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Liu Y, Huang J, Zhong S, Zheng Z, Xu Z, Zhou D, Xie S, Lin Z, Li S, Chen R. Efficacy and safety of anti-reflux surgery in gastroesophageal-related cough: a systematic review and meta-analysis. Int J Surg 2024; 111:01279778-990000000-01929. [PMID: 39206849 PMCID: PMC11745681 DOI: 10.1097/js9.0000000000001998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/15/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a prevalent condition that manifests a spectrum of symptoms, including gastroesophageal-related cough (GERC). Anti-reflux procedures have been employed to alleviate these symptoms, yet their efficacy varies. This systematic review and meta-analysis aim to evaluate the improvement in gastroesophageal-related cough and other reflux symptoms following anti-reflux procedures. METHODS A systematic review was performed by searching PubMed, Embase, and Cochrane Library. All observational studies reporting the improvement of GERC and other reflux symptoms after the anti-reflux procedures. Data were extracted and pooled using a random effects model to assess the overall effect size and heterogeneity between studies. We found that anti-reflux surgery has some clear benefits for common reflux-related symptoms. RESULTS Fifty-nine eligible studies with 7431 patients with GERD were included in this study. The pooled cough remission rate was 80.0% (95%CI 75.4-84.2) and the mean time of follow up was 35.8 months. Anti-reflux surgery significantly improved overall reflux-related symptom scores (all P<0.001). We also assessed the rate of remission of other reflux symptoms. The pooled heartburn remission rate was 87.7% (95%CI 82.3-92.2) and the pooled regurgitation remission rate was 91.2%(95%CI 87.8-94.1). CONCLUSION Anti-reflux procedures significantly improve gastroesophageal-related cough and other reflux symptoms. These findings support the use of anti-reflux procedures as a viable treatment option for patients with GERD symptoms. Further research is needed to identify predictors of success and to optimize patient selection for anti-reflux procedures.
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Affiliation(s)
- Yuheng Liu
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine
- Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University
- Clinical Medical College, Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Junfeng Huang
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine
- Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University
| | - Shuxin Zhong
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine
- Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University
| | - Ziwen Zheng
- Clinical Medical College, Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Zhixing Xu
- Clinical Medical College, Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Dongda Zhou
- Clinical Medical College, Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Shuojia Xie
- Clinical Medical College, Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Zikai Lin
- Clinical Medical College, Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Shiyue Li
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine
- Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University
| | - Ruchong Chen
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine
- Department of Allergy and Clinical Immunology, The First Affiliated Hospital of Guangzhou Medical University
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Zimmermann CJ, Kuchta K, Amundson JR, VanDruff VN, Joseph S, Che S, Hedberg HM, Ujiki MB. Gas and Bloat in Female Patients after Antireflux Procedures: Analysis of 934 Cases. J Am Coll Surg 2024; 239:18-29. [PMID: 38666653 DOI: 10.1097/xcs.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Antireflux procedures (ARPs) are effective treatments for GERD. However, variation in objective and patient-reported outcomes persists. Limited evidence and anecdotal experience suggest that patient sex may play a role. The objective of this study was to compare outcomes after ARPs between male and female patients. STUDY DESIGN We performed a retrospective review of a prospectively maintained database at a single institution. All patients who underwent an ARP for GERD were included. Demographic, clinical, and patient-reported outcomes data (GERD health-related quality of life [HRQL] and reflux symptom index), and radiographic hernia recurrence were collected and stratified by sex. Univariable and multivariable logistic and mixed-effects linear regression were used to control for confounding effects. RESULTS Between 2009 and 2022, 934 patients (291 men and 643 women) underwent an ARP. Reflux symptom index, GERD-HRQL, and gas and bloat scores improved uniformly for both sexes, though female patients were more likely to have higher gas and bloat scores 1 year postprocedure (mean ± SD 1.7 ± 1.4 vs 1.4 ± 1.3, p = 0.03) and higher GERD-HRQL scores 2 years postprocedure (6.3 ± 8.1 vs 4.7 ± 6.8, p = 0.04). Higher gas and bloat scores in women persisted on regression controlling for confounders. Hernia recurrence rate was low (85 patients, 9%) and was similar for both sexes. A final intraprocedural distensibility index 3 mm 2 /mmHg or more was significantly associated with a 7 times higher rate of recurrence (95% CI 1.62 to 31.22, p = 0.01). CONCLUSIONS Although patients of either sex experience symptom improvement and low rate of recurrence after ARPs, women are more likely to endorse gas and bloat compared with men. Final distensibility index 3 mm 2 /mmHg or more carries a high risk of recurrence. These results may augment how physicians prognosticate during consultation and tailor their treatment in patients with GERD.
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Affiliation(s)
- Christopher J Zimmermann
- From the Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Zimmermann, Kuchta, Joseph, Che, Hedberg, Ujiki)
| | - Kristine Kuchta
- From the Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Zimmermann, Kuchta, Joseph, Che, Hedberg, Ujiki)
| | - Julia R Amundson
- Department of Surgery, University of Chicago Medical Center, Chicago, IL (Amundson, VanDruff)
| | - Vanessa N VanDruff
- Department of Surgery, University of Chicago Medical Center, Chicago, IL (Amundson, VanDruff)
| | - Stephanie Joseph
- From the Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Zimmermann, Kuchta, Joseph, Che, Hedberg, Ujiki)
| | - Simon Che
- From the Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Zimmermann, Kuchta, Joseph, Che, Hedberg, Ujiki)
| | - H Mason Hedberg
- From the Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Zimmermann, Kuchta, Joseph, Che, Hedberg, Ujiki)
| | - Michael B Ujiki
- From the Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Zimmermann, Kuchta, Joseph, Che, Hedberg, Ujiki)
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Pflüger MJ, Coker AM, Zosa BM, Adrales GL, Parker BC. To wean or not to wean: proton pump inhibitor management after anti-reflux surgery amongst foregut experts. Surg Endosc 2024; 38:3992-3998. [PMID: 38844731 DOI: 10.1007/s00464-024-10910-y] [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: 03/18/2024] [Accepted: 05/04/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Most patients undergoing anti-reflux surgery (ARS) have a history of preoperative proton pump inhibitor (PPI) use. It is well-established that ARS is effective in restoring the anti-reflux barrier, eliminating the ongoing need for costly PPIs. Current literature lacks objective evidence supporting an optimal postoperative PPI cessation or weaning strategy, leading to wide practice variations. We sought to objectively gauge current practice and opinion surrounding the postoperative management of PPIs among expert foregut surgeons and gastroenterologists in the United States. METHODS We created a survey of postoperative PPI management protocols, with an emphasis on discontinuation and timing of PPI cessation, and aimed to determine what factors played a role in the decision-making. An electronic survey tool (Qualtrics XM, Qualtrics, Provo, UT) was used to distribute the survey and to record the responses anonymously for a period of three months. RESULTS The survey was viewed 2658 times by 373 institutions and shared with 644 members. In total, 121 respondents participated in the survey and 111 were surgeons (92%). Fifty respondents (42%) always discontinue PPIs immediately after ARS. Of the remaining 70 respondents (58%), 46% always wean or taper PPIs postoperatively and 47% wean or taper them selectively. The majority (92%) of practitioners taper within a 3-month period postoperatively. Five respondents never discontinue PPIs after ARS. Overall, only 23 respondents (19%) stated their protocol is based on medical literature or evidence-based medicine. Instead, decision-making is primarily based on anecdotal evidence/personal preference (42%, n = 50) or prior training/mentors (39%, n = 47). CONCLUSIONS There are two major protocols used for PPI discontinuation after ARS: Nearly half of providers abruptly stop PPIs, while just over half gradually tapers them, most often in the early postoperative period. These decisions are primarily driven by institutional practices and personal preferences, underscoring the need for evidence-based recommendations.
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Affiliation(s)
- Michael Johannes Pflüger
- Division of Minimally Invasive Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alisa Mae Coker
- Division of Minimally Invasive Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Brenda Marie Zosa
- Division of Minimally Invasive Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gina Lynn Adrales
- Division of Minimally Invasive Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Brett Colton Parker
- Division of Minimally Invasive Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
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Yao L, Lin Y, He X, Liu G, Wang B, Wang W, Li D. Efficacy of different endoscopic treatments for gastroesophageal reflux disease: a systematic review and network meta-analysis. J Gastrointest Surg 2024; 28:1051-1061. [PMID: 38670431 DOI: 10.1016/j.gassur.2024.04.020] [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: 01/17/2024] [Revised: 03/21/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND There are no direct comparisons across different endoscopic therapies for gastroesophageal reflux disease (GERD). This study aimed to evaluate the relative effects of different endoscopic therapies in GERD. METHODS Five databases were searched until August 2023 for randomized controlled trials (RCTs) that compared the efficacy of endoscopic band ligation (EBL), Stretta, endoscopic fundoplication (transoral incisionless fundoplication [TIF], endoscopic full-thickness plication [EFTP], and EndoCinch plication procedure [EndoCinch, CR BARD, Billerica, Mass., USA]), or proton pump inhibitors (PPIs)/sham procedure for GERD. Bayesian network meta-analysis was performed. RESULTS A total of 19 trials comprising 1181 patients were included. EBL (mean difference [MD], -7.75; 95% credible interval [CrI], -13.90 to -1.44), Stretta (MD, -9.86; 95% CrI, -19.05 to -0.58), and TIF (MD, -12.58; 95% CrI, -20.23 to -4.91) all significantly improved patients' health-related quality of life score with equivalent efficacy compared with PPIs. TIF and EBL achieved equivalent efficacy in reducing PPIs utility (risk ratio [RR], 0.66; 95% CrI, 0.40-1.05) and both were significantly superior to other endoscopic interventions (Stretta, EFTP, and EndoCinch). Besides, EBL and TIF also could significantly decrease the esophagitis incidence compared with PPIs (EBL [RR, 0.34; 95% CrI, 0.22-0.48] and TIF [RR, 0.38; 95% CrI, 0.15-0.88]). In terms of lower esophageal sphincter (LES) pressure, only TIF could significantly increase the LES pressure (MD, 6.53; 95% CrI, 3.65-9.40) to PPIs. In contrast, TIF was inferior to PPIs in decreasing esophageal acid exposure (MD, 2.57; 95% CrI, 0.77-4.36). CONCLUSION Combining the evidence, EBL and TIF may have comparable efficacy and both might be superior to Stretta, EFTP, or EndoCinch in GERD treatment.
