphate-6-azophenyl-2',4' disulfonic acid (PPADS), and ondansetron did not block the stretch-activated LES relaxation and contraction. Axial stretch-activated LES relaxation was blocked by nitric oxide inhibitor and transverse stretch-activated LES contraction was blocked by a combination of atropine and substance P antagonist. Electrical stimulation of the vagus nerve induced LES relaxation and axial stretch on the LES, both of which were blocked by rocuronium. Axial and transverse stretch-activated LES relaxation and contraction were present in the W/W(v) mice that lack interstitial cells of Cajal (ICC). Stretch-activated LES relaxation and contraction are mediated through mechanosensitive neurons located in the myenteric plexus, which involves neither synaptic transmission nor ICC.
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Affiliation(s)
- Yanfen Jiang
- Division of Gastroenterology, San Diego Veterans Affairs HealthCare System and University of California, San Diego, San Diego, California
| | - Valmik Bhargava
- Division of Gastroenterology, San Diego Veterans Affairs HealthCare System and University of California, San Diego, San Diego, California
| | - Ravinder K. Mittal
- Division of Gastroenterology, San Diego Veterans Affairs HealthCare System and University of California, San Diego, San Diego, California
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Burton PR, Button B, Brown W, Lee M, Roberts S, Hassen S, Bailey M, Smith A, Snell G. Medium-term outcome of fundoplication after lung transplantation. Dis Esophagus 2009; 22:642-8. [PMID: 19515194 DOI: 10.1111/j.1442-2050.2009.00980.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux disease (GERD) in lung transplant recipients has gained increasing attention as a factor in allograft failure. There are few data on the impact of fundoplication on survival or lung function, and less on its effect on symptoms or quality of life. Patients undergoing fundoplication following lung transplantation from 1999 to 2005 were included in the study. Patient satisfaction, changes in GERD symptoms, and the presence of known side effects were assessed. The effect on lung function, body mass index, and rate of progression to the bronchiolitis obliterans syndrome (BOS) were recorded. Twenty-one patients (13 males), in whom reflux was confirmed on objective criteria, were included, with a mean age of 43 years (range 20-68). Time between transplantation and fundoplication was 768 days (range 145-1524). The indication for fundoplication was suspected microaspiration in 13 and symptoms of GERD in 8. There was one perioperative death, at day 17. There were three other late deaths. Fundoplication did not appear to affect progression to BOS stage 1, although it may have slowed progression to stage 2 and 3. Forced expiratory volume-1% predicted was 72.9 (20.9), 6 months prior to fundoplication and 70.4 (26.8), six months post-fundoplication, P= 0.33. Body mass index decreased significantly in the 6 months following fundoplication (23 kg/m(2) vs. 21 kg/m(2), P= 0.05). Patients were satisfied with the outcome of the fundoplication (mean satisfaction score 8.8 out of 10). Prevalence of GERD symptoms decreased significantly following surgery (11 of 14 vs. 4 of 17, P= 0.002). Fundoplication does not reverse any decline in lung function when performed at a late stage post-lung transplantation in patients with objectively confirmed GERD. It may, however, slow progression to the more advanced stages of BOS. Reflux symptoms are well controlled and patients are highly satisfied. Whether performing fundoplication early post-lung transplant in selected patients can prevent BOS and improve long-term outcomes requires formal evaluation.
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Affiliation(s)
- P R Burton
- Department of Surgery, The Alfred Hospital, Melbourne, Victoria, Australia.
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