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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 antireflux surgery in gastroesophageal-related cough: a systematic review and meta-analysis. Int J Surg 2025; 111:1348-1356. [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [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). Antireflux 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 antireflux 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 antireflux procedures. Data were extracted and pooled using a random effects model to assess the overall effect size and heterogeneity between studies. The authors found that antireflux 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. Antireflux surgery significantly improved overall reflux-related symptom scores (all P <0.001). The authors 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 Antireflux procedures significantly improve gastroesophageal-related cough and other reflux symptoms. These findings support the use of antireflux 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 antireflux 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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Smout AJ, Schijven MP, Bredenoord AJ. Antireflux surgery - choosing the right candidate. Expert Rev Gastroenterol Hepatol 2025; 19:27-38. [PMID: 39756007 DOI: 10.1080/17474124.2024.2449455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Accepted: 12/31/2024] [Indexed: 01/07/2025]
Abstract
INTRODUCTION Surgical gastric fundoplication is an effective treatment option for gastroesophageal reflux disease. In contrast to acid suppression, fundoplication nearly abolishes all types of reflux, acid and nonacid. However, in some cases, lasting side effects of the procedure may overshadow its positive effects. It has remained difficult to determine which patients are the most suitable candidates for fundoplication. AREAS COVERED This review aims to evaluate the available data on preoperative factors that are associated with the outcome of fundoplication and to determine which combination of patient characteristics and preoperative test results provides optimal selection. In addition, we assess the need for tailoring the procedure on the basis of the preoperative quality of esophageal peristalsis. EXPERT OPINION Surgical treatment of gastroesophageal reflux disease is underutilized as it may provide an excellent option for a subset of GERD patients. It is not sensible to restrict surgical treatment to patients who do not respond to acid suppression. However, meticulous patient selection is key. Most importantly, surgical treatment should not be considered in patients in whom there is no convincing evidence that the symptoms are caused by reflux. Impaired esophageal peristalsis should not be regarded as a contraindication against fundoplication.
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Affiliation(s)
- André J Smout
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
| | - Marlies P Schijven
- Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Digital Health, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
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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: 437] [Impact Index Per Article: 145.7] [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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Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis. Ann Surg 2021; 274:78-85. [PMID: 33214483 DOI: 10.1097/sla.0000000000004639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF). SUMMARY OF BACKGROUND DATA Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair. METHODS A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%). CONCLUSIONS LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.
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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: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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Abstract
PURPOSE OF REVIEW Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients. RECENT FINDINGS A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.
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Affiliation(s)
- Semeret Munie
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Hassan Nasser
- Department of General Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
| | - Jon C Gould
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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Surgical results of laparoscopic Toupet fundoplication for gastroesophageal reflux disease with special reference to recurrence. Esophagus 2018; 15:217-223. [PMID: 30225741 DOI: 10.1007/s10388-018-0616-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/17/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical results of GERD have mainly been reported from the Western countries, with a few reports found in Japan. We examined the surgical results of laparoscopic Toupet fundoplication and clarify the characteristics of recurrent cases. METHODS The subjects included 375 patients who underwent laparoscopic Toupet fundoplication from June 1997 to December 2016 as the initial surgery. Patient characteristics, pathophysiology, and surgical results were examined. In addition, we compared the patient characteristics and pathophysiology of recurrent cases in comparison with non-recurrent cases. RESULTS Age 59 (43-70) and male 211 (56.3%). The operation time was 141 min (113-180) and intraoperative complications were found to have onset in 13 subjects (3.5%). Dysphagia after surgery was found in 18 cases (4.8%). The A factor (the degree of hiatal hernia), P factor (the degree of esophagitis), and pH < 4 holding time significantly improved after surgery compared with prior to surgery (p < 0.001 for all), while the LES lengths and abdominal LES lengths were extended (p < 0.001 for each). Recurrence was found in 48 patients (15.1%) among the 318 patients for whom we could confirm the presence or absence of recurrence. The A factor, P factor, and pH < 4 holding time prior to surgery were, respectively, higher in the recurrence group (p = 0.031, p < 0.001, p < 0.001). CONCLUSIONS Laparoscopic Toupet fundoplication for GERD could be performed safely, with a response rate as good as 85%. Compared with non-recurrent cases, preoperative clinical conditions such as esophageal hiatal hernia, reflux esophagitis, and acid reflux time were all advanced in recurrent cases.
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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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Statz AK, Stroud AM, Jolles SA, Greenberg JA, Lidor AO, Shada AL, Wang X, Funk LM. Psychosocial Factors Are Associated with Quality of Life After Laparoscopic Antireflux Surgery. J Laparoendosc Adv Surg Tech A 2017; 27:755-760. [PMID: 28557566 DOI: 10.1089/lap.2017.0176] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Laparoscopic antireflux surgery (LARS) is the gold standard treatment for refractory gastroesophageal reflux disease (GERD). Traditional surgical outcomes following LARS are well described, but limited data exist regarding patient-reported outcomes. We aimed to identify preoperative characteristics that were independently associated with a high GERD health-related quality of life (GERD-HRQL) following LARS. METHODS Clinical data from our single institution foregut surgery database were used to identify all patients with GERD who underwent primary LARS from June 2010 to November 2015. Electronic health record data were reviewed to extract patient characteristics, diagnostic study characteristics, and operative data. Postoperative GERD-HRQL data were obtained through telephone follow-up. Variables hypothesized a priori to be associated with high GERD-HRQL after LARS, which were significant at P ≤ .2 on bivariate analysis, were entered into a multivariable linear regression model with GERD-HRQL as the outcome. RESULTS The study included 248 patients; 69.0% were female, 56.9% were married, and 58.1% had concurrent atypical symptoms. The most commonly performed fundoplications were Nissen (44.8%), Toupet (41.3%), and Dor (14.1%), respectively. The median follow-up interval was 3.4 years. The telephone response rate was 60.1%. GERD-HRQL scores improved from 24.8 (SD ±11.4) preoperatively to 3.0 (SD ±5.9) postoperatively. 79.9% of patients were satisfied with their condition at follow-up. On multivariable analysis, being married (P = .04) and absence of depression (P = .02) were independently associated with a higher postoperative QoL. CONCLUSIONS Strong social support and psychiatric well-being appear to be important predictors of a higher QoL following LARS. Optimizing social support and treating depression preoperatively and postoperatively may improve QoL outcomes for LARS patients.