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Affiliation(s)
- Lijia Yao
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Gastroenterology, 900TH Hospital of Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Yanfang Lin
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Gastroenterology, 900TH Hospital of Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Xiaojian He
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Gastroenterology, 900TH Hospital of Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Gang Liu
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Gastroenterology, 900TH Hospital of Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Baoshan Wang
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Gastroenterology, 900TH Hospital of Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Wen Wang
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Gastroenterology, 900TH Hospital of Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Dongliang Li
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; Department of Hepatobiliary Disease, 900TH Hospital of Joint Logistics Support Force, Fuzhou, Fujian, China.
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Lee YS, Kim JH, Yon DK, Yoo IK. Short and long term effect of anti-reflux mucosectomy with cap-assisted endoscopic mucosal resection for refractory gastroesophageal disease. Surg Endosc 2024; 38:2180-2187. [PMID: 38448622 DOI: 10.1007/s00464-024-10766-2] [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: 12/10/2023] [Accepted: 02/21/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND AND AIMS Anti-reflux mucosectomy with cap-assisted endoscopic mucosal resection (ARMS-C) is a safe and effective treatment for managing refractory gastroesophageal reflux disease (GERD). This study aimed to investigate the short and long-term outcomes of ARMS-C. METHODS This study was conducted from 2018 to 2022, during which 115 eligible patients underwent ARMS-C. The primary endpoints of this study were to evaluate the GERD-Q questionnaire score and determine the number of patients who reduced their proton pump inhibitor (PPI) dosage or discontinued PPI usage. The secondary endpoints included the evaluation of the DeMeester score, acid exposure time (AET), gastroesophageal flap valve grade (GEFV), lower esophageal sphincter pressure, the rate of successful esophageal peristalsis, and GERD-Q questionnaires. Additionally, we analyzed the long-term efficacy of ARMS-C. RESULTS Out of the 120 patients, 115 underwent ARMS-C, 96 were followed up for at least six months after the procedure, and 22 were followed up for at least two years. The primary outcome showed a significant improvement in GERD-Q scores, decreasing from 10.67 to 7.55 (p < 0.001). Out of the 96 patients, 36 were able to reduce or completely stop using PPIs. The DeMeester score, GEFV, AET, and the proportion of intact peristalsis also demonstrated improvement. As for the long-term efficacy of ARMS-C, 86% of patients showed improvement in symptoms, and no serious adverse effects were reported after the procedure. CONCLUSION ARMS-C is a safe and effective endoscopic technique to treat refractory GERD patients.
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Affiliation(s)
- Yoon Soo Lee
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, 13496, Korea
| | - Jee Hyun Kim
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, 13496, Korea
| | - Dong Keon Yon
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - In Kyung Yoo
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, 13496, Korea.
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cha Bundang Medical Center, 59 Yatapro, Bundang-gu, Seongnam-si, Korea.
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Louis H, Van Ouytsel P, Leclercq L, Houinsou Hans M, Devière J, Rio-Tinto R, Huberty V. Pilot study of an endoluminal-suturing device as a treatment for patients with gastroesophageal reflux disease. Endosc Int Open 2023; 11:E1092-E1098. [PMID: 38026783 PMCID: PMC10681806 DOI: 10.1055/a-2185-5947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/22/2023] [Indexed: 12/01/2023] Open
Abstract
Background and study aims Endoscopic therapy is a promising option for patients with gastroesophageal reflux disease (GERD). The aim of this study was to assess safety and feasibility of the Endomina suturing platform as a treatment for GERD. Patients and methods This was a two-center study of patients with chronic GERD symptoms that responded at least partially to proton pump inhibitors (PPIs). Primary endpoints were to assess the safety of the procedure and persistence of the sutures. Secondary endpoints were to assess esophageal pH-impedance and manometry parameters changes at 6 months, as well as GERD symptoms and PPI use up to 12 months of follow-up. Results Fourteen patients were treated (13 males, mean of 43±12 years), with a mean number of three plications per patient. Thirteen, 10, and nine patients were analyzed at 3, 6, and 12 months of follow-up, respectively. One device-related adverse event occurred (loss of needle tip requiring endoscopic retrieval 1 week later). A mean of two plications persisted at 3 and 12 months. A decrease in median acid exposure time and reflux episodes was observed after the procedure. Mean Reflux Symptom Index and GERD-Health-Related Quality of Life scores decreased during follow-up visits and 90% of the patients discontinued PPI use at 1 year. Conclusions Endoscopic full-thickness suturing of the esophagogastric junction with the Endomina suturing platform is feasible, allowing persistence of two-thirds of the plications, with promising results for decreasing reflux and improving GERD symptoms.
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Affiliation(s)
- Hubert Louis
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Hôpital Universitaire de Bruxelles (H.U.B.), C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Pauline Van Ouytsel
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Hôpital Universitaire de Bruxelles (H.U.B.), C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | | | - Mélina Houinsou Hans
- Department of Biomedical Research, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Jacques Devière
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Hôpital Universitaire de Bruxelles (H.U.B.), C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | | | - Vincent Huberty
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Hôpital Universitaire de Bruxelles (H.U.B.), C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
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Calabrese F, Poletti V, Auriemma F, Paduano D, Gentile C, Facciorusso A, Franchellucci G, De Marco A, Brandaleone L, Ofosu A, Samanta J, Ramai D, De Luca L, Al-Lehibi A, Zuliani W, Hassan C, Repici A, Mangiavillano B. New Perspectives in Endoscopic Treatment of Gastroesophageal Reflux Disease. Diagnostics (Basel) 2023; 13:2057. [PMID: 37370952 DOI: 10.3390/diagnostics13122057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Gastroesophageal reflux disease has a high incidence and prevalence in the general population. Clinical manifestations are heterogenous, and so is the response to medical treatment. Proton pump inhibitors are still the most common agents used to control reflux symptoms and for healing esophagitis, but they are not a one-size-fits-all solution for the disease. Patients with persistent troublesome symptoms despite medical therapy, those experiencing some adverse drug reaction, or those unwilling to take lifelong medications deserve valid alternatives. Anti-reflux Nissen fundoplication is an effective option, but the risk of adverse events has limited its spread. In recent years, advancements in therapeutic endoscopy have been made, and three major endoluminal alternatives are now available, including (1) the delivery of radiofrequency energy to the esophago-gastric junction, (2) transoral incisionless fundoplication (TIF), and (3) anti-reflux mucosal interventions (ARMI) based on mucosal resection (ARMS) and mucosal ablation (ARMA) techniques to remodel the cardia. Endoscopic techniques have shown interesting results, but their diffusion is still limited to expert endoscopists in tertiary centers. This review discusses the state of the art in the endoscopic approach to gastroesophageal reflux disease.
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Affiliation(s)
- Federica Calabrese
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Valeria Poletti
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Danilo Paduano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Carmine Gentile
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, 71100 Foggia, Italy
| | | | - Alessandro De Marco
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Luca Brandaleone
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Andrew Ofosu
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Luca De Luca
- Endoscopic Unit, ASST Santi Paolo e Carlo, 20142 Milan, Italy
| | - Abed Al-Lehibi
- King Fahad Medical City, Faculty of Medicine, King Saud Bin Abduaziz University-Health Science, Riyadh 11525, Saudi Arabia
| | - Walter Zuliani
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Cesare Hassan
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
| | - Alessandro Repici
- Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
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Scheese D, Chehab M, Puig CA. Sex Differences in Gastroesophageal Reflux Disease (GERD). FOREGUT: THE JOURNAL OF THE AMERICAN FOREGUT SOCIETY 2023; 3:192-198. [DOI: 10.1177/26345161231166136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Gastroesophageal reflux disease (GERD) is the most commonly diagnosed digestive disorder in the United States. Higher rates of non-erosive reflux disease (NERD) are found in females while higher rates of erosive reflux disease (ERD) are found in males. Pre-menopausal females appear to be protected from esophageal mucosal damage, as they demonstrate lower rates of ERD, Barrett’s esophagus, and esophageal adenocarcinoma. A protective effect of estrogen on the esophageal mucosa is thought to contribute to this decreased prevalence. A better understanding of sex-related differences in GERD may help alleviate the reported differences in outcomes between sexes regarding medical and surgical management.
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Affiliation(s)
- Daniel Scheese
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Mohamad Chehab
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Carlos A. Puig
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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The Lyon Consensus Criteria for GERD Diagnosis in a Greek Population: The Clinical Impact and Changes in GERD Diagnosis in a Real-World, Retrospective Study. J Clin Med 2022; 11:jcm11185383. [PMID: 36143030 PMCID: PMC9503370 DOI: 10.3390/jcm11185383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Introduction/aim: Gastroesophageal reflux disease (GERD) affects 8−33% globally. The gold standard examination technique in diagnosing GERD is 24 h pHmetry ± impedance. Recently, new diagnostic criteria were introduced by the Lyon Consensus for GERD diagnosis. Our aim was to investigate the diagnostic yield of pHmetry + impedance using the Lyon Consensus criteria in a real-world study. (2) Patients and methods: Our study included 249 consecutive patients (M/F: 120/129, mean age 50 ± 15 years) who underwent 24 h pH+ impedance monitoring in our department, during a 5-year period. Epidemiological, endoscopic, clinical, and 24 h pH+ impedance data were retrospectively collected. (3) Results: Typical GERD symptoms were reported by 140/249 (56.2%) patients, whereas 99/249 (39.6%) patients reported various extraesophageal symptoms. Endoscopic findings supportive of GERD based on the Lyon Consensus were present in 42/185 (22.7%). An AET value of >6% was observed in 60/249 (24.1%). GERD diagnosis according to the Lyon Consensus criteria was set in 63/249 (25.3%) patients; a rate significantly lower than that observed by implementing the older criteria (32.1%), p < 0.001. In the multivariate analysis, the existence of endoscopic findings supportive of GERD diagnosis as defined by the Lyon Consensus (p = 0.036), a De Meester score of over 14.7, and the presence of typical GERD symptoms were correlated to GERD diagnosis (p < 0.001, respectively) using the criteria defined for pH−impedance monitoring. (4) Conclusions: Changes in the diagnostic criteria concerning the 24 h pH−impedance monitoring of GERD based on the Lyon Consensus led to a conclusive GERD diagnosis in approximately 25% of the patients. This rate of GERD diagnosis is reduced in comparison to the one confirmed with the use of previously established criteria.
