This study aims to compare pHmetric characteristics of diurnal and nocturnal supine reflux. We studied 500 consecutive individuals with clinical suspicion of gastroesophageal reflux disease (GERD) who underwent esophageal high-resolution manometry and prolonged ambulatory pH monitoring. Patients were classified with supine GERD pattern when the percentage of acid reflux time in the supine position was equal to or greater than 2.2%. Data on acid reflux in the supine position during daytime and nighttime recumbency were: (i) acid exposure time, (ii) number of reflux episodes, (iii) longest reflux episode, (iv) interval between the last meal and the supine position, (v) interval between the supine position and the first acid reflux episode, and (vi) reported symptoms. Of the 500 evaluated patients, 238 (48%) had GERD. Among these, supine pattern was observed in 134 (56%) patients, bipositional in 53 (23%), and orthostatic in 51 (21%). In patients with daytime recumbency, 112 (51% of 217) were pathological refluxers, with a mean DeMeester score of 45 ± 26. Total acid exposure time (P = 0.8) and reported Symptom Index (P = 0.2) did not differ depending on the period, whether diurnal or nocturnal. All other pHmetric parameters were lower during daytime recumbency. In conclusion, diurnal supine reflux has similar acid exposure time and temporal correlation between symptoms and reflux episodes as nocturnal supine reflux. Other pHmetric parameters are lower for diurnal supine reflux.

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.

Gastroesophageal reflux disease affects almost 20% of the population in the United States. Today, proton pump inhibitors are the most frequently prescribed drugs, with an estimated cost of 10 billion dollars per year. Although these medications control heartburn in the majority of patients, other symptoms such as regurgitation and respiratory symptoms often are not controlled, particularly in patients with large hiatal hernias. In these patients a properly performed laparoscopic fundoplication controls esophageal and extraesophageal symptoms and avoids life-long medical therapy. Key elements for the success of a fundoplication are careful patient selection, a complete preoperative evaluation, and a properly executed operation.

Patients with gastroesophageal reflux referred for fundoplication present with different symptom patterns. Previous studies have not analyzed the clinical outcome after fundoplication in patients stratified according to symptom patterns.

Five hundred eighteen patients undergoing laparoscopic fundoplication were stratified according to reflux symptom patterns: group 1, regurgitation; group 2, poorly controlled reflux; group 3, regurgitation and poor reflux control (combination of 1 and 2); and group 4, symptoms well controlled but patient does not want to continue taking medication. Clinical outcomes (heartburn control, dysphagia, satisfaction) were assessed prospectively using a standardized questionnaire at early (6 months to 2 years) and late (3-5 years) follow-up intervals.

Preoperative demographic data for the four groups were similar, except for age and the frequency of esophagitis (patients in group 4 were younger and more likely to have esophagitis). Perioperative morbidity was similar for the four groups. Eighty-seven percent of the overall study group was satisfied at early follow-up and 88% at late follow-up. Early clinical outcomes were similar for all subgroups, except dysphagia scores were higher in early follow-up in groups 1 and 3 (P = 0.001). At late clinical follow-up, there were no significant differences in clinical outcome between any groups.

At early follow-up (6 months to 2 years), patients who had reported regurgitation as the primary indication for surgery had a less favorable clinical outcome for the side effect dysphagia. However, at later follow-up, the type of preoperative reflux symptoms did not influence the clinical outcome.

Laparoscopic Nissen fundoplication offers significant improvement in gastroesophageal reflux disease (GERD) symptom severity and frequency. This study was undertaken to determine the impact of preoperative medical comorbidities on the outcome and satisfaction of patients undergoing fundoplication for GERD.

Prior to fundoplication, patients underwent esophageal motility testing and 24-h pH monitoring. Before and after fundoplication, the frequency and severity of reflux symptoms were scored using a Likert scale. Medical comorbidities were classified by organ systems, and patients were assigned points corresponding to the number of medical comorbidities they had. In addition, all patients were assigned Charlson comorbidity index (CCI) scores according to the medical comorbidities they had. A medical comorbidity was defined as a preexisting medical condition, not related to GERD, for which the patient was receiving treatment. Analyses were then conducted to determine the impact of medical comorbidities as well as CCI score on overall outcome, symptom improvement, and satisfaction.

Six hundred and ninety-six patients underwent fundoplication: 538 patients had no medical comorbidities and 158 patients had one or more medical comorbidities. Preoperatively, there were no differences in symptom severity and frequency scores between patients with or without medical comorbidities. Postoperatively, all patients had improvement in their symptom severity and frequency scores. There were no differences in postoperative symptom scores between the patients with medical comorbidities and those without. The majority of patients were satisfied with their overall outcome; there was no relationship between the number of medical comorbidities and satisfaction scores. These findings were mirrored when patients' CCI scores were compared with satisfaction, overall outcome, and symptom improvement.

These results promote further application of laparoscopic Nissen fundoplication, even for patients with medical comorbidities.

We set out to investigate the impact of the preoperative reflux pattern on long-term outcome after Nissen fundoplication. Recent studies disagree on whether patients with pathological upright reflux should be discouraged from undergoing surgery.

A total of 338 patients underwent Nissen fundoplication. Of these, 234 of 289 patients had pathological acid exposure on preoperative 24-h esophageal pH monitoring and their reflux was classified as pathological upright (n=81), supine (n=55), or bipositional (n=98). Clinical outcomes and results of endoscopy, manometry, and 24-h pH monitoring were compared before surgery, and at 3 months and 5 years after surgery.

Patients with pathological upright and supine reflux had similar preoperative reflux parameters. In patients with pathological bipositional reflux, however, preoperative total acid exposure was higher than that in patients with upright or supine reflux (18.3% vs. 10.7 and 7.5%; P<0.001 and P<0.001). Prevalence of esophagitis was higher in patients with bipositional reflux than in those with upright reflux, both before (64.0 vs. 45.6%; P=0.035) and 3 months after surgery (16.0 vs. 3.5%; P=0.018). Before surgery, mean lower esophageal sphincter (LES) pressure was lower compared with the upright and supine reflux groups (1.0 vs. 1.5 and 1.6 kPa; P=0.007 and 0.005, respectively). The increase in quality of life, reduction of symptoms, use of acid-suppressing drugs, total acid exposure, and esophagitis were independent of reflux pattern at 3 months and 5 years after surgery (all P<0.05). Prevalence of recurrent pathological acid exposure was higher in the bipositional group than in the upright group (40.9 vs. 10.7%; P=0.013). Surgical reintervention was significantly more common in bipositional reflux patients (20.0 vs. 8.9% for upright and 4.1% for supine).

All three pathological reflux patterns respond favorably to Nissen fundoplication in the long term. Patients with pathological bipositional reflux, however, suffer from more severe disease with higher chance of recurrence and reoperation.