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Affiliation(s)
- Alexa K Statz
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Andrea M Stroud
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Sally A Jolles
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Jacob A Greenberg
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Anne O Lidor
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Amber L Shada
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Xing Wang
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Luke M Funk
- 1 Department of Surgery, University of Wisconsin , Madison, Wisconsin.,2 William S. Middleton Memorial Veteran Hospital , Madison, Wisconsin
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Primary versus redo paraesophageal hiatal hernia repair: a comparative analysis of operative and quality of life outcomes. Surg Endosc 2017; 31:5166-5174. [DOI: 10.1007/s00464-017-5583-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/02/2017] [Indexed: 12/18/2022]
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Krill JT, Naik RD, Higginbotham T, Slaughter JC, Holzman MD, Francis DO, Garrett CG, Vaezi MF. Association Between Response to Acid-Suppression Therapy and Efficacy of Antireflux Surgery in Patients With Extraesophageal Reflux. Clin Gastroenterol Hepatol 2017; 15:675-681. [PMID: 27840185 DOI: 10.1016/j.cgh.2016.10.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/12/2016] [Accepted: 10/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The effectiveness of antireflux surgery (ARS) varies among patients with extraesophageal manifestations of gastroesophageal reflux disease (GERD). By studying a cohort of patients with primary extraesophageal symptoms and abnormal physiologic markers for GERD, we aimed to identify factors associated with positive outcomes from surgery, and compare outcomes to those with typical esophageal manifestations of GERD. METHODS We performed a retrospective cohort study to compare adult patients with extraesophageal and typical reflux symptoms who underwent de novo ARS from 2004 through 2012 at a tertiary care center. All 115 patients (79 with typical GERD and 36 with extraesophageal manifestations of GERD) had evidence of abnormal distal esophageal acid exposure based on pH testing or endoscopy. The principle outcome was time to primary symptom recurrence after surgery, based on patient reports of partial or total recurrence of symptoms at follow-up visits. Patients were followed up for a median duration of 66 months (interquartile range, 52-77 mo). RESULTS The median time to recurrence of symptoms in the overall cohort was 68 months (11.5 months in the extraesophageal cohort vs >132 months in the typical cohort). Symptom recurrence after ARS was associated with having primarily extraesophageal symptoms (adjusted hazard ratio, 2.34; 95% confidence interval, 1.31-4.17) and poor preoperative symptom response to acid-suppression therapy (AST) (hazard ratio, 3.85; 95% confidence interval, 2.05-7.22). Patients with primary extraesophageal symptoms who had a full or partial preoperative AST response experienced lower rates of symptom recurrence compared to patients with poor AST response (P < .01). The rate of symptom recurrence was lowest among patients with primary typical reflux symptoms who had a partial or full symptom response to AST (P < .01). The severity of acid reflux on pH testing, symptom indices, severity of esophagitis, and hiatal hernia size were not associated with symptom response. CONCLUSIONS In a retrospective study, we found the effectiveness of ARS to be less predictable in patients with extraesophageal symptoms of GERD than in patients with typical GERD. Response to AST before surgery was associated with ARS effectiveness in patients with extraesophageal reflux symptoms. Caution should be exercised when advocating ARS for patients with extraesophageal symptoms that do not respond to AST.
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Affiliation(s)
- Joseph T Krill
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rishi D Naik
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tina Higginbotham
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael D Holzman
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David O Francis
- Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C Gaelyn Garrett
- Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
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Park JM, Kim BJ, Kim JG, Chi KC. Factors predicting outcomes of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: experience at a single institution in Korea. Ann Surg Treat Res 2017; 92:184-190. [PMID: 28382290 PMCID: PMC5378558 DOI: 10.4174/astr.2017.92.4.184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 10/31/2016] [Accepted: 11/16/2016] [Indexed: 12/31/2022] Open
Abstract
Purpose Laparoscopic fundoplication is considered the standard surgical treatment for gastroesophageal reflux disease (GERD) in Western countries. However, some patients experience poor surgical outcomes with this procedure. The study aimed to identify the predictive factors of the surgical outcomes of laparoscopic Nissen fundoplication for the treatment of Korean GERD patients. Methods Sixty-one patients with GERD were treated using laparoscopic Nissen fundoplication between November 2012 and February 2015. Symptom control rates were compared according to clinical and surgical factors to identify predictive factors of successful surgical outcomes. Results Thirty-five men and 26 women were enrolled. Preoperatively, typical symptoms were present in 60 patients (98%), while atypical symptoms were present in 40 patients (66%). Postoperatively, typical symptoms were controlled in 51 of 60 patients (85.0%), while atypical symptoms were controlled in 33 of 40 patients (82.5%). Overall, at 6 months postsurgery, 54 (88.5%) reported some resolution of GERD symptoms, with 48 (78.7%) achieving complete control. Patients who exhibited a good response to proton pump inhibitor therapy had a significantly greater rate of complete symptom control (P = 0.035). Conclusion Laparoscopic fundoplication is effective for controlling GERD symptoms. Response to preoperative proton pump inhibitor was a predictor of successful outcome.
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Affiliation(s)
- Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jae Gyu Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyong-Choun Chi
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
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Tolone S, Gualtieri G, Savarino E, Frazzoni M, de Bortoli N, Furnari M, Casalino G, Parisi S, Savarino V, Docimo L. Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors. World J Gastrointest Surg 2016; 8:719-728. [PMID: 27933133 PMCID: PMC5124700 DOI: 10.4240/wjgs.v8.i11.719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/17/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.
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Scharitzer M, Pokieser P. What is the role of radiological testing of lower esophageal sphincter function? Ann N Y Acad Sci 2016; 1380:67-77. [PMID: 27496165 DOI: 10.1111/nyas.13181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/13/2016] [Accepted: 06/17/2016] [Indexed: 12/11/2022]
Abstract
Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.
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Affiliation(s)
| | - Peter Pokieser
- Unified Patient Project, Medical University of Vienna, Vienna, Austria
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15
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Prolene Suture Web-Shoelace–Like Pattern: An Alternative to Avoid the Use of Mesh in the Repair of a Large Hiatus Hernia. J Laparoendosc Adv Surg Tech A 2015; 25:1019-24. [DOI: 10.1089/lap.2015.0279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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O Dea J. Measurement of Esophagogastric Junction Distensibility May Assist in Selecting Patients for Endoluminal Gastroesophageal Reflux Disease Surgery. J Neurogastroenterol Motil 2015; 21:448-9. [PMID: 26130642 PMCID: PMC4496898 DOI: 10.5056/jnm15045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- John O Dea
- Crospon, Galway, Ireland.,National University of Ireland, Galway, Ireland
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17
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Abstract
Patient satisfaction with primary antireflux surgery is high, but a small percentage of patients experience recurrent reflux and dysphagia, requiring reoperation. The major anatomic causes of failed fundoplication are slipped fundoplication, failure to identify a short esophagus, and problems with the wrap. Minimally invasive surgery has become more common for these procedures. Options for surgery include redo fundoplication with hiatal hernia repair if needed, conversion to Roux-en-Y anatomy, or, as a last resort, esophagectomy. Conversion to Roux-en-Y anatomy has a high rate of success, making this approach an important option in the properly selected patient.