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Hodges MM, DeSouza ML, Reavis KM, Davila Bradley D, Dunst CM. Abnormal response after multiple rapid swallow provocation is not predictive of post-operative dysphagia following a tailored fundoplication approach. Surg Endosc 2022; 37:3982-3993. [PMID: 36068387 DOI: 10.1007/s00464-022-09507-0] [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: 03/23/2022] [Accepted: 07/23/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The aim was to evaluate the clinical significance of multiple rapid swallows (MRS) during high-resolution manometry (HRM) prior to fundoplication. Despite pre-operative HRM, up to 38% of patients report post-fundoplication dysphagia. Suggestion that MRS improves prediction of dysphagia after fundoplication has not been investigated when using a tailored approach. We hypothesize response to MRS is predictive of dysphagia after tailored fundoplication. METHODS A retrospective cohort study was performed on patients undergoing HRM with MRS provocation 5/2019-7/2021 at a single institution. Patients who underwent subsequent index laparoscopic fundoplication, without peptic stricture or achalasia, were included. After performing standard 10-swallow HRM, MRS provocation was performed. Patient-reported dysphagia frequency scores were collected at initial consultation and post-operative follow-up. At least weekly symptoms were considered clinically significant. Normal MRS response was defined as adequate deglutitive inhibition and MRS contractile response. Fundoplications were tailored based on standard HRM values. RESULTS HRM was performed in 1201 patients, 220 met inclusion criteria. Clinically significant pre-operative dysphagia was reported by 85 (38.6%). Patients undergoing partial fundoplication (n = 123, 55.9%) had lower mean distal contractile integer, distal esophageal contraction amplitude, and percent peristalsis (p < 0.005). Post-operatively, 120 (54.5%) were without dysphagia, 59 (26.8%) had improved dysphagia, 26 (11.8%) had unchanged dysphagia, and 15 (6.8%) reported new dysphagia. There was no statistical difference in early or late dysphagia outcome between tailored fundoplication groups (p = 0.69). On univariate and multivariate analysis, neither MRS response, nor standard HRM metrics were significantly associated with post-operative dysphagia. Younger age (OR 0.96, 95% CI 0.94-0.986, p = 0.042) and the presence of pre-operative dysphagia (OR 2.54, 95% CI 1.17-5.65, p = 0.015) were significant predictors of post-operative dysphagia. CONCLUSION The risk of clinically significant dysphagia post-fundoplication is low when using a tailored approach based on standard HRM metrics. Additional data provided by MRS does not add to surgical decision-making using the investigated approach.
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Affiliation(s)
- Maggie M Hodges
- Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR, 97213, USA.
| | - Melissa L DeSouza
- Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR, 97213, USA
- Center for Advanced Surgery, The Oregon Clinic, Portland, OR, 97213, USA
| | - Kevin M Reavis
- Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR, 97213, USA
- Center for Advanced Surgery, The Oregon Clinic, Portland, OR, 97213, USA
| | - Daniel Davila Bradley
- Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR, 97213, USA
- Center for Advanced Surgery, The Oregon Clinic, Portland, OR, 97213, USA
| | - Christy M Dunst
- Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR, 97213, USA
- Center for Advanced Surgery, The Oregon Clinic, Portland, OR, 97213, USA
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11
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Garg R, Mohammed A, Singh A, Schleicher M, Thota PN, Rustagi T, Sanaka MR. Anti-reflux mucosectomy for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E854-E864. [PMID: 35692929 PMCID: PMC9187426 DOI: 10.1055/a-1802-0220] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/15/2021] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Anti-reflux mucosectomy (ARMS) is an emerging endoscopic treatment for refractory gastroesophageal reflux disease (GERD). We conducted a systematic review and meta-analysis to evaluate the safety and efficacy ARMS in refractory GERD. Methods A comprehensive search of multiple databases (through March 2020) was performed to identify studies that reported outcomes of ARMS for refractory GERD. Outcomes assessed included technical success, clinical response, and adverse events (AEs). Clinical response was defined as discontinuation (complete) or reduction (partial) of proton pump inhibitors post-ARMS at follow up. Results A total of 307 patients (mean age 46.9 [8.1] years, 41.5 % females) were included from 10 studies. The technical success and clinical response rates were 97.7 % (95 % confidence interval [CI], 94.6-99.0) and 80.1 % (95 % CI, 61.6-91.0), respectively. The pooled rate of complete and partial clinical response was 65.3 % (95 % CI, 51.4-77.0) and 21.5 % (95 % CI, 14.2-31.2), respectively. The rate of AEs was 17.2 % (95 % CI, 13.1-22.2) with most common AE being dysphagia/esophageal stricture followed by bleeding with rates of 11.4 % and 5.0 %, respectively. GERD health-related quality of life (GERD-HRQL) (mean difference [MD] = 14.9, P < 0.001), GERD questionnaire (GERD-Q) (MD = 4.85, P < 0.001) and mean acid exposure time (MD = 2.39, P = 0.01) decreased significantly post-ARMS as compared to pre-procedure. There was no difference in terms of clinical response and AEs between ARMS and ARMS with banding on subgroup analysis. Conclusions ARMS is a safe and effective procedure for treatment of refractory GERD with high rates of clinical response, acceptable safety profile and significant improvement in GERD-related quality of life. Prospective studies are needed to validate our findings.
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Affiliation(s)
- Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Abdul Mohammed
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, United States
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Mary Schleicher
- Cleveland Clinic Alumni library, Cleveland Clinic, Cleveland, Ohio, United States
| | - Prashanthi N. Thota
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
| | - Tarun Rustagi
- Department of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, United States
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12
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ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117:27-56. [PMID: 34807007 PMCID: PMC8754510 DOI: 10.14309/ajg.0000000000001538] [Citation(s) in RCA: 377] [Impact Index Per Article: 125.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 01/30/2023]
Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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13
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Zimmermann CJ, Lidor A. Endoscopic and Surgical Management of Gastroesophageal Reflux Disease. Gastroenterol Clin North Am 2021; 50:809-823. [PMID: 34717872 DOI: 10.1016/j.gtc.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Approximately, 10% to 15% of patients in the United States experience gastroesophageal reflux symptoms on a weekly basis, negatively affecting the quality of life and increasing the risk of reflux-related complications. For patients with symptoms recalcitrant to proton pump inhibitor (PPI) therapy or those who cannot take PPIs, surgical fundoplication is the gold standard. The preoperative workup is complex but vital for operative planning and ensuring good postoperative outcomes. Most patients are highly satisfied after fundoplication, though transient dysphagia, gas bloating, and resumption of PPI use are common postoperatively. Multiple newer technologies offer safe alternatives to fundoplication with similar outcomes.
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Affiliation(s)
- Christopher J Zimmermann
- Department of Surgery, University of Wisconsin- Madison, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-7375, USA
| | - Anne Lidor
- Department of Surgery, University of Wisconsin- Madison, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-7375, USA.
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14
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Howden CW, Manuel M, Taylor D, Jariwala-Parikh K, Tkacz J. Estimate of Refractory Reflux Disease in the United States: Economic Burden and Associated Clinical Characteristics. J Clin Gastroenterol 2021; 55:842-850. [PMID: 33780218 DOI: 10.1097/mcg.0000000000001518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/25/2021] [Indexed: 02/07/2023]
Abstract
GOALS To update the estimate of the prevalence of refractory gastroesophageal reflux disease (GERD) in the United States, and to assess the clinical and economic differences between patients with and without refractory GERD. BACKGROUND GERD affects 18% to 28% of the US population, with nearly 40% of GERD patients presenting with refractory symptoms despite ongoing therapy. STUDY Retrospective analysis of the IBM MarketScan databases between January 2011 and June 2018. Inclusion criteria were prescription fill and subsequent refill of a proton pump inhibitor or H2-receptor antagonist (earliest claim=index date), diagnosis of GERD 60 days preceding and/or following index, continuous insurance enrolment for 12 months preceding/following index, and absence of prior GERD diagnosis or GERD medication. We derived refractory GERD symptom scores for all patients on the basis of a previously published algorithm. Health care costs and comorbidities were assessed for all patients and compared between those with and without refractory GERD. RESULTS In total, 399,017 GERD patients qualified for the study; 103,654 (26%) met our definition of having indications of refractory GERD symptoms. Patients with refractory GERD symptoms reported significantly higher rates of hiatal hernia (25.1% vs. 5.9%), esophagitis (37.3% vs. 11.8%), esophageal stricture (11.3% vs. 1.5%), and dysphagia (26.8% vs. 7.1%; P<0.01 for each). The refractory GERD symptoms cohort incurred ~$10,000 greater health care costs per patient per year compared with patients without refractory GERD symptoms ($26,057±$58,948 vs. $15,285±$39,307; P<0.01). CONCLUSIONS Refractory GERD symptoms were associated with a substantial increase in health care costs. Treatments aimed at improving refractory GERD symptoms may mitigate symptom burden, potentially reducing health care expenditure.
