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Frankel A, Ong HS, Smithers BM, Nathanson LK, Gotley DC. Efficacy of laparoscopic fundoplication in patients with chronic cough and gastro-oesophageal reflux. Esophagus 2023; 20:170-177. [PMID: 36201134 PMCID: PMC9813203 DOI: 10.1007/s10388-022-00953-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/06/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The outcome of anti-reflux surgery in patients with suspected gastro-oesophageal reflux-induced cough is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication for controlling cough in patients with chronic cough without asthma, who have pathologic gastro-oesophageal reflux, and to identify predictors of response. METHODS From a prospective database of 1598 patients who have undergone laparoscopic fundoplication, 66 (4%) with proven gastro-oesophageal reflux disease (GORD) and chronic cough without asthma were studied. All patients underwent gastroscopy and 24-h pH monitoring before operation. Heartburn and regurgitation were assessed using a modified DeMeester score. Severity of cough before and after surgery was self-assessed by the patient using a visual analog scale at a minimum of 12 months post-operatively (median 43 mo; range: 14-104 mo). Patients were considered to have responded to fundoplication if they had no cough or the cough had improved by 50% or more after operation. RESULTS Cough and heartburn/regurgitation were relieved in 61% (40/66) and 90% (44/49) of the patients, respectively. The presence of typical GORD symptoms or oesophagitis, and pH study variables did not predict the response of the cough to fundoplication. CONCLUSION Refinement in the aetiological diagnosis of chronic cough due to GORD is necessary for improved outcome. Patients diagnosed with GORD-related chronic cough need to be counseled regarding their expectations from anti-reflux surgery.
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Affiliation(s)
- Adam Frankel
- Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital Clinical School, Level 4, Building 1, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia.
| | - Hock Soo Ong
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - B Mark Smithers
- Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital Clinical School, Level 4, Building 1, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
- Mater Private Hospital, South Brisbane, QLD, Australia
| | - Les K Nathanson
- Department of Surgery, Royal Brisbane Hospital, Herston, QLD, Australia
| | - David C Gotley
- Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital Clinical School, Level 4, Building 1, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
- Mater Private Hospital, South Brisbane, QLD, Australia
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Tustumi F, Bernardo WM, Mariano da Rocha JR, Szachnowicz S, Bernal da Costa Seguro FC, Bianchi ET, Takeda FR, Afonso de Miranda Neto A, Aissar Sallum RA, Cecconello I. Anti-reflux surgery for controlling respiratory symptoms of gastro-esophageal reflux disease: A systematic review and meta-analysis. Asian J Surg 2020; 44:2-10. [PMID: 32534727 DOI: 10.1016/j.asjsur.2020.04.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/15/2020] [Accepted: 04/05/2020] [Indexed: 02/08/2023] Open
Abstract
Gastro-esophageal reflux disease (GERD) patients have a higher prevalence of airway symptoms, such as chronic cough, wheezing, and hoarseness. The therapeutic management of patients with these symptoms is controversial. Therefore, this study aims to perform a systematic review and meta-analysis evaluating the efficacy of anti-reflux surgery for controlling respiratory symptoms related to GERD. A systematic review and meta-analysis was performed. Extraction of the data concerning proportions of participants who were not free of respiratory symptoms related to GERD (cough, wheezing, hoarseness) or not substantially improved at follow-ups (failure to cure) was performed. Of the 3,424 initially screened articles, 68 studies were included for systematic review and 61 were included for meta-analysis, with a cumulative sample size of 3,869 patients. Of all the included patients, after anti-reflux surgery, the general symptoms improvement was 80% (95% CI 75.2-84%). The numbers needed to harm (NNH) and the numbers needed to treat (NNT) were 15.21 and 1.23, respectively. Of the included patients, 83.4% (95% CI 78.3-87.5%) patients reported improvement in cough symptoms after surgery. For the wheezing symptom, 71.5% (95% CI 62.9-78.8%) reported improvement after surgery. Moreover, surgery presented better results in improving respiratory symptoms than medical therapy (risk difference: -0.46; 95% CI -0.77, -0.16). Physicians should strongly consider surgical anti-reflux procedures for controlling respiratory symptoms in GERD patients after proper patient selection. Anti-reflux surgery has shown high efficacy in improving respiratory symptoms related to GERD, even when compared to medical therapy.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil.