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Affiliation(s)
- Brandon T Grover
- Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA
| | - Shanu N Kothari
- Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA.
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Staehelin A, Zingg U, Devitt PG, Esterman AJ, Smith L, Jamieson GG, Watson DI. Preoperative factors predicting clinical outcome following laparoscopic fundoplication. World J Surg 2014; 38:1431-1443. [PMID: 24366275 DOI: 10.1007/s00268-013-2415-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antireflux surgery is effective for the treatment of gastroesophageal reflux, but not all patients benefit equally from it. The challenge is to identify the patients who will ultimately benefit from antireflux surgery. The aim of this study was to identify preoperative factors that predict clinical outcome after antireflux surgery, with special interest in the influence of socioeconomic factors. METHODS Preoperative clinical and socioeconomic data from 1,650 patients who were to undergo laparoscopic fundoplication were collected prospectively. Clinical outcome measures (persistent heartburn, dysphagia, satisfaction) were assessed at short-term (1 year) and longer-term (≥ 3 years) follow-up. RESULTS At early follow-up, male gender (relative risk [RR] 1.091, p < 0.001) and the presence of a hiatus hernia (RR 1.065, p = 0.002) were independently associated with less heartburn. Male gender was also associated with higher overall satisfaction (RR 1.046, p = 0.034). An association was found between postoperative dysphagia and age (RR 0.988, p = 0.007) and the absence of a hiatus hernia (RR 0.767, p = 0.001). At longer-term follow-up, only male gender (RR 1.125, p < 0.001) was an independent prognostic factor for heartburn control. Male gender (RR 0.761, p = 0.001), the presence of a hiatus hernia (RR 0.823, p = 0.014), and cerebrovascular comorbidities (RR 1.306, p = 0.019) were independent prognosticators for dysphagia at longer-term follow-up. A hiatus hernia was the only factor associated with better overall satisfaction. Socioeconomic factors did not influence any clinical outcomes at short- and longer-term follow-up. CONCLUSION Male gender and hiatus hernia are associated with a better clinical outcome following laparoscopic fundoplication, whereas socioeconomic status does not influence outcome.
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Affiliation(s)
- Annina Staehelin
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
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Kim D, Velanovich V. Surgical treatment of GERD: where have we been and where are we going? Gastroenterol Clin North Am 2014; 43:135-45. [PMID: 24503364 DOI: 10.1016/j.gtc.2013.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Surgical management of gastroesophageal reflux disease has evolved from relatively invasive procedures requiring open laparotomy or thoracotomy to minimally invasive laparoscopic techniques. Although side effects may still occur, with careful patient selection and good technique, the overall symptomatic control leads to satisfaction rates in the 90% range. Unfortunately, the next evolution to endoluminal techniques has not been as successful. Reliable devices are still awaited that consistently produce long-term symptomatic relief with correction of pathologic reflux. However, newer laparoscopically placed devices hold promise in achieving equivalent symptomatic relief with fewer side effects. Clinical trials are still forthcoming.
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Affiliation(s)
- David Kim
- Division of General Surgery, University of South Florida, One Tampa General Circle, Tampa, FL 33606, USA
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, One Tampa General Circle, Tampa, FL 33606, USA.
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Balsara KP, Shah CR, Hussain M. [Not Available]. J Minim Access Surg 2013; 4:99-103. [PMID: 19547698 PMCID: PMC2699224 DOI: 10.4103/0972-9941.45205] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 10/23/2008] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND: Laparoscopic fundoplication (LF) has become the operation of choice for patients who need surgery for gastro esophageal reflux disease (GERD). Several studies have shown that the long-term results with surgery for GERD are better than medical therapy. In this retrospective study, we outline our experience with LF over an 8 year period. We analyzed factors that would affect the results of surgery and help in a better selection of patients for the operation. MATERIALS AND METHODS: From 1999 to 2007, 107 patients underwent a LF. Eighty five patients had surgery for GERD and form the basis of this article. The other 22 patients had paraesophageal hernias and were excluded from the study. Pre-operative evaluation consisted of endoscopy, a barium study, esophageal manometry and 24h pH monitoring. Patients were followed up every 3rd month for the 1st year, twice in the 2nd year and then annually. Follow up was by personal interview or telephonic conversation. At the last follow up the results of surgery were graded as good or poor as per a scoring system. Those with a poor result were evaluated and re-operation advised when an anatomical problem caused the poor result. Subjective, objective and technical variables were analyzed which could affect the outcome of surgery. RESULTS: In 84 patients, the operation was completed by laparoscopic access. One patient with bleeding was converted to open surgery. There were 5 intra-operative complications; 3 pnemothoracis, 1 esophageal perforation and 1 gastric fundus perforation. There was no mortality. Two patients underwent re-operation, 1 for delayed gastric emptying and 1 for dysphagia. Seventy four patients have been followed up from 7 months to 8 years. Eleven have been lost to follow up. Fifty seven patients (77%) have had a good result from surgery. Seventeen (23%) had a poor result; of these there were 4 wrap failures, 1 delayed gastric emptying and 1 excessive gas bloat as the cause. In 11 patients, there was no apparent cause of a poor result. Individual variables which predicted a good response to surgery (P<0.5); were a good response to proton pump inhibitors (PPis), volume reflux and a pH score of more than 14. CONCLUSION: LF gives good long-term relief of symptoms in patients with GERD. Strict selection criteria are necessary to optimize the results of surgery. Poor selection will result in a patient who is no better, or often worse than before surgery.
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Affiliation(s)
- K P Balsara
- Department of GI and Minimal Access Surgery, Bhatia, Breach Candy and Jaslok Hospitals, Mumbai, India
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Humphries LA, Hernandez JM, Clark W, Luberice K, Ross SB, Rosemurgy AS. Causes of dissatisfaction after laparoscopic fundoplication: the impact of new symptoms, recurrent symptoms, and the patient experience. Surg Endosc 2013; 27:1537-45. [PMID: 23508812 DOI: 10.1007/s00464-012-2611-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 09/17/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication. METHODS All patients undergoing laparoscopic fundoplication in the authors' series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from "very satisfying" to "very unsatisfying." Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported. RESULTS Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication. CONCLUSIONS Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time.
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Affiliation(s)
- Leigh A Humphries
- Advanced Laparoscopic and Robotic HPB and Foregut Surgery, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL 33613, USA
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Bhandarwar AH, Kasat GV, Palep JH, Shaikh TA, Bakhshi GD, Nichat PD. Impact of laparoscopic Nissen's fundoplication on response of disease specific symptoms and quality of life. Updates Surg 2013; 65:35-41. [PMID: 23275254 DOI: 10.1007/s13304-012-0193-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/17/2012] [Indexed: 01/10/2023]
Abstract
The aim of this study is to establish responsiveness of gastroesophageal reflux disease (GERD) symptom score, quality of life SF-36 score in GERD with relation to oesophageal manometry and upper gastrointestinal endoscopy following laparoscopic Nissen's fundoplication (LNF). Interventional prospective study was done enrolling 77 patients of GERD who respond to proton pump inhibitor (PPI) and have undergone LNF, strict diagnostic criteria were followed with GERD score, upper gastrointestinal endoscopy, oesophageal manometry, and endoscopically negative patients have further undergone 24-h pH study. Follow-up was done at 12 and 24 months by GERD score, SF-36 score, endoscopy, oesophageal manometry. GERD score shows significant difference in pre-operative and post-operative score with P value <0.001 except dysphagia. Post-LNF improvement in GERD score is consistent with improvement in lower oesophageal sphincter (LES) pressure at 12 months. All dimensions in quality of life SF-36 show significant difference in pre-operative and post-operative score at 12 months with P value <0.001. Results are consistent at 24 months. Oesophagitis was decreased from 40.2 to 11.6 % as well as it showed down grading on endoscopy in post-operative period. Out of three patients of complete disruption of wrap, two patients underwent redo surgery and showed improvement. In properly diagnosed PPI respondent patients by GERD score, LNF has got improvement in GERD score, quality of life in all dimensions of SF-36 score in relation to improvement with LES pressure and oesophagitis.
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Affiliation(s)
- Ajay H Bhandarwar
- Department of General Surgery, Grant Government Medical College, Maharashtra, India.
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Massullo JM, Singh TP, Dunnican WJ, Binetti BR. Preliminary study of hiatal hernia repair using polyglycolic acid: trimethylene carbonate mesh. JSLS 2012; 16:55-9. [PMID: 22906331 PMCID: PMC3407458 DOI: 10.4293/108680812x13291597715943] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Repairing large hiatal hernias using mesh has been shown to reduce recurrence. Drawbacks to mesh include added time to place and secure the prosthesis as well as complications such as esophageal erosion. We used a laparoscopic technique for repair of hiatal hernias (HH) >5cm, incorporating primary crural repair with onlay fixation of a synthetic polyglycolicacid:trimethylene carbonate (PGA:TMC) absorbable tissue reinforcement. The purpose of this report is to present short-term follow-up data. METHODS Patients with hiatal hernia types I-III and defects >5cm were included. Primary closure of the hernia defect was performed using interrupted nonpledgeted sutures, followed by PGA:TMC mesh onlay fixed with absorbable tacks. A fundoplication was then performed. Evaluation of patients was carried out at routine follow-up visits. Outcomes measured were symptoms of gastroesophageal reflux disease (GERD), or other symptoms suspicious for recurrence. Patients exhibiting these complaints underwent further evaluation including radiographic imaging and endoscopy. RESULTS Follow-up data were analyzed on 11 patients. Two patients were male; 9 were female. The mean age was 60 years. The mean length of follow-up was 13 months. There were no complications related to the mesh. One patient suffered from respiratory failure, one from gas bloat syndrome, and another had a superficial port-site infection. One patient developed a recurrent hiatal hernia. CONCLUSIONS In this small series, laparoscopic repair of hiatal hernias >5cm with onlay fixation of PGA:TMC tissue reinforcement has short-term outcomes with a reasonably low recurrence rate. However, due to the preliminary and nonrandomized nature of the data, no strong comparison can be made with other types of mesh repairs. Additional data collection is warranted.
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Affiliation(s)
- James M Massullo
- Department of General Surgery, Albany Medical Center, Albany, NY, USA.
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Abstract
Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.
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Brown SR, Gyawali CP, Melman L, Jenkins ED, Bader J, Frisella MM, Brunt LM, Eagon JC, Matthews BD. Clinical outcomes of atypical extra-esophageal reflux symptoms following laparoscopic antireflux surgery. Surg Endosc 2011; 25:3852-8. [PMID: 21717265 DOI: 10.1007/s00464-011-1806-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 02/21/2011] [Indexed: 01/27/2023]
Abstract
INTRODUCTION While it is well established that antireflux surgery is effective in relieving typical gastroesophageal reflux disease (GERD) symptoms such as heartburn and regurgitation, it is currently unclear whether atypical symptoms (cough, hoarseness, wheeze) foreshadow a less satisfactory outcome following laparoscopic antireflux surgery (LARS). The purpose of this study is to critically analyze the clinical outcomes of atypical symptoms in patients undergoing LARS. METHODS Patients scheduled for LARS for GERD were prospectively enrolled over a 7-year period; all subjects underwent preoperative high-resolution manometry (HRM) and had evidence of GERD on ambulatory pH study. Cough, wheeze, and hoarseness were considered atypical symptoms. During preoperative and postoperative examinations, patients completed detailed foregut symptomatology questionnaires, using both 5-point Likert and 10-point visual analog scales (VAS) to document typical as well as atypical symptoms. Atypical symptom burden was calculated as a sum of VAS for the three atypical symptoms, termed the atypical score (ATS). HRM patterns were grouped into normal, spastic, and hypomotile. Statistical significance (p < 0.05) was determined using paired t-test, and analysis of variance with post hoc least significant difference (LSD). RESULTS One hundred thirteen patients (age 49 ± 1.26 years, range 20-84 years, M:F 47:66) with mean follow-up of 28 ± 2.31 months (range 1-92 months) fulfilled inclusion criteria, having mean modified DeMeester score of 45.5 ± 2.78. Heartburn was noted in 84.1%, while atypical symptoms of some degree were reported by 92.0% (104 patients). Heartburn improved from a preoperative score of 7.1 ± 0.54 to 0.9 ± 0.24 after LARS, and ATS improved from 8.9 ± 0.71 to 2.2 ± 0.42. Significant improvements were noted for all atypical symptoms analyzed (p < 0.0001 for each). Improvement in atypical symptoms was least in the presence of hypomotility features on HRM (21.7% improvement), compared with normal motility (72.4%) and spastic features (83.9%). Preoperative atypical score (p < 0.0001) and esophageal hypomotility (p = 0.04) demonstrated a linear relationship with postoperative atypical score. CONCLUSIONS In an unselected cohort of patients undergoing LARS, atypical GERD symptoms improved as significantly as typical symptoms. Symptom improvement was significantly lower in the presence of esophageal hypomotility and with higher symptomatic state. Therefore, patients with severe atypical symptoms or hypomotile esophagus may not achieve the same clinical satisfaction from LARS.
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Affiliation(s)
- Shaun R Brown
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8109, St. Louis, MO 63110, USA
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Davis CS, Baldea A, Johns JR, Joehl RJ, Fisichella PM. The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease. JSLS 2011; 14:332-41. [PMID: 21333184 PMCID: PMC3041027 DOI: 10.4293/108680810x12924466007007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND For nearly 2 decades, the laparoscopic correction of gastroesophageal reflux disease (GERD) has demonstrated its utility. However, the surgical technique has evolved over time, with mixed long-term results. We briefly review the evolution of antireflux surgery for the treatment of GERD, provide an update specific to the long-term efficacy of laparoscopic antireflux surgery (LARS), and analyze the factors predictive of a desirable outcome. MATERIALS AND METHODS PubMed and Medline database searches were performed to identify articles regarding the laparoscopic treatment of GERD. Emphasis was placed on randomized control trials (RCTs) and reports with follow-up >1 year. Specific parameters addressed included operative technique, resolution of symptoms, complications, quality of life, division of short gastric vessels (SGVs), mesh repair, and approximation of the crura. Those studies specifically addressing follow-up of <1 year, the pediatric or elderly population, redo fundoplication, and repair of paraesophageal hernia and short esophagus were excluded. RESULTS LARS has varied in technical approach through the years. Not until recently have more long-term, objective studies become available to allow for evidenced-based appraisals. Our review of the literature found no long-term difference in the rates of heartburn, gas-bloat, antacid use, or patient satisfaction between laparoscopic Nissen and Toupet fundoplication. In addition, several studies have shown that more patients had an abnormal pH profile following laparoscopic partial as opposed to total fundoplication. Conversely, dysphagia was more common following laparoscopic total versus partial fundoplication in 50% of RCTs at 12-month follow-up, though this resolved over time, being present in only 20% with follow-up >24 months. We confirmed that preoperative factors, such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Last, no trial disfavored division of the short gastric vessels (SGVs), closure of the crura, or mesh repair for hiatal defects. CONCLUSION LARS has significantly evolved over time. The laparoscopic total fundoplication appears to provide more durable long-term results than the partial approach, as long as the technical elements of the operation are respected. Division of the SGVs, closure of the crura, and the use of mesh for large hiatal defects positively impacts long-term outcome. Hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting are potential predictors of failure in LARS.
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Affiliation(s)
- C S Davis
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
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Broeders JAJL, Roks DJGH, Draaisma WA, Vlek ALM, Hazebroek EJ, Broeders IAMJ, Smout AJPM. Predictors of objectively identified recurrent reflux after primary Nissen fundoplication. Br J Surg 2011; 98:673-9. [DOI: 10.1002/bjs.7411] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2010] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Laparoscopic Nissen fundoplication is the most frequently performed operation for gastro-oesophageal reflux disease (GORD). Studies on predictors of subjective outcome of fundoplication have yielded inconsistent results. This study identified predictors of objective reflux control after Nissen fundoplication.
Methods
This was a retrospective analysis of prospectively collected data from patients who underwent Nissen fundoplication for proton pump inhibitor-refractory GORD with pathological acid exposure in a single centre between 1997 and 2005. The predictive value of demographics, endoscopic hiatal hernia size, oesophagitis, lower oesophageal sphincter pressure, distal oesophageal contraction amplitude, percentage of peristaltic contractions and acid exposure was determined. Endpoints were recurrent pathological acid exposure on 24-h pH monitoring at 6 months and surgical reintervention for recurrent GORD up to 6 years.
Results
Of 177 patients, 22 had recurrent pathological acid exposure at 6 months for which 11 had surgery within 6 years. Only low percentage of peristaltic contractions (odds ratio (OR) 0·97, 95 per cent confidence interval 0·95 to 0·99; P = 0·004) and high supine acid exposure (OR 1·03, 1·00 to 1·07; P = 0·025) were independent predictors of recurrent pathological acid exposure. The absolute risk of recurrent exposure was 45·5 per cent in patients with both predictors. High supine acid exposure was also an independent predictor of surgical reintervention (OR 1·05, 1·01 to 1·08; P = 0·006).
Conclusion
Nissen fundoplication should not necessarily be withheld from patients with poor oesophageal peristalsis or excessive supine acid exposure. As about half of patients with both variables experience recurrent pathological acid exposure after primary Nissen fundoplication, surgery should be restricted in this group.
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Affiliation(s)
- J A J L Broeders
- Department of Surgery, Gastrointestinal Research Unit of the University Medical Center Utrecht, Utrecht, The Netherlands
| | - D J G H Roks
- Department of Surgery, Gastrointestinal Research Unit of the University Medical Center Utrecht, Utrecht, The Netherlands
| | - W A Draaisma
- Department of Surgery, Gastrointestinal Research Unit of the University Medical Center Utrecht, Utrecht, The Netherlands
| | - A L M Vlek
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E J Hazebroek
- Department of Surgery, Gastrointestinal Research Unit of the University Medical Center Utrecht, Utrecht, The Netherlands
| | - I A M J Broeders
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - A J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
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Abstract
BACKGROUND Because of complications and its invasive nature, fundoplication is often a treatment of last resort for children with gastroesophageal reflux. Gastroesophageal reflux testing does not always predict who will benefit from antireflux surgery. Furthermore, there are no studies to determine whether a higher preoperative reflux burden, including acid and nonacid reflux, is associated with an improved postfundoplication outcome. The aim of the study was to determine predictors of fundoplication outcome including acid and nonacid reflux burden. PATIENTS AND METHODS We retrospectively reviewed preoperative pH-multichannel intraluminal impedance tracings and medical records of 34 patients who underwent fundoplication. Patients were categorized as improved or not improved, and the demographic and reflux characteristics were compared between groups. Multivariate analysis was performed to determine predictors of outcome. RESULTS No single reflux marker, including the number of acid, nonacid, total events, or the percentage of time that reflux was in the esophagus, predicted fundoplication outcome (P > 0.1). Neither a positive symptom index nor a positive symptom sensitivity index predicted postoperative improvement (P > 0.4). Receiver operating characteristic curve analysis failed to reveal an ideal value to maximize sensitivity for either the symptom index or the symptom sensitivity index. CONCLUSIONS pH-multichannel intraluminal impedance testing may not be a useful tool in predicting fundoplication outcome.
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Antireflux 'barriers': problems with patient recruitment for a new endoscopic antireflux procedure. Eur J Gastroenterol Hepatol 2009; 21:1110-8. [PMID: 19300273 DOI: 10.1097/meg.0b013e32832937c2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most first-generation endoscopic antireflux procedures (EARPs) have been withdrawn because of variable success rates, economic considerations, and/or complications. As a result, subsequent methods may meet 'skepticism' by physicians and patients. AIMS To identify potential barriers to patient recruitment for a new EARP METHODS: We prospectively analyzed our recruitment for a phase 2 study of a transoral incisionless fundoplication procedure. We contacted 50 private practices and 23 hospitals for potential referrals, and placed three newspaper advertisements. All patient replies were followed up by a phone call. Patients were then invited for a personal interview, and eligible patients underwent further preprocedure testing. In addition, poststudy questionnaires regarding their opinions about EARPs were sent to referring physicians. RESULTS Of 134 interviewed patients, only 10% (n=13) were successfully recruited. Candidates mostly responded to newspaper advertisements (87%) or were referred from our own institution (7%). Primary exclusion criteria included failure of proton pump inhibitor response (34%), lack of proton pump inhibitor use (20%), atypical symptoms (18%), or a large hiatal hernia (17%). Seventy percent of the responding physicians did not believe that new EARPs would be superior to previous methods. CONCLUSION The EARP market seems to be much smaller than anticipated, partially because of skepticism of referring physicians, and partially because of strict selection criteria.
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Broeders JA, Draaisma WA, de Vries DR, Bredenoord AJ, Smout AJ, Gooszen HG. The preoperative reflux pattern as prognostic indicator for long-term outcome after Nissen fundoplication. Am J Gastroenterol 2009; 104:1922-30. [PMID: 19491839 DOI: 10.1038/ajg.2009.228] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Joris A Broeders
- Gastrointestinal Research Unit of the University Medical Center Utrecht, Department of Surgery, Utrecht 3508 GA, The Netherlands
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Frantzides CT, Madan AK, Carlson MA, Zeni TM, Zografakis JG, Moore RM, Meiselman M, Luu M, Ayiomamitis GD. Laparoscopic revision of failed fundoplication and hiatal herniorraphy. J Laparoendosc Adv Surg Tech A 2009; 19:135-9. [PMID: 19216692 DOI: 10.1089/lap.2008.0245] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication. BACKGROUND Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006. METHODS A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication. RESULTS Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%). CONCLUSION Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.
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Affiliation(s)
- Constantine T Frantzides
- Department of Surgery, Northwestern University, Chicago Institute of Minimally Invasive Surgery, Skokie, Illinois, USA.
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Khajanchee YS, Ujiki M, Dunst CM, Swanstrom LL. Patient factors predictive of 24-h pH normalization following endoluminal gastroplication for GERD. Surg Endosc 2009; 23:2525-30. [PMID: 19430838 DOI: 10.1007/s00464-009-0448-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 02/17/2009] [Accepted: 02/27/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoluminal full-thickness gastroplication has been documented to provide significant and long-lasting improvement of GERD symptoms and health-related quality of life (HRQL) with very little patient morbidity. These treatments, however, are criticized for normalizing esophageal acid exposure in only 30-40% of patients treated. We hypothesize that there are objective criteria that will identify those patients who will have a normal DeMeester score (DMS) following endoluminal treatment. METHODS Data from a prospective multicenter trial using the NDO Plicator device to treat GERD were available for statistical analysis. All patients were treated with endoluminal full-thickness gastroplication. All patients had GERD symptoms and abnormal 24-h pH exposure preoperatively. Postoperative objective outcome was assessed by performing 24-h pH studies at 6 months. Univariate and multivariate regression analyses were performed to determine factors predictive of successful treatment (normalized 24-h pH). RESULTS A total of 266 patients were included in the study. Mean preoperative DMS was 47.91 (+/-31.34). Postoperatively, mean DMS decreased significantly (37.11 +/- 24.63, p < 0.001), and 31.67% of patients had a DMS within normal range (DMS < 22). Results of multivariate regression analysis demonstrated that the following preoperative patient characteristics were predictive of postoperative success (normal DMS): DMS < 30 (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 1.73, 10.36, p < 0.001), heartburn score < 2 (OR = 3.37, CI = 1.44, 7.89, p = 0.005), and BMI < 30 (OR = 4.93, CI = 1.55, 15.61, p = 0.007). CONCLUSION Data analysis from this prospective study indicates that the odds of objective success would be significantly greater if the treatment was restricted to thinner patients with mild reflux disease. This may help define the optimal place for endoluminal therapy in a comprehensive GERD treatment algorithm.
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Affiliation(s)
- Yashodhan S Khajanchee
- Minimally Invasive Surgery Program, Legacy Health System, 1040 NW 22nd Ave., Suite 560, Portland, OR 97210, USA.
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Predictors of clinical outcomes following fundoplication for gastroesophageal reflux disease remain insufficiently defined: a systematic review. Am J Gastroenterol 2009; 104:752-8; quiz 759. [PMID: 19262527 DOI: 10.1038/ajg.2008.123] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Surgical treatment is a therapeutic option for patients with gastroesophageal reflux disease (GERD). It is unclear which patient characteristics influence postoperative success. The purpose of this paper was to review the literature on prognostic factors for patients with GERD treated with fundoplication. METHODS We searched Medline and the Cochrane Library Central for studies from 1966 through July 2007. We identified additional studies by reviewing bibliographies of retrieved articles and by consulting experts. We included English language studies that evaluated factors potentially affecting the outcomes after surgical treatments in patients with GERD. We recorded baseline patient characteristics associated with treatment efficacy, details on the study design, comparators, and definitions of outcomes. RESULTS We assessed 6,318 abstracts; 53 cohorts and 10 case-control studies met our inclusion criteria. Age, body mass index, sex, esophagitis grade, and dysmotility were generally not associated with treatment outcomes. There were no consistent associations between preoperative response to acid suppression medications, baseline symptoms, baseline acid exposure, degree of lower esophageal sphincter competence, or position of reflux and surgical outcomes. Certain psychological factors might be associated with worse treatment outcomes. CONCLUSIONS Although several preoperative predictors of surgical outcomes have been described, the quality and consistency of the data were mixed and the strength of the associations remains unclear. Additional studies with improved methodological designs are needed to better define which patient characteristics are associated with surgical outcomes following fundoplication.
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Morse JS, Schallhorn SC, Hettinger K, Tanzer D. Role of depressive symptoms in patient satisfaction with visual quality after laser in situ keratomileusis. J Cataract Refract Surg 2009; 35:341-6. [PMID: 19185253 DOI: 10.1016/j.jcrs.2008.10.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2008] [Accepted: 10/31/2008] [Indexed: 10/21/2022]
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Kornmo TS, Ruud TE. Long-term results of laparoscopic Nissen fundoplication due to gastroesophageal reflux disease. A ten year follow-up in a low volume center. Scand J Surg 2009; 97:227-30. [PMID: 18812271 DOI: 10.1177/145749690809700304] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic 360 degrees nissen fundoplication has been our routine surgical procedure since 1995, in the treatment of gastroesophageal reflux disease (GERD). We have reviewed our results of patients treated with laparoscopic Nissen fundoplication (LNF) during 1995-1998. MATERIAL AND METHODS 170 patients have undergone LNF in our hospital since 1995. during the period of 1995-1998, 33 patients were treated. all patients were asked to return a structured follow-up questionnaire, using a Visick grading scale, after an average of 69 months (2003) and 117 months (2007). 29 questionnaires (90%) were answered in 2003, and 31 questionnaires (97%) were answered in 2007. one patient died at home before the first questionnaire in 2003, and is therefore not included. We present our results on LNF after an observation time of 117 months (range 99-144 months). RESULTS patient satisfaction after LNF is rated as very good or good (Visick 1-2) in 93% in 2003 and 97% in 2007. 97% of the patients would recommend the same treatment to other patients with similar symptoms at ten year follow up. One patient has undergone resurgery during follow up. Daily gas bloat and flatulence is reported in 52% in 2003 and 39% in 2007, and is the most common reason for reduced satisfaction. Five patients report of reflux symptoms, one patient daily and four patients sometimes, where the first patient still uses proton pump inhibitor (PPI) daily and three patients use PPI occasionally. CONCLUSIONS patient satisfaction after LNF treatment for gerd is high at long-term (10 years) follow-up. Bloating and flatulence persistently occurred to a great extent and the need for preoperative information regarding these symptoms is important.