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Affiliation(s)
- Colin W Howden
- College of Medicine, University of Tennessee, Memphis, TN
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15
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Mahmoud T, Jaruvongvanich V, Ghazi R, Abusaleh R, Abu Dayyeh BK. Complete endoscopic removal of an eroded magnetic sphincter augmentation device. VideoGIE 2021; 6:450-453. [PMID: 34660945 PMCID: PMC8503934 DOI: 10.1016/j.vgie.2021.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Rabih Ghazi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rami Abusaleh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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16
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Hoshino M, Omura N, Yano F, Tsuboi K, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Kashiwagi H. Therapeutic effect of laparoscopic fundoplication for GERD-related disease in the elderly. Gen Thorac Cardiovasc Surg 2021; 70:72-78. [PMID: 34561760 DOI: 10.1007/s11748-021-01713-2] [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: 07/26/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is anticipated that surgical treatment for gastro-esophageal reflux disease (GERD) in the elderly will increase. This time, using propensity score matching, we examined the results of laparoscopic fundoplication (LF) for GERD-related diseases in the elderly. METHODS Of 302 cases which underwent initial LF for GERD-related diseases during the period from June 2008 to February 2019, we classified them into elderly (65 years of age or older) and non-elderly groups (64 years of age or younger). 57 cases each were extracted upon performing propensity score matching regarding five factors including: gender; body mass index; esophageal hiatal hernia; extent of reflux esophagitis; and the use of mesh. RESULTS With regard to the preoperative disease status, the pH < 4 holding time was indicated as 2.8% (0.5-10.7%) in the elderly group and 3.4% (0.6-8.0%) in the non-elderly group, with no difference in terms of the illness period as well (p = 0.889 and p = 0.263, respectively). Although there was no difference in terms of the operative time (155 vs. 139 min, p = 0.092) and estimated blood loss (both ≒ 0 ml, p = 0.298), postoperative hospital stay was prolonged in the elderly group [7 (7-9) vs. 7 (7-7), p = 0.007]. On the other hand, esophageal hiatal hernia, reflux esophagitis, and acid reflux time in the esophagus were all improved following surgery in both groups (p < 0.001 in both groups). CONCLUSION The treatment results of LF for GERD-related diseases in the elderly were as good as those in the non-elderly, indicating possible safe implementation.
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Affiliation(s)
- Masato Hoshino
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Nobuo Omura
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
- Department of Surgery, National Hospital Organization, Nishisaitama-Chuo National Hospital, Saitama, Japan
| | - Fumiaki Yano
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kazuto Tsuboi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Se Ryung Yamamoto
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shunsuke Akimoto
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takahiro Masuda
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuki Sakashita
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Naoko Fukushima
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
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17
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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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18
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Yodice M, Mignucci A, Shah V, Ashley C, Tadros M. Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing. World J Gastroenterol 2021; 27:1751-1769. [PMID: 33967555 PMCID: PMC8072189 DOI: 10.3748/wjg.v27.i16.1751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/18/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.
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Affiliation(s)
- Michael Yodice
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Alexandra Mignucci
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Virali Shah
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Christopher Ashley
- Section of Gastroenterology, Stratton VA Medical Center, Albany, NY 12208, United States
| | - Micheal Tadros
- Department of Gastroenterology, Albany Medical Center, Schenectady, NY 12309, United States
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19
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Lang JE. Contribution of comorbidities to obesity-related asthma in children. Paediatr Respir Rev 2021; 37:22-29. [PMID: 32828671 DOI: 10.1016/j.prrv.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 01/21/2023]
Abstract
Children with obesity are at increased risk for developing asthma that is difficult to control. A complicating factor to asthma management among these children is likely the commonplace co-morbidities that also result from obesity. We discuss three common obesity-related comorbidities which appear to complicate the effective management of asthma, including hypovitaminosis D, obstructive sleep apnea and gastro-esophageal reflux. Each conditions requires more research to understand their effects on asthma management.
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Affiliation(s)
- J E Lang
- Duke University School of Medicine, Duke Clinical Research Institute, 301 West Morgan Street, Durham, NC 27701, USA.
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20
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Dumitru V, Hoara P, Dumitru D, Birla R, Gindea C, Constantinoiu S. Invasive Treatment Options for Gastro-Esophageal Reflux Disease. J Med Life 2021; 13:442-448. [PMID: 33456589 PMCID: PMC7803320 DOI: 10.25122/jml-2020-0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reflux disease continues to be one of the most common pathologies in the world. There is much discussion regarding the mechanism of developing and the variety of possible symptoms. In recent years, the use of new technologies, like high-resolution manometry and pH impedance, brought new insights into this disease. Also, there are emerging therapies that are covering the gap between the patients treated with proton-pump inhibitor (PPI) therapy and those who benefit the most from laparoscopic treatment (hiatal hernia, complications of gastroesophageal reflux disease (GERD). Also, most of them are less invasive than a laparoscopic fundoplication. We present a short review of the treatment options in patients who need more than lifestyle changes and PPI therapy.
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Affiliation(s)
- Vlad Dumitru
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,General and Esophageal Surgery Clinic, "Sf Maria" Clinical Hospital, Bucharest, Romania
| | - Petre Hoara
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,General and Esophageal Surgery Clinic, "Sf Maria" Clinical Hospital, Bucharest, Romania
| | - Daniela Dumitru
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,General and Esophageal Surgery Clinic, "Sf Maria" Clinical Hospital, Bucharest, Romania
| | - Rodica Birla
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,General and Esophageal Surgery Clinic, "Sf Maria" Clinical Hospital, Bucharest, Romania
| | - Cristina Gindea
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,General and Esophageal Surgery Clinic, "Sf Maria" Clinical Hospital, Bucharest, Romania
| | - Silviu Constantinoiu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,General and Esophageal Surgery Clinic, "Sf Maria" Clinical Hospital, Bucharest, Romania
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21
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Ravindran A, Iyer PG. Gastroesophageal Reflux Disease and Complications. GERIATRIC GASTROENTEROLOGY 2021:1161-1177. [DOI: 10.1007/978-3-030-30192-7_42] [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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22
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Laparoscopic Fundoplication Is Effective Treatment for Patients with Gastroesophageal Reflux and Absent Esophageal Contractility. J Gastrointest Surg 2021; 25:2192-2200. [PMID: 33904061 PMCID: PMC8484087 DOI: 10.1007/s11605-021-05006-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, particularly in individuals with an aperistaltic esophagus (absent esophageal contractility). This study determined the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility. METHODS A prospective database was used to identify all (40) patients with absent esophageal contractility who subsequently underwent fundoplication (36 anterior partial, 4 Nissen). Cases were propensity matched based on age, gender, and fundoplication type with another 708 patients who all had normal motility. Groups were assessed using prospective symptom assessment questionnaires to assess heartburn, dysphagia for solids and liquids, regurgitation, and satisfaction with surgery, and outcomes were compared. RESULTS Across follow-up to 10 years, no significant differences were found between the two groups for any of the assessed postoperative symptoms. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5- and 10-year follow-up. No differences in overall patient satisfaction were identified across the follow-up period. CONCLUSION Laparoscopic partial fundoplication in patients with absent esophageal contractility achieves acceptable symptom control without significantly worse dysphagia compared with patients with normal contractility. Patients with absent contractility should still be considered for surgery.
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Johnson MK, Venkatesh M, Liu N, Breuer CR, Shada AL, Greenberg JA, Lidor AO, Funk LM. pH Impedance Parameters Associated with Improvement in GERD Health-Related Quality of Life Following Anti-reflux Surgery. J Gastrointest Surg 2021; 25:28-35. [PMID: 33111260 PMCID: PMC7855403 DOI: 10.1007/s11605-020-04831-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/17/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery. METHODS Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome. RESULTS We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p = 0.01) and Toupet fundoplication (vs. Nissen; p = 0.03) were independently associated with greater improvement in GERD-HRQL. CONCLUSIONS Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.
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Affiliation(s)
- Morgan K Johnson
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Manasa Venkatesh
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Natalie Liu
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Catherine R Breuer
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Amber L Shada
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Jacob A Greenberg
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Anne O Lidor
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Luke M Funk
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.
- William S. Middleton Memorial VA Hospital, Madison, WI, USA.
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Weltz AS, Addo A, Broda A, Connors K, Zahiri HR, Park A. The impact of laparoscopic anti-reflux surgery on quality of life: do patients with atypical symptoms benefit? Surg Endosc 2020; 35:2515-2522. [PMID: 32468262 DOI: 10.1007/s00464-020-07665-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/20/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) may manifest atypically as cough, hoarseness or difficulty breathing. However, it is difficult to diagnostically establish a cause-and-effect between atypical symptoms and GERD. In addition, the benefit of laparoscopic anti-reflux surgery (LARS) in patients with laryngopharyngeal manifestations of GERD are not well characterized. We report the largest series reported to date assessing operative and quality of life (QOL) outcomes after LARS in patients experiencing extraesophageal manifestations of GERD and discuss recommendations for this patient population. METHODS A retrospective review of patients with extraesophageal symptoms and pathologic reflux that underwent LARS between February 2012 and July 2019 was conducted. Inclusion criteria consisted of patients with atypical manifestations of GERD as defined by preoperative survey in addition to physiological diagnosis of pathological reflux. Patient QOL outcomes was analyzed using four validated instruments: the Reflux Symptom Index (RSI), Laryngopharyngeal Reflux QOL, Swallowing QOL (SWAL), and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQOL) surveys. RESULTS 420 patients (24% male, 76% female) with a mean age of 61.7 ± 13.0 years and BMI of 28.6 ± 5.0 kg/m2 were included in this study. Thirty-day wound (0.2%) and non-wound (6.74%) related complication rates were recorded in addition to thirty-day readmission rate (2.6%). Patients reported significant improvements in laryngopharyngeal symptoms at mean follow-up of 18.9 ± 16.6 months post LARS reflected by results of four QOL instruments (RSI - 64%, LPR - 75%, GERD-HRQOL - 80%, SWAL + 18%). The majority of patients demonstrated complete resolution of symptoms upon subsequent encounters with 68% of patients reporting no atypical extraesophageal manifestations during follow-up survey (difficulty breathing - 86%, chronic cough - 81%, hoarseness - 66%, globus sensation - 68%) and 68% of patients no longer taking anti-reflux medication. Seventy-two percent of patients reported being satisfied with their symptom control at latest follow-up. CONCLUSIONS In appropriately selected candidates with atypical GERD symptomatology and objective diagnosis of GERD LARS may afford significant QOL improvements with minimal operative or long-term morbidity.