| | - Wanderley Marques Bernardo
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
| | - Julio Rafael Mariano da Rocha
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
| | - Sérgio Szachnowicz
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
| | | | - Edno Tales Bianchi
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
| | - Flávio Roberto Takeda
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
| | - Antonio Afonso de Miranda Neto
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
| | - Rubens Antonio Aissar Sallum
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Digestive Surgery Division, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, 05403-000, Brazil
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Duman M, Polat E, Ozer M, Demirci Y, Yasar NF, Akyuz C, Uzun O, Peker KD, Genc E, Yol S. The effect of rabeprazole on LES tone in experimental rat model. J INVEST SURG 2013; 26:186-90. [PMID: 23514061 DOI: 10.3109/08941939.2012.733487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Despite adequate treatment with proton pump inhibitors (PPIs), symptoms of gastroesophageal reflux disease (GERD) may remain persistent as well as Barrett's esophagus may emerge. It may be proposed that the relaxant effect of PPIs on the smooth muscles may lead to resistance of symptoms. The aim of this study is to investigate effects of rabeprazole on the lower esophageal sphincter (LES) pressure with a rat model. MATERIALS AND METHODS Sixteen rats were grouped as control and treatment groups. After obtaining LES tissues followed by a 60 min equilibration period for stabilization, contractile response to carbachol was obtained by application of single dose of carbachol to have a final concentration of 10(-6) M in the organ bath. After the contractions reached a plateau, concentration-response relationships for rabeprazole were obtained in a cumulative manner in the treatment group. RESULTS In the carbachol contracted LES preparations; 1.5 × 10(-6) and 1.5×10(-5) M of rabeprazole caused 6.08% and 11.34% relaxations respectively which were not statistically significant. However, mean integral relaxation value for 4.5 × 10(-5) M of rabeprazole was 17.34% and this relaxation was significant compared with controls. CONCLUSIONS In the present study, rabeprazole caused no direct significant change in LES tone in the therapeutic dose range applied to the organ bath. However, rabeprazole at the high dose caused a significant decrease in the LES tone.
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Affiliation(s)
- Mustafa Duman
- Department of Gastrointestinal Surgery, Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey.
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Trad KS, Turgeon DG, Deljkich E. Long-term outcomes after transoral incisionless fundoplication in patients with GERD and LPR symptoms. Surg Endosc 2011; 26:650-60. [PMID: 21959689 PMCID: PMC3271216 DOI: 10.1007/s00464-011-1932-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 08/31/2011] [Indexed: 02/06/2023]
Abstract
Background A retrospective study evaluated safety, symptom resolution, patient satisfaction, and medication use 1–2 years after transoral incisionless fundoplication (TIF) in patients with gastroesophageal reflux disease (GERD) and/or laryngopharyngeal reflux (LPR) symptoms. Methods Thirty-four patients with a confirmed diagnosis of GERD symptoms that were inadequately controlled by antisecretory medications, and who where either dissatisfied with their current therapy or not willing to continue taking medication, underwent TIF using EsophyX at our community-based hospital. Follow-up assessments were completed in 28 patients. Results Median age of the study group was 57 (range = 23–77) years, BMI was 25.7 (18.3–36.4) kg/m2, and 50% were female. All patients had documented chronic GERD for a median 5 (1–20) years and refractory symptoms to proton pump inhibitors (PPIs). Hiatal hernia was present in 75% (21/28) of patients, and 21% (6/28) had erosive esophagitis (LA grade A or B). TIF was performed following a standardized TIF-2 protocol and resulted in reducing hiatal hernia and restoring the natural anatomy of the gastroesophageal (GE) junction (Hill grade I). There were no postoperative complications. At a median 14-months follow-up, 82% (23/28) of patients were off daily PPIs (64% completely off PPIs), and 68% (19/28) were satisfied with their current health condition compared to 4% before TIF. Median GERD Health-Related Quality of Life scores were significantly reduced to 4 (0–25) from 26 (0–45) before TIF (P < 0.001). Heartburn was eliminated in 65% (17/26) and improved by >50% in 86% (24/28) of patients. Regurgitation was eliminated in 80% (16/20) of patients. Atypical LPR symptoms such as hoarseness, coughing, and throat clearing were eliminated in 63% (17/27) of patients as measured by Reflux Symptom Index scores. Conclusion Our results in 28 patients confirm the safety and effectiveness of TIF, documenting symptomatic improvement of GERD and LPR symptoms and clinically significant discontinuation of daily PPIs in 82% of patients.