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Affiliation(s)
- T S Kornmo
- Department of Surgery, Sykehuset Asker and Baerum, Rud, Norway.
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Morgenthal CB, Lin E, Shane MD, Hunter JG, Smith CD. Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes. Surg Endosc 2007; 21:1978-84. [PMID: 17623236 DOI: 10.1007/s00464-007-9490-7] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 05/17/2007] [Accepted: 06/19/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND A small but significant percentage of patients are considered failures after laparoscopic Nissen fundoplication (LNF). We sought to identify preoperative predictors of failure in a cohort of patients who underwent LNF more than 10 years ago. METHODS Of 312 consecutive patients undergoing primary LNF between 1992 and 1995, recent follow-up was obtained from 166 patients at a mean of 11.0 +/- 1.2 years. Eight additional patients who underwent reoperation were lost to follow-up but are included. Failure is broadly defined as any reoperation, lack of satisfaction, or any severe symptoms at follow-up. Potential predictors evaluated included sex, age, body-mass index (BMI), response to acid reducing medications (ARM), psychiatric history, typical versus atypical symptoms, manometry, esophageal pH, and others. Logistic regression was used to assess significance of predictors in univariate analysis. RESULTS Of 174 known outcomes, 131 were classified as successful (75.3%), while 43 were failures (24.7%): 26 reoperations, 13 unsatisfied, and 13 with severe symptoms. Response and lack of response to ARM were associated with 77.1% and 56.0% success rates respectively (P = 0.035). Eighty five percent of patients with typical symptoms had a successful outcome, compared to only 41% with atypical symptoms (P < 0.001). Preoperative morbid obesity (BMI > 35 kg/m2) was associated with failure (P = 0.036), while obesity (BMI 30-34.9 kg/m2) was not. A history of psychiatric illness trended toward significance (P = 0.06). CONCLUSIONS In a cohort with 11 years follow-up after LNF, factors predictive of a successful outcome include preoperative response to ARM, typical symptoms, and BMI < 35 kg/m2. Patients with atypical symptoms, no response to ARM, or morbid obesity should be informed of their higher risk of failure. Some patients in these groups do have successful outcomes, and further research may clarify which of these patients can benefit from LNF.
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Affiliation(s)
- Craig B Morgenthal
- Endosurgery Unit, Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Suite H-124, Atlanta, Georgia 30322, USA
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Wayman J, Myers JC, Jamieson GG. Preoperative gastric emptying and patterns of reflux as predictors of outcome after laparoscopic fundoplication. Br J Surg 2007; 94:592-8. [PMID: 17377929 DOI: 10.1002/bjs.5465] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Some studies have suggested that patients with predominantly upright reflux have a poor outcome after laparoscopic antireflux surgery. It has been proposed that this might be related to gastric emptying. The aim of this study was to evaluate the relationship between preoperative upright reflux pattern, gastric emptying rate and outcome after laparoscopic fundoplication. METHODS Patients presenting for antireflux surgery underwent 24-h ambulatory pH testing and dual-isotope radionuclide gastric emptying studies. Reflux pattern was determined by the acid exposure in the distal oesophagus (percentage of time at pH < 4) during supine and upright posture. Outcome after fundoplication was assessed by a standardized postal questionnaire administered at 3 months, and 1, 2 and 5 years after surgery. RESULTS Of 372 patients identified from a prospectively maintained database, 109 had upright reflux, 57 supine reflux and 206 bipositional reflux. Overall patient satisfaction was not influenced by reflux pattern at any time after surgery. Delayed gastric emptying was documented in 31.0 per cent of patients, but there was no relationship with reflux pattern. CONCLUSION Patients with upright reflux did not have a less favourable outcome after fundoplication. Categorizing patients according to reflux pattern is of no value in predicting outcome or selecting patients for surgery.
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Affiliation(s)
- J Wayman
- University of Adelaide Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Biertho L, Sanjeev D, Sebajang H, Antony M, Anvari M. The influence of psychological factors on the outcomes of laparoscopic Nissen fundoplication. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2007; 1:2. [PMID: 17411450 PMCID: PMC1839765 DOI: 10.1186/1750-1164-1-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2006] [Accepted: 02/20/2007] [Indexed: 11/19/2022]
Abstract
Background Psychological factors play a role in a variety of gastrointestinal illness, including gastroesophageal reflux disease (GERD). Their impact on the surgical outcomes of antireflux surgery is unknown. Methods This is a single institution prospective controlled trial, comparing patients undergoing a laparoscopic Nissen fundoplication for GERD (LNF Group, n = 17) to patients undergoing an elective laparoscopic cholecystectomy for biliary colic (Control Group, n = 10). All patients had a psychological assessment before surgery, at 3 months and 6 months after surgery (i.e. Symptom CheckList-90-R somatization subset (SCL-90-R), Depression Anxiety Stress Scales, Anxiety sensitivity index, Illness attitude scale and Beck Depression Inventory II). GERD symptoms were recorded in the LNF Group using a standardized questionnaire (score 0–60). Patients with post-operative GERD symptoms score above 12 at 6 months were evaluated specifically. Statistical analysis was performed using a Student T test, and statistical significance was set at 0.05. Results There was no significant difference in preoperative and postoperative psychological assessment between the two groups. In the LNF Group, 7 patients had persisting GERD symptoms at 6 months (GERD score greater than 12). The preoperative SCL-90-R score was also significantly higher in this subgroup, when compared to the rest of the LNF Group (18.2 versus 8.3, p < 0.05) and to the Control Group (18.2 versus 7.9, p < 0.05). There was no significant difference for the other psychological tests. Conclusion The SCL-90-R Somatization Subset, reflecting the level of somatization in a patient, may be useful to predict poor outcomes after antireflux surgery. Cognisance of psychological disorders could improve the selection of an optimal treatment for GERD and help reduce the rate of ongoing symptoms after LNF.