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Affiliation(s)
- Adam S Weltz
- Department of Surgery, Anne Arundel Medical Center, School of Medicine, Johns Hopkins University, 2000 Medical Parkway, Belcher Pavilion, Suite 106, Annapolis, MD, 21401, USA
| | - Alex Addo
- Department of Surgery, Anne Arundel Medical Center, School of Medicine, Johns Hopkins University, 2000 Medical Parkway, Belcher Pavilion, Suite 106, Annapolis, MD, 21401, USA
| | - Andrew Broda
- Department of Surgery, Anne Arundel Medical Center, School of Medicine, Johns Hopkins University, 2000 Medical Parkway, Belcher Pavilion, Suite 106, Annapolis, MD, 21401, USA
| | - Kevin Connors
- Department of Surgery, Anne Arundel Medical Center, School of Medicine, Johns Hopkins University, 2000 Medical Parkway, Belcher Pavilion, Suite 106, Annapolis, MD, 21401, USA
| | - H Reza Zahiri
- Department of Surgery, Anne Arundel Medical Center, School of Medicine, Johns Hopkins University, 2000 Medical Parkway, Belcher Pavilion, Suite 106, Annapolis, MD, 21401, USA
| | - Adrian Park
- Department of Surgery, Anne Arundel Medical Center, School of Medicine, Johns Hopkins University, 2000 Medical Parkway, Belcher Pavilion, Suite 106, Annapolis, MD, 21401, USA.
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Ayazi S, Zheng P, Zaidi AH, Chovanec K, Salvitti M, Newhams K, Hoppo T, Jobe BA. Clinical Outcomes and Predictors of Favorable Result after Laparoscopic Magnetic Sphincter Augmentation: Single-Institution Experience with More than 500 Patients. J Am Coll Surg 2020; 230:733-743. [DOI: 10.1016/j.jamcollsurg.2020.01.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 12/20/2022]
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Monino L, Gonzalez JM, Vitton V, Barthet M. Antireflux mucosectomy band in treatment of refractory gastroesophageal reflux disease: a pilot study for safety, feasibility and symptom control. Endosc Int Open 2020; 8:E147-E154. [PMID: 32010747 PMCID: PMC6976317 DOI: 10.1055/a-1038-4012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Antireflux mucosectomy band ligation (ARM-b) is an endoscopic procedure that mimics a fundoplication for managing gastroesophoageal reflux disease (GERD). The aim of this study was to assess safety and feasibility of ARM-b. Patients and methods This was a single-center study on consecutive patients operated between June 2017 and January 2019 with refractory GERD, confirmed with pH-metry and without motility disorder at high-resolution manometry. A piecemeal mucosectomy of three quarters of circumference of esophagogastric junction was performed using a band ligation system and a hexagonal snare. The primary objective was to assess procedural safety and feasibility. The secondary objective was to document the clinical improvement at 3 and 6 months based on patient satisfaction, proton pump inhibitor (PPI) intake, symptoms, and quality of life scores. Results Twenty-onepatients (11 men) with mean age 56.9 ± 14.4 years were analyzed. The technical success rate was 100 % (mean duration 35 ± 11 min). Four patients (19 %) had mild adverse events: one delayed bleeding at Day 1 managed conservatively, and three dysphagia endoscopically managed. Mean follow-up was 10 ± 5 months. Decrease/discontinuation of PPI intake was 76 % at 3 months and 72 % at 6 months. Improvement in mean symptoms and quality of life scores (GERD-Q and GERD-HQL) were statistically significant. One patient required laparoscopic fundoplication after ARM-b failure without complication. Conclusion ARM-b is safe, feasible, and symptom-effective for treating refractory GERD, and it can be performed in the ambulatory setting. Further prospective studies are required to confirm these promising outcomes.
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Affiliation(s)
- Laurent Monino
- Department of Hepatogastroenterology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium,Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France,Corresponding author Laurent Monino, MD Department of HepatogastroenterologyAP-HM, Aix-Marseille UniversitéHôpital NordChemin des Bourrely13015 MarseilleFrance+33-4-91968737
| | - Jean-Michel Gonzalez
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
| | - Véronique Vitton
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
| | - Marc Barthet
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
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Pauwels A, Boecxstaens V, Andrews CN, Attwood SE, Berrisford R, Bisschops R, Boeckxstaens GE, Bor S, Bredenoord AJ, Cicala M, Corsetti M, Fornari F, Gyawali CP, Hatlebakk J, Johnson SB, Lerut T, Lundell L, Mattioli S, Miwa H, Nafteux P, Omari T, Pandolfino J, Penagini R, Rice TW, Roelandt P, Rommel N, Savarino V, Sifrim D, Suzuki H, Tutuian R, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Tack J. How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery). Gut 2019; 68:1928-1941. [PMID: 31375601 DOI: 10.1136/gutjnl-2019-318260] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery. DESIGN We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous. RESULTS Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis. CONCLUSION With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.
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Affiliation(s)
- Ans Pauwels
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Veerle Boecxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Department of Surgical Oncology, Oncological and Vascular Access Surgery, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | | | | | - Richard Berrisford
- Peninsula Oesophago-gastric Surgery Unit, Derriford Hospital, Plymouth, Plymouth, UK
| | - Raf Bisschops
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Guy E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Serhat Bor
- Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Albert J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Michele Cicala
- Digestive Diseases, Universita Campus Bio Medico, Roma, Italy
| | - Maura Corsetti
- Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Fernando Fornari
- Programa de Pós-Graduação: Ciências em Gastroenterologia e Hepatologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jan Hatlebakk
- Gastroenterology, Haukeland Sykehus, University of Bergen, Bergen, Norway
| | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, USA
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lars Lundell
- Department of Surgery, Karolinska, Stockholm, Sweden
| | - Sandro Mattioli
- Department of Medical and Surgical Sciences, Universita degli Studi di Bologna, Bologna, Emilia-Romagna, Italy
| | - Hiroto Miwa
- Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Taher Omari
- Department of Gastroenterology, Flinders University, Adelaide, Australia
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Ospedale Maggiore Policlinico, Milano, Lombardia, Italy
| | - Thomas W Rice
- Thoracic Surgery, Emeritus Staff Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, USA
| | - Philip Roelandt
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Nathalie Rommel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Neurosciences, KU Leuven, Leuven, Belgium
| | - Vincenzo Savarino
- Internal Medicine and Medical Specialties, Universita di Genoa, Genoa, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Hidekazu Suzuki
- Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Radu Tutuian
- Gastroenteroloy, Tiefenauspital Bern, Bern, Switzerland
| | - Tim Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | | | - David I Watson
- Department of Surgery, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Jan Tack
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
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Laparoscopic antireflux surgery (LARS) is highly effective in the treatment of select patients with chronic cough. Surgery 2019; 166:34-40. [DOI: 10.1016/j.surg.2019.01.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/23/2019] [Accepted: 01/29/2019] [Indexed: 12/15/2022]
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Walle KV, Funk LM, Xu Y, Davies KD, Greenberg J, Shada A, Lidor A. Persistent Dysphagia Rate After Antireflux Surgery is Similar for Nissen Fundoplication and Partial Fundoplication. J Surg Res 2018; 235:52-57. [PMID: 30691837 DOI: 10.1016/j.jss.2018.09.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/06/2018] [Accepted: 09/11/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Laparoscopic fundoplication is the gold standard operation for treatment of gastroesophageal reflux disease (GERD). It has been suggested that persistent postoperative dysphagia is increased following Nissen fundoplication compared to partial fundoplication. This study aimed to determine risk factors for persistent postoperative dysphagia, specifically examining the type of fundoplication. METHODS Patients experiencing GERD symptoms who underwent laparoscopic Nissen, Toupet, or Dor fundoplication from 2009 to 2016 were identified from a single-institutional database. A dysphagia score was obtained as part of the GERD health-related quality of life questionnaire. Persistent dysphagia was defined as a difficulty swallowing score ≥1 (noticeable) on a scale from 0 to 5 at least 1 y postoperatively. Odds ratios of persistent dysphagia among those who underwent antireflux surgery were calculated in a multivariate logistic regression model adjusted for fundoplication type, sex, age, body mass index, and redo operation. RESULTS Of the 441 patients who met inclusion criteria, 255 had ≥1 y of follow-up (57.8%). The median duration of follow-up was 3 y. In this cohort, 45.1% of patients underwent Nissen fundoplication and 54.9% underwent partial fundoplication. Persistent postoperative dysphagia was present in 25.9% (n = 66) of patients. On adjusted analysis, there was no statistically significant association between the type of fundoplication (Nissen versus partial) and the likelihood of postoperative dysphagia. CONCLUSIONS Persistent postoperative dysphagia after antireflux surgery occurred in approximately one-quarter of patients and did not differ by the type of fundoplication. These findings suggest that both Nissen and partial fundoplication are reasonable choices for an antireflux operation for properly selected patients.
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Affiliation(s)
- Kara Vande Walle
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Luke M Funk
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin; Department of Surgery, William S. Middleton VA, Madison, Wisconsin
| | - Yiwei Xu
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Kevin D Davies
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Jacob Greenberg
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Amber Shada
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Anne Lidor
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin.
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Sidwa F, Moore AL, Alligood E, Fisichella PM. Surgical Treatment of Extraesophageal Manifestations of Gastroesophageal Reflux Disease. World J Surg 2018; 41:2566-2571. [PMID: 28508234 DOI: 10.1007/s00268-017-4058-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review the current literature on the role of antireflux surgery (ARS) for the treatment of extraesophageal manifestations of GERD. The extraesophageal manifestations of gastroesophageal reflux disease (GERD) include chronic cough, laryngopharyngeal reflux, and asthma. They are responsible for significant morbidity in affected patients and a high economic burden on healthcare resources. We recently published a larger review on the symptoms, diagnosis, medical, and surgical treatment of the extraesophageal manifestations of GERD. Through our investigation, we found that the role of ARS for respiratory symptoms was unclear. Hence, we resorted through the data of our previous meta-analysis to compile a comprehensive and focused review on the role of ARS for respiratory symptoms. METHODS Using the archive of our previous meta-analysis, we selected studies extracted from the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases pertaining to the surgical treatment of extraesophageal manifestations of reflux (cough laryngopharyngeal reflux, and asthma). We applied a similar reporting methodology as was used in our previous manuscript and then hand searched the bibliographies of included studies yielding a total of 27 articles for review. We graded the level of evidence and classified recommendations by size of treatment effect per the American Heart Association Task Force on Practice Guidelines. RESULTS Observational data indicated that syndromes of chronic cough, laryngopharyngeal reflux and asthma might improve after antireflux surgery only in highly selected patients-likely those with non-acid reflux-while those patients with objective markers of asthma severity do not. Because of the varied methods of diagnosis and surgical technique, non-comparative observational data may be unreliable. Additionally, our search found no randomized controlled trials (RCTs) comparing antireflux surgery to medical therapy in the treatment of cough or laryngopharyngeal reflux. One RCT compared medical treatment to antireflux surgery in patients with asthma, but medical treatment included high-dose H2 blockers instead of PPIs. CONCLUSIONS Extraesophageal manifestations of GERD are common, costly, and difficult to treat. ARS might be effective in highly selected patients, especially in those whose extraesophageal manifestations are caused by non-acid reflux. The available data to date are generally of poor quality or outdated. Well-designed randomized controlled trials or large-scale observational cohort studies are urgently needed.
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Affiliation(s)
- Feroze Sidwa
- Brigham and Women's Hospital, Boston VA Healthcare System, Harvard Medical School, West Roxbury, Boston, MA, 02132, USA
| | - Alessandra L Moore
- Brigham and Women's Hospital, Boston VA Healthcare System, Harvard Medical School, West Roxbury, Boston, MA, 02132, USA
| | - Elaine Alligood
- Brigham and Women's Hospital, Boston VA Healthcare System, Harvard Medical School, West Roxbury, Boston, MA, 02132, USA
| | - P Marco Fisichella
- Brigham and Women's Hospital, Boston VA Healthcare System, Harvard Medical School, West Roxbury, Boston, MA, 02132, USA.
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Shapiro M, Lee BE, Rutledge JR, Korst RJ. The Use of Standardized Measures to Predict and Assess Quality of Life after Laparoscopic Hiatal Hernia Repair. Am Surg 2018. [DOI: 10.1177/000313481808400620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The literature regarding laparoscopic hiatal hernia repair is difficult to interpret because of inconsistencies in describing hernia characteristics and outcome measures. This study was performed to evaluate risk factors for an unsatisfactory outcome after repair using objective definitions of hernia size and a clinically relevant outcome instrument. A retrospective review of a prospectively maintained database was conducted over a seven-year period. Data collected included patient demographics and hernia-related variables. Outcomes were defined using a validated quality of life (QOL) instrument. Postoperatively, the mean total QOL score decreased from 22.9 to 5.8 (P < 0.001). In all, 13.8 per cent of patients had unsatisfactory QOL scores postoperatively. Multivariate analysis showed that high gastroesophageal (GE) junction position (P = 0.03) and female gender (P = 0.02) were the only significant factors associated with an unsatisfactory postoperative QOL. Laparoscopic hiatal hernia repair significantly improves QOL. With respect to predicting clinically relevant outcomes, hernias are best characterized by the position of the GE junction. Females with high GE junction position are at the highest risk for an unsatisfactory outcome.
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Affiliation(s)
- Mark Shapiro
- The Daniel and Gloria Blumenthal Cancer Center, Paramus, New Jersey
- Division of Thoracic Surgery, Department of Surgery, The Valley Hospital/Valley Health System, Ridgewood, New Jersey
| | - Benjamin E. Lee
- The Daniel and Gloria Blumenthal Cancer Center, Paramus, New Jersey
- Division of Thoracic Surgery, Department of Surgery, The Valley Hospital/Valley Health System, Ridgewood, New Jersey
| | - John R. Rutledge
- The Daniel and Gloria Blumenthal Cancer Center, Paramus, New Jersey
| | - Robert J. Korst
- The Daniel and Gloria Blumenthal Cancer Center, Paramus, New Jersey
- Division of Thoracic Surgery, Department of Surgery, The Valley Hospital/Valley Health System, Ridgewood, New Jersey
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Abstract
Gastroesophageal reflux disease (GERD) is a gastrointestinal motility disorder that results from the reflux of stomach contents into the esophagus or oral cavity resulting in symptoms or complications. The typical symptoms of GERD are heartburn and regurgitation of gastric contents into the oropharynx. GERD affects quality of life and may cause erosive esophagitis, esophageal strictures, and Barrett esophagus, a precursor to esophageal adenocarcinoma. GERD is a clinical diagnosis and is most effectively treated with proton-pump inhibitors (PPIs). Long-term use of PPIs is associated with bone fractures, chronic renal disease, acute renal disease, community-acquired pneumonia, and Clostridium difficile intestinal infection.
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Affiliation(s)
- Rick Kellerman
- Department of Family and Community Medicine, University of Kansas School of Medicine Wichita, 1010 North Kansas, Wichita, KS 67214, USA.
| | - Thomas Kintanar
- Department of family medicine, Lutheran Health Services, 10020 Dupont Circle Court, Suite 110, Fort Wayne, IN 46825, USA; Department of family medicine, Indiana University School of Medicine, 1110 West Michigan Street, Long Hall Suite 200, Indianapolis, IN 46202, USA
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Pandit S, Boktor M, Alexander JS, Becker F, Morris J. Gastroesophageal reflux disease: A clinical overview for primary care physicians. ACTA ACUST UNITED AC 2017; 25:1-11. [PMID: 28943113 DOI: 10.1016/j.pathophys.2017.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/26/2017] [Accepted: 09/07/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE GERD is among the most common outpatient disease processes encountered by clinicians on a daily basis. This review provides insights about how to approach GERD in terms of disease management and treatment. METHODS Review articles were searched using PUBMED and MEDLINE using criteria that included English language articles published in the last 5 years concerning studies carried out only in humans. The key words used in the searches were GERD, PPI, and erosive esophagitis. Recommendations from the American College of Gastroenterology are also included in this manuscript. RESULTS The search resulted in ∼260 articles. The manuscript brings together and presents the results of recent recommendations from professional societies and recently published review articles on GERD. CONCLUSION GERD is one of the most common diagnoses made by gastroenterologists and primary care physicians. It is important to recognize the typical and atypical presentations of GERD. This paper helps primary care physicians understand the disease's pathophysiology, and when, how, and with what to treat GERD before referring patients to gastroenterologists or surgeons.
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Affiliation(s)
- Sudha Pandit
- Department of Medicine, Section of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, School of Medicine, Shreveport, LA, United States
| | - Moheb Boktor
- Department of Medicine, Section of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, School of Medicine, Shreveport, LA, United States
| | - Jonathan S Alexander
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, School of Medicine, Shreveport, LA,United States
| | - Felix Becker
- Department for General and Visceral Surgery, University Hospital Muenster, Germany
| | - James Morris
- Department of Medicine, Section of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, School of Medicine, Shreveport, LA, United States.
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Diagnosis and Treatment of the Extraesophageal Manifestations of Gastroesophageal Reflux Disease. Ann Surg 2017; 265:63-67. [PMID: 27455157 DOI: 10.1097/sla.0000000000001907] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To review the clinical presentation, diagnosis, and treatment options available for management of extraesophageal manifestations of gastroesophageal reflux disease (GERD) and to compare the most recent technological advances to the existing guidelines. SUMMARY BACKGROUND DATA Extraesophageal manifestations of GERD include cough, laryngopharyngeal reflux (LPR), and asthma. Recent advances in diagnostic modalities may have outpaced the existing diagnostic and therapeutic clinical guidelines. METHODS We searched the MEDLINE, Cochrane, and Embase databases for articles pertaining to the presentation, diagnosis, and treatment of extraesophageal manifestations of reflux, specifically cough due to reflux, LPR, and asthma due to reflux. Search terms applied to 3 thematic topics: diagnosis, medical treatment, and surgical treatment. We had searched the bibliographies of included studies, yielding a total of 271 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines. RESULTS One hundred twenty-eight articles met criteria for analysis. Our findings show that the diagnosis of cough, LPR, or asthma due to gastroesophageal reflux is difficult, as no criterion standard test exits. Also, patients often present without heartburn or regurgitation typical of GERD. Combined multichannel intraluminal impedance, the pH (MII-pH) monitoring system, and the symptom association probability (SAP) test might distinguish extraesophageal manifestations of reflux from idiopathic chronic cough, laryngitis due to other causes, and atopic asthma. In addition, extraesophageal manifestations of reflux are most effectively diagnosed with a stepwise approach incorporating empiric treatment and antisecretory therapy, combined MII-pH monitoring, and surgical intervention in few selected cases. CONCLUSIONS Recent studies demonstrate the potential diagnostic role of MII-pH monitoring. Surgical intervention provides resolution of extraesophageal symptoms less reliably than typical symptoms when the patient has GERD.
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Schneider AM, Aye RW, Wilshire CL, Farivar AS, Louie BE. Tri-comparison of Laparoscopic Nissen, Hill, and Nissen-Hill Hybrid Repairs for Uncomplicated Gastroesophageal Reflux Disease. J Gastrointest Surg 2017; 21:434-440. [PMID: 27813017 DOI: 10.1007/s11605-016-3317-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/26/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND A randomized controlled trial (RCT) showed that laparoscopic Nissen fundoplication (LNF) and Hill (LHR) repairs are equivalent in treating uncomplicated GERD. We combined both repairs to create a laparoscopic Nissen-Hill Hybrid repair (HYB). The purpose of this study is to compare clinical and objective outcomes of a matched group of HYB to the two cohorts of the RCT. METHODS A retrospective analysis of prospectively collected data from the RCT and a prospectively collected data base was performed. Data were collected preoperatively, postoperatively short-term (ST) at 6 weeks and mid-term (MT) at 6-12 months. Evaluation was standardized according to the RCT and included three quality of life metrics (QOLRAD, GERD-HRQL, Dysphagia), endoscopy, manometry, pH testing, and barium swallow. RESULTS There were 51 HYB, 46 LNF, and 56 LHR patients. Age, BMI, follow-up, and gender were comparable. QOLRAD, HRQL, PPI use, DeMeester scores, and pH% time <4 significantly improved in all groups and were equivalent. Anatomic recurrence was seen in five LNF, four LHR, and two HYB patients. Reoperations were performed in three LHR, two LNF, and zero HYB patients. CONCLUSION Tri-comparison shows that HYB is a promising alternative to LHR and LNF. Side effects were not increased and there were fewer reoperations for failure.
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Affiliation(s)
- Andreas M Schneider
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison St. Suite 900, Seattle, WA, 98104, USA
| | - Ralph W Aye
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison St. Suite 900, Seattle, WA, 98104, USA.
| | - Candice L Wilshire
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison St. Suite 900, Seattle, WA, 98104, USA
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison St. Suite 900, Seattle, WA, 98104, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison St. Suite 900, Seattle, WA, 98104, USA
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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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Yan C, Liang WT, Wang ZG, Hu ZW, Wu JM, Zhang C, Chen MP. Comparison of Stretta procedure and toupet fundoplication for gastroesophageal reflux disease-related extra-esophageal symptoms. World J Gastroenterol 2015; 21:12882-12887. [PMID: 26668513 PMCID: PMC4671044 DOI: 10.3748/wjg.v21.i45.12882] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 08/09/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes between the Stretta procedure and laparoscopic toupet fundoplication (LTF) in patients with gastroesophageal reflux disease (GERD)-related extra-esophageal symptoms.
METHODS: From January 2011 to February 2012, a total of 98 patients diagnosed with GERD-related extra-esophageal symptoms who met the inclusion criteria were enrolled in this study. All patients who either underwent the Stretta procedure or LTF treatment have now completed the 3-year follow-up. Primary outcome measures, including frequency and severity of extra-esophageal symptoms, proton pump inhibitor (PPI) use, satisfaction, and postoperative complications, were assessed. The results of the Stretta procedure and LTF therapy were analyzed and compared.
RESULTS: There were 47 patients in the Stretta group and 51 patients in the LTF group. Ninety patients were available at the 3-year follow-up. The total of the frequency and severity scores for every symptom improved in both groups (P < 0.05). Improvement in symptom scores of cough, sputum, and wheezing did not achieve statistical significance between the two groups (P > 0.05). However, the score for globus hysterics was different between the Stretta group and the LTF group (4.9 ± 2.24 vs 3.2 ± 2.63, P < 0.05). After the Stretta procedure and LTF treatment, 29 and 33 patients in each group achieved PPI therapy independence (61.7% vs 64.7%, P = 0.835). The patients in the LTF group were more satisfied with their quality of life than those in the Stretta procedure group (P < 0.05). Most complications resolved without intervention within two weeks; however, two patients in the LTF group still suffered from severe dysphagia 2 wk after the operation, and it improved after bougie dilation treatment in both patients.
CONCLUSION: The Stretta procedure and LTF were both safe and effective for the control of GERD-related extra-esophageal symptoms and the reduction of PPI use.
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El Khoury R, Ramirez M, Hungness ES, Soper NJ, Patti MG. Symptom Relief After Laparoscopic Paraesophageal Hernia Repair Without Mesh. J Gastrointest Surg 2015; 19:1938-42. [PMID: 26242885 DOI: 10.1007/s11605-015-2904-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic repair of paraesophageal hernia (LPEHR) is considered today the standard of care for this condition. While attention has been mostly focused on the incidence of postoperative radiologic recurrence of a hiatal hernia, few data are available about the effect of the operation on symptoms. AIMS In this study, we aim to determine the effect of primary LPEHR on postoperative symptoms. PATIENTS AND METHODS One hundred and sixty-two patients underwent LPEH repair in two academic tertiary care centers. Preoperative evaluation included barium swallow (100 %), endoscopy (80 %), manometry (81 %), and pH monitoring (25 %). Type III PEH was the most common (94 %), and it was associated with a gastric volvulus in 27 % of patients. RESULTS A fundoplication was performed in all patients: Nissen in 57 %, Dor in 36 %, and Toupet in 6 %. A Collis gastroplasty was added in 6 % of patients. There were no perioperative deaths. The intraoperative complication rate was 7 %. The operation was completed laparoscopically in 98 % of patients. Postoperative complications occurred in four patients, and three needed a second operation. Average follow-up was 24 months. Heartburn, regurgitation, chest pain, dysphagia, respiratory symptoms, and hoarseness improved as a result of the operation. Anemia fully resolved in all patients. CONCLUSIONS LPEH repair is safe and effective, and the need for reoperation is rare. Few patients experience postoperative symptoms, and these are easily controlled with acid-reducing medications.
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Northwestern University, 676 North Saint Clair, Suite 650, Chicago, IL, 60611, USA.
| | | | - Eric S Hungness
- Department of Surgery, Northwestern University, 676 North Saint Clair, Suite 650, Chicago, IL, 60611, USA
| | - Nathaniel J Soper
- Department of Surgery, Northwestern University, 676 North Saint Clair, Suite 650, Chicago, IL, 60611, USA
| | - Marco G Patti
- Department of Surgery, University of Chicago, Chicago, IL, USA
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Routine versus selective contrast imaging to identify the need for early re-intervention following laparoscopic fundoplication: A retrospective cohort study. Int J Surg 2015; 20:123-7. [PMID: 26118598 DOI: 10.1016/j.ijsu.2015.06.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 06/10/2015] [Accepted: 06/18/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND The prompt recognition of complications is essential in reducing morbidity following anti-reflux surgery. Consequently, many centres employ a policy of routine post-operative contrast studies. The study aimed to examine whether routine contrast studies more effectively recognised early post-operative complications following anti-reflux surgery compared with selective use. METHODS This was a retrospective analysis of 240 adults who had undergone primary anti-reflux surgery. Selective use of water-soluble contrast swallows was employed for 115 patients (Group 1) while 125 patients (Group 2) had routine studies. RESULTS 10 (0.9%) patients from Group 1 underwent contrast studies, four (40%) of which were abnormal. Routine studies in Group 2 identified thirty-two abnormalities (27%) however the inter-group difference was not significant (p = 0.32). Only one case from group 2 required immediate re-intervention. This was not statistically significant (p = 0.78). Multivariate analysis found no significant association between selective or routine imaging and re-intervention rates. One patient from group 2 presented three days following discharge with wrap migration requiring reoperation despite a normal post-operative study. CONCLUSION Routine use of contrast imaging following anti-reflux and hiatus hernia surgery is not necessary. It does not identify a significantly greater number of post-operative complications in comparison to selective use. Additionally, routine use of contrast studies does not ensure the diagnosis of all complications in the post-operative period.
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Feasibility, safety, and short-term efficacy of the laparoscopic Nissen-Hill hybrid repair. Surg Endosc 2015; 30:551-558. [PMID: 26065538 DOI: 10.1007/s00464-015-4238-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND A novel antireflux procedure combining laparoscopic Nissen fundoplication and Hill repair components was tested in 50 patients with paraesophageal hernia (PEH) and/or Barrett's esophagus (BE) because these two groups have been found to have a high rate of recurrence with conventional repairs. METHODS Patients with symptomatic PEH and/or non-dysplastic BE underwent repair. Quality of life (QOL) metrics, manometry, EGD, and pH testing were administered pre- and postoperatively. RESULTS Fifty patients underwent repair. There was no mortality and four major complications. At 13-month follow-up, there was one (2%) clinical recurrence, and two (4%) asymptomatic fundus herniations. Mean DeMeester scores improved from 57.2 to 7.7 (p < 0.0001). Control of preoperative symptoms was achieved in 90% with 6% resumption of antisecretory medication. All QOL metrics improved significantly. CONCLUSIONS The hybrid Nissen-Hill repair for patients with PEH and BE appears safe and clinically effective at short-term follow-up. It is hoped that the combined structural components may reduce the rate of recurrence compared to existing repairs.
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Parekh PJ, Johnson DA. Medical treatment versus surgery for treatment of gastroesophageal reflux disease. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ciorba A, Bianchini C, Zuolo M, Feo CV. Upper aerodigestive tract disorders and gastro-oesophageal reflux disease. World J Clin Cases 2015; 3:102-11. [PMID: 25685756 PMCID: PMC4317603 DOI: 10.12998/wjcc.v3.i2.102] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 09/20/2014] [Accepted: 10/28/2014] [Indexed: 02/05/2023] Open
Abstract
A wide variety of symptoms and diseases of the upper aerodigestive tract are associated to gastro-oesophageal reflux disease (GORD). These disorders comprise a large variety of conditions such as asthma, chronic otitis media and sinusitis, chronic cough, and laryngeal disorders including paroxysmal laryngospasm. Laryngo-pharyngeal reflux disease is an extraoesophageal variant of GORD that can affect the larynx and pharynx. Despite numerous research efforts, the diagnosis of laryngopharyngeal reflux often remains elusive, unproven and controversial, and its treatment is then still empiric. Aim of this paper is to review the current literature on upper aerodigestive tract disorders in relation to pathologic gastro-oesophageal reflux, focusing in particular on the pathophysiology base and results of the surgical treatment of GORD.
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Luna RA, Bronson NW, Hunter JG. Indications for Antireflux Surgery. ANTIREFLUX SURGERY 2015:45-51. [DOI: 10.1007/978-1-4939-1749-5_5] [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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Lin DC, Chun CL, Triadafilopoulos G. Evaluation and management of patients with symptoms after anti-reflux surgery. Dis Esophagus 2015; 28:1-10. [PMID: 23826861 DOI: 10.1111/dote.12103] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the past two decades, there has been an increase in the number of anti-reflux operations being performed. This is mostly due to the use of laparoscopic techniques, the increasing prevalence of gastroesophageal reflux disease (GERD) in the population, and the increasing unwillingness of patients to take acid suppressive medications for life. Laparoscopic fundoplication is now widely available in both academic and community hospitals, has a limited length of stay and postoperative recovery time, and is associated with excellent outcomes in carefully selected patients. Although the operation has low mortality and postoperative morbidity, it is associated with late postoperative complications, such as gas bloat syndrome, dysphagia, diarrhea, and recurrent GERD symptoms. This review summarizes the diagnostic evaluation and appropriate management of such postoperative complications. If a reoperation is needed, it should be performed by experienced foregut surgeons.