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Affiliation(s)
- Karim S Trad
- Reston Surgical Associates, 1800 Town Center Dr. # 312, Reston, VA 20190, USA.
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Bresadola V, Adani GL, Londero F, Leo CA, Cherchi V, Lorenzin D, Rossetto A, Vit G, Baccarani U, Terrosu G, Anna DD. Non-erosive and uncomplicated erosive reflux diseases: Difference in physiopathological and symptom pattern. World J Gastrointest Pathophysiol 2011; 2:42-8. [PMID: 21860835 PMCID: PMC3158890 DOI: 10.4291/wjgp.v2.i3.42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/31/2011] [Accepted: 04/07/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate differences in the physiopathological findings (manometry and pH monitoring) and symptoms between cases of non-erosive reflux disease (NERD) and erosive reflux disease (ERD) found positive at 24 h pH monitoring.
METHODS: For a total of 670 patients who underwent 24 h pH monitoring, esophageal manometry and upper endoscopy were retrospectively evaluated, assessing the reflux symptoms, manometric characteristics of the lower esophageal sphincter (LES) and esophageal body and the presence or absence of esophagitis and hiatal hernia. Typical and atypical symptoms were also evaluated. For inclusion in the study, patients had to have NERD or ERD and be found positive on pH monitoring (NERD+). Patients with Gastroesophageal reflux disease (GERD) complicated by stenosis, ulcers or Barrett's esophagus were ruled out.
RESULTS: 214 patients were involved in the study, i.e. 107 cases of NERD+ and 107 of ERD. There were no significant gender- or age-related differences between the two groups. The ERD group had more cases of hiatal hernia (P = 0.02) and more acid reflux, both in terms of number of reflux episodes (P = 0.01) and as a percentage of the total time with a pH < 4 (P = 0.00), when upright (P = 0.007) and supine (P = 0.00). The NERD+ cases had more reflux episodes while upright (P = 0.02) and the ERD cases while supine (P = 0.01). The LES pressure was higher in cases of NERD+ (P = 0.03) while the amplitude and duration of their esophageal peristaltic waves tended to be better than in the ERD group (P >0.05). The NERD+ patients presented more often with atypical symptoms (P = 0.01).
CONCLUSION: The NERD+ patients’ fewer reflux episodes and the fact that they occurred mainly while in the upright position (unlike the cases of ERD) may be two factors that do not favor the onset of esophagitis. The frequently atypical symptoms seen in patients with NERD+ need to be accurately evaluated for therapeutic purposes because patients with GERD and atypical symptoms generally respond only partially to medical and surgical treatments.
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Corrêa MCCSF, Lerco MM, Henry MACDA. [Study in oral cavity alterations in patients with gastroesophageal reflux disease]. ARQUIVOS DE GASTROENTEROLOGIA 2009; 45:132-6. [PMID: 18622467 DOI: 10.1590/s0004-28032008000200008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Accepted: 12/26/2007] [Indexed: 11/22/2022]
Abstract
BACKGROUND The gastroesophageal reflux disease, which has become highly and increasingly incident, may be manifested by typical (pyrosis and regurgitation) and atypical (pulmonary, otorhinolaryngological and buccal) symptoms. AIM To analyze alterations in the oral cavity patients with gastroesophageal reflux disease. METHODS One hundred patients were studied being 50 gastroesophageal reflux disease patients (group 1) and 50 controls (group 2). All patients were submitted to an oral clinical exam and specific survey. Patients in group 1 were submitted to upper endoscopy, manometry and esophageal pH monitoring. RESULTS The upper endoscopy revealed esophagitis in all patients, 20 erosive esophagitis, 30 no-erosive esophagitis and 38 hiatal hernia. Average pressure of the lower esophageal sphincter was 11 +/- 4,8 mm Hg and of the upper esophageal sphincter 75 +/- 26,5 mm Hg. In 42 patients of group 1 (84%) pathological gastroesophageal reflux was observed. Clinical exams revealed: dental erosions in group 1: 273 faces and in group 2: 5 tooth decays in group 1: 23 and 115 in group 2; abrasion in group 1: 58 and in group 2: 95; attrition wear: 408 in group 1 and 224 in group 2. The most damages was the palatine face. In group 1, 21 patients complained about frequent episodes of canker sores, 35 of tooth sensibility, 26 of burning mouth and 42 of sour taste in the mouth. In group 2 the complaints were observed in lower number of patients. CONCLUSIONS Patients with gastroesophageal reflux disease present higher incidence of dental erosion, canker sores, mouth burning sensation, sensitivity and sour taste than controls. Patients with gastroesophageal reflux disease show lower incidence of tooth decays as compared to controls.