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Affiliation(s)
- Laurent Biertho
- Centre for Minimal Access Surgery, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Dutta Sanjeev
- Centre for Minimal Access Surgery, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Herawati Sebajang
- Centre for Minimal Access Surgery, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Marty Antony
- Department of Psychology, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Mehran Anvari
- Centre for Minimal Access Surgery, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
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Fei L, del Genio G, Brusciano L, Esposito V, Cuttitta D, Pizza F, Rossetti G, Trapani V, Filippone G, Francesco M, del Genio A. Crura ultrastructural alterations in patients with hiatal hernia: a pilot study. Surg Endosc 2006; 21:907-11. [PMID: 17103273 DOI: 10.1007/s00464-006-9043-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Revised: 04/05/2006] [Accepted: 04/30/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) and hiatal hernia has been validated worldwide in the past decade. However, hiatal hernia recurrence still represents the most frequent long-term complication after primary repair. Different techniques for hiatal closure have been recommended, but the problem remains unsolved. The authors theorized that ultrastructural alterations may be implicated in hiatal hernia. Thus, this study was undertaken to investigate the presence of these alterations in patients with or without hiatal hernia. METHODS Samples from Laimer-Bertelli connective membrane and muscular crura at the esophageal hiatus were collected from 19 patients with GERD and hiatal hernia (HH group), and from 7 patients without hiatal hernia enrolled as the control group (NHH group). Specimens were processed and analyzed by transmission electron microscopy. RESULTS Muscle and connective samples from the NHH group did not present any ultrastructural alteration that could be detected by transmission electron microscopy. Similarly, connective samples from the HH group showed no ultrastructural alterations. In contrast, all muscle samples from the HH group exhibited sarcolemmal alterations, subsarcolemmal vacuolar degeneration, extended disruption of sarcotubular complexes, increased intermyofibrillar spaces, and sarcomere splitting. CONCLUSION The evidence of ultrastructural alterations in all the patients in the HH group raises the suspicion that the long-term outcomes of antireflux surgery depend not only on the surgical technique, but also on the underlying muscular diaphragmatic illness.
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Affiliation(s)
- L Fei
- Unit of Surgical Digestive Physiopathology, Second University of Naples, Naples, Italy.
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Abstract
Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery.
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Affiliation(s)
- Jeremyd Hayden
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Thibault R, Coron E, Sébille V, Sacher-Huvelin S, Bruley des Varannes S, Gournay J, Galmiche JP. Antireflux surgery for non-erosive and erosive reflux disease in community practice. Aliment Pharmacol Ther 2006; 24:621-32. [PMID: 16907894 DOI: 10.1111/j.1365-2036.2006.03024.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antireflux surgery has been mainly evaluated in tertiary referral centres. Data regarding post-operative outcome in non-erosive reflux disease are lacking. AIM To assess long-term outcome after antireflux surgery performed in a community practice setting. METHODS We selected consecutively 60 non-erosive reflux disease patients and 61 erosive oesophagitis patients with symptomatic gastro-oesophageal reflux disease. After surgery, each subject answered a validated disease-specific health-related quality of life questionnaire and another questionnaire focusing on symptoms, late morbidity and drug use. RESULTS After a 43-month median follow-up, an excellent outcome was reported by less than two-thirds of patients. Quality of life scores were lower in the non-erosive reflux disease group, especially in female patients. Non-erosive reflux disease patients reported more daily symptoms and more reflux-related symptoms (P = 0.04). Proton-pump inhibitor use was higher in non-erosive reflux disease patients (P < 0.005). Multivariate analysis identified four independent predictive factors associated with better outcome, namely male gender, abnormal preoperative acid exposure, a long duration of symptoms and surgical expertise. CONCLUSIONS In community practice, the results of antireflux surgery are inferior to those reported by tertiary centres. Outcome seems poorer in non-erosive reflux disease especially in female patients. Nearly one-third of the non-erosive reflux disease patients continue to take proton-pump inhibitors. These results highlight the need for careful selection of patients before antireflux surgery.
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Affiliation(s)
- R Thibault
- Department of Gastroenterology, Hepatology and Nutritional Support, Institut des Maladies de l'Appareil Digestif, University Hospital, Nantes, France
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Manning BJ, Salman R, Gillen P. Laparoscopic Nissen fundoplication: predicting outcome from peri-operative evaluation. Ir J Med Sci 2006; 175:55-8. [PMID: 16872031 DOI: 10.1007/bf03167951] [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: 10/20/2022]
Abstract
BACKGROUND Although laparoscopic Nissen fundoplicaton is a safe, effective treatment for gastrooesophageal reflux (GOR), questions remain about the durability of the procedure and patient selection criteria. AIMS To review a single surgeon's experience of laparoscopic Nissen fundoplicaton and to determine which factors, if any are likely to influence long term outcome. METHODS Data were collected on all 124 patients who underwent laparoscopic Nissen fundoplication over a five-year period, and a detailed questionnaire was used to evaluate outcome. RESULTS Eighty-nine per cent of patients were satisfied with the results of surgery whilst 8.8% of patients had significant recurrence of symptoms. Time since surgery was longer in those patients with symptom recurrence who were also more likely to be female. Pre-operative age, body mass index (BMI),Visick Score, endoscopic findings or pH analysis scores were not predictive of outcome, nor were intra-operative findings or post-operative complications. CONCLUSION Although laparoscopic Nissen fundoplication is a safe and effective treatment for GOR, it is difficult to predict the small but significant group of patients with poor longterm outcome based on pre-operative assessment and peri-operative parameters alone.
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Affiliation(s)
- B J Manning
- Dept of Surgery, Our Lady of Lourdes Hospital, Drogheda, Co Louth
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Canon CL, Morgan DE, Einstein DM, Herts BR, Hawn MT, Johnson LF. Surgical approach to gastroesophageal reflux disease: what the radiologist needs to know. Radiographics 2006; 25:1485-99. [PMID: 16284130 DOI: 10.1148/rg.256055016] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.
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Affiliation(s)
- Cheri L Canon
- Division of Gastroenterology, Department of Radiology, University of Alabama, Birmingham, AL 35249-6830, USA.
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Abstract
Laparoscopic surgery is the most significant advancement in the field of surgery over the past 15 years. This minimal access approach has been widely embraced and adopted to many common operations. Demonstrated benefits include decreased post-operative pain, shorter lengths of in-patient hospitalization, increased patient acceptance, and a more rapid return to gainful employment. With its ever-growing popularity, it has become fertile ground for civil litigation, ranking along with birth injuries and failure to diagnose cancer. A brief synopsis of the history of its evolution is presented along with general and specific comments concerning potential errors as they relate to specific common operations which are commonly done utilizing this technique.
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Affiliation(s)
- Earl Gaar
- Department of Surgery, University of Louisville School of Medicine and Louisville Veterans Administration Medical Center, Louisville, Kentucky, USA.
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