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Affiliation(s)
- D C Lin
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Bell RCW, Barnes WE, Carter BJ, Sewell RW, Mavrelis PG, Ihde GM, Hoddinott KM, Fox MA, Freeman KD, Gunsberger T, Hausmann MG, Dargis D, Gill BD, Wilson E, Trad KS. Transoral Incisionless Fundoplication: 2-year Results from the Prospective Multicenter U.S. Study. Am Surg 2014. [DOI: 10.1177/000313481408001124] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this study was to assess prospectively 2-year outcomes of transoral incisionless fundoplication (TIF) in a multicenter setting. A 14-center U.S. registry was designed to evaluate the effects of the TIF 2.0 procedure on chronic gastroesophageal reflux disease (GERD) in over 100 patients. Primary outcome was symptom assessment. Secondary outcomes were proton pump inhibitor (PPI) use, degree of esophagitis, safety, and changes in esophageal acid exposure. One hundred twenty-seven patients underwent TIF between January 2010 and April 2011, 19 (15%) of whom were lost to follow-up. Eight patients undergoing revisional surgery were included, as failures, in the 108 remaining patients. No serious adverse events were reported. GERD Health-related Quality of Life and regurgitation scores improved by 50 per cent or greater in 63 of 96 (66%) and 62 of 88 (70%) patients who had elevated preoperative scores. The Reflux Symptom Index score normalized in 53 of 82 (65%) patients. Daily PPI use decreased from 91 to 29 per cent. In patients amenable to postoperative testing, esophagitis healed in 12 of 16 (75%) and esophageal acid exposure normalized in eight of 14 (57%). TIF safely achieved sustained symptomatic control over a 2-year period in two-thirds of patients with a virtual absence of de novo side effects.
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Affiliation(s)
| | - William E Barnes
- Livingston Hospital and Healthcare Services, Inc. CAH, Salem, Kentucky
| | | | | | | | | | | | - Mark A. Fox
- Crossville Medical Group, PA, Crossville, Tennessee
| | | | | | | | | | | | - Erik Wilson
- University of Texas Health Science Center, Houston, Texas
| | - Karim S. Trad
- The George Washington University School of Medicine and Health Sciences, Washington, DC; and
- Reston Surgical Associates, Reston, Virginia
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Freys SM, Heimbucher J. [Reflux and hiatus hernia in the controversy between conservative and operative therapy]. Chirurg 2014; 85:1046-54. [PMID: 25323490 DOI: 10.1007/s00104-014-2804-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Approximately 20 % of the population are affected by gastroesophageal reflux disease (GERD). The subjective clinical and objective pathological extent of the disease is highly variable and the underlying pathophysiological mechanisms extraordinarily diverse. The importance of hiatus hernia for GERD has been intensively debated for decades. Hiatus hernia was initially considered to be at the center of the pathophysiology but later the function of the lower esophageal sphincter was increasingly considered to be of importance. Currently, additional relevant pathophysiological cofactors are being detected with the continuous improvement in diagnostic methods and used for therapeutic decision-making. Despite standardization of the operative technique and increasing criticism on long-term proton pump inhibitor (PPI) therapy, antireflux surgery still requires a very critical assessment of indications based on a comprehensive diagnostic evaluation.
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Affiliation(s)
- S M Freys
- Chirurgische Klinik, Interdisziplinäres Bauchzentrum, Darmkrebszentrum Bremen West, DIAKO Ev. Diakonie-Krankenhaus gGmbH, Gröpelinger Heerstr. 406-408, 28239, Bremen, Deutschland,
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Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther 2014; 5:105-112. [PMID: 25133039 PMCID: PMC4133436 DOI: 10.4292/wjgpt.v5.i3.105] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 02/21/2014] [Accepted: 06/20/2014] [Indexed: 02/07/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common disease with a prevalence as high as 10%-20% in the western world. The disease can manifest in various symptoms which can be grouped into typical, atypical and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of alarm symptoms, these symptoms can allow one to make a presumptive diagnosis and initiate empiric therapy. In certain situations, further diagnostic testing is needed to confirm the diagnosis as well as to assess for complications or alternate causes for the symptoms. GERD complications include erosive esophagitis, peptic stricture, Barrett’s esophagus, esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modification, medical therapy and surgical therapy. Lifestyle modifications including weight loss and/or head of bed elevation have been shown to improve esophageal pH and/or GERD symptoms. Medical therapy involves acid suppression which can be achieved with antacids, histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy, others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The purpose of this review is to discuss the current approach to the diagnosis and treatment of gastroesophageal reflux disease.
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Durability of Stretta Radiofrequency Treatment for GERD: Results of an 8-Year Follow-Up. Gastroenterol Res Pract 2014; 2014:531907. [PMID: 24959175 PMCID: PMC4052191 DOI: 10.1155/2014/531907] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 04/15/2014] [Accepted: 04/29/2014] [Indexed: 02/07/2023] Open
Abstract
From June 2002 to March 2013 26 patients that underwent Stretta procedure (16 females, 10 males) reached to date an eight-year follow-up. Primary end point of the study was to verify the durability of the procedure at this time. All patients underwent clinical evaluation by upper endoscopy, oesophageal pressure, and pH studies. For each patient 8-year data were compared to those recorded at baseline and at 4 years. There was a significant decrease in both heartburn and GERD HRQL scores at 4 years (P = 0.001) and at 8 years (P = 0.003) as well as a significant increase of QoL scores at each control time (mental SF-36 and physical SF-36, P = 0.001). After 4 and 8 years, 21 patients (80.7%, P = 0.0001) and 20 patients (76.9%, P = 0.0001) were completely off PPIs. Median LES pressure did not show significant amelioration at 4 and 8 years and mean oesophageal acid exposure significantly improved at 4 years (P = 0.001) but returned to baseline values after 8 years. This further follow-up study of ours from four to eight years confirms that RF energy delivery for GERD provides durable improvement in symptoms and in quality of life and reduces antireflux drugs consumption.
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Simorov A, Ranade A, Jones R, Tadaki C, Shostrom V, Boilesen E, Oleynikov D. Long-term patient outcomes after laparoscopic anti-reflux procedures. J Gastrointest Surg 2014; 18:157-62; discussion 162-3. [PMID: 24234243 DOI: 10.1007/s11605-013-2401-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 10/22/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic anti-reflux surgery with or without large hiatal hernia has been shown to have good short-term outcomes. However, limited data are available on long-term outcomes of greater than 5 years. The aim of this study is to review functional and symptomatic outcomes of anit-reflux surgery in a large tertiary referral medical center. METHODS Two hundred ninety-seven patients who underwent anti-reflux surgery at the University of Nebraska Medical Center between 2002 and 2013 were included in this study. Patient data including pre- and post-operative studies and symptom questionnaires were prospectively collected and the database was used to analyze postoperative outcomes. RESULTS A total of 297 Nissen fundoplications, 35 redo fundoplications and 22 Toupet procedures were performed. Mean BMI was 30.0 ± 6.2. The median follow-up was 70 (6-135) months. There were three reoperations (0.9 %) for recurrent symptoms. Mesh was used in 210 cases where hiatal hernia was larger than 2 cm. Median preoperative DeMeester score was 50.8 ± 46. There was a statistically significant improvement in composite heartburn score (83 % (CI 78.2, 87.7); p < 0.05), regurgitation (81.1 % (CI 76.1, 86.1); p < 0.05), and belching (63 % (CI 56.7, 69.3); p < 0.05). Atypical presentation such as pulmonary (e.g., aspiration (25.8 % (CI 20, 31.6), wheezing (20.3 % (CI 15, 25.6); p < 0.05), and throat symptoms (e.g., laryngitis 28 % (CI 22.1, 33.9); p < 0.05) also improved. Available radiographic studies for patients more than 3 years follow-up show an overall recurrence of 33.9 % (47.8 % in hiatal hernia > 5 cm repaired with mesh). Of those with recurrence, over 84 % were asymptomatic at follow-up. CONCLUSIONS This study shows that patients had excellent symptom control and low rates of complications and reoperations in long-term follow-up. We found that typical gastro intestinal symptoms responded better compared with atypical symptoms in spite of clear evidence of reflux on preoperative studies. Hiatal hernia was very commonly seen in our patient population and long-term radiographic follow-up suggest that asymptomatic recurrence may be high but rarely requires any surgical intervention. Anti-reflux surgery with correction of hiatal hernia if present is safe and effective in long-term follow-up.
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Franciosa M, Triadafilopoulos G, Mashimo H. Stretta Radiofrequency Treatment for GERD: A Safe and Effective Modality. Gastroenterol Res Pract 2013; 2013:783815. [PMID: 24078808 PMCID: PMC3775401 DOI: 10.1155/2013/783815] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 06/17/2013] [Accepted: 07/03/2013] [Indexed: 12/28/2022] Open
Abstract
Gastroesophageal reflux disease is one of the leading gastrointestinal disorders. Current treatments include lifestyle modifications, pharmacological therapies, surgical fundoplications, and, more recently, endoscopic procedures. The rising concern of long-term side effects of the popular proton-pump inhibitors and the more recent evidence raising doubts about the durability of fundoplication have spurred reinterest in endoscopic procedures to treat reflux disorders. In the aftermath of several innovative antireflux procedures that were introduced and failed clinically or financially over the past decade, there is lingering confusion regarding the merits of the presently available interventions. This paper focuses on one endoscopic procedure, Stretta, which now enjoys the longest experience, a recent meta-analysis, and robust data supporting its safety, efficacy, and durability. Stretta reduces esophageal acid exposure, decreases the frequency of transient lower esophageal relaxation, increases patient satisfaction, decreases medication use, and improves quality of life. As such, this procedure remains a valuable nonsurgical treatment option in the management of gastroesophageal reflux disease.
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Affiliation(s)
- Mark Franciosa
- Center for Swallowing and Motility Disorders, VA Boston Healthcare System, Harvard Medical School, Boston, MA 02132, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94040, USA
| | - Hiroshi Mashimo
- Center for Swallowing and Motility Disorders, VA Boston Healthcare System, Harvard Medical School, Boston, MA 02132, USA
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