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Iqbal M, Batch AJ, Spychal RT, Cooper BT. Outcome of Surgical Fundoplication for Extraesophageal (Atypical) Manifestations of Gastroesophageal Reflux Disease in Adults: A Systematic Review. J Laparoendosc Adv Surg Tech A 2008; 18:789-96. [DOI: 10.1089/lap.2007.0165] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Mohd Iqbal
- Department of General Surgery, City Hospital, Birmingham, United Kingdom
| | - Andrew J. Batch
- Department of ENT Surgery, City Hospital, Birmingham, United Kingdom
| | - Robert T. Spychal
- Department of General Surgery, City Hospital, Birmingham, United Kingdom
| | - Brian T. Cooper
- Department of Gastroenterology, City Hospital, Birmingham, United Kingdom
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Chin KF, Myers JC, Jamieson GG, Devitt PG. Symptoms experienced during 24-h pH monitoring and their relationship to outcome after laparoscopic total fundoplication. Dis Esophagus 2008; 21:445-51. [PMID: 19125799 DOI: 10.1111/j.1442-2050.2007.00798.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Some patients having a 24-h pH monitoring test prior to laparoscopic fundoplication experience no symptoms at all in spite of having a positive test, and other patients experience only atypical symptoms in spite of having a positive test. This study investigates the postoperative outcome of such patients. All patients underwent esophageal manometry and 24-h esophageal pH monitoring before laparoscopic total fundoplication. Patients were divided into three groups based on their symptom profile recorded during a positive 24-h pH monitoring: those with typical symptoms (n = 104), those with atypical symptoms (n = 28) and those who experienced no symptoms at all (n = 23). The outcomes measured were heartburn score (0-10), dysphagia composite score (0-45) and satisfaction score (0-10) at 12 months after surgery. Outcome analysis reveals the heartburn scores were significantly reduced postoperatively for all groups of patients. At 1 year after surgery, there was no difference among the three groups of patients in terms of heartburn score and dysphagia composite scores, nor the experience of bloating, belching, or their willingness to repeat surgery. Despite one group experiencing no symptoms, and another group atypical symptoms during a positive pH study, the postoperative satisfaction scores for these two groups was good, but significantly less (P = 0.03, P = 0.02, respectively) than the group of patients with a typical symptom index. In conclusion, patients who experience only atypical symptoms or no symptoms at all during their preoperative positive 24-h pH monitoring may still obtain a good result from antireflux surgery. However, these symptom profiles should alert the surgeon that such patients may have an outcome which is not as good as patients who experience only typical symptoms during a pH study.
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Affiliation(s)
- K-F Chin
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia
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Kaufman JA, Houghland JE, Quiroga E, Cahill M, Pellegrini CA, Oelschlager BK. Long-term outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder. Surg Endosc 2008; 20:1824-30. [PMID: 17063301 DOI: 10.1007/s00464-005-0329-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Accepted: 02/21/2006] [Indexed: 12/19/2022]
Abstract
UNLABELLED A strong link exists between gastroesophageal reflux disease (GERD) and airway diseases. Surgical therapy has been recommended as it is more effective than medical therapy in the short-term, but there is little data on the effectiveness of surgery long-term. We analyzed the long-term response of GERD-related airway disease after laparoscopic anti-reflux surgery (LARS). METHODS In 2004, we contacted 128 patients with airway symptoms and GERD who underwent laparoscopic antireflux surgery (LARS) between 12/1993 and 12/ 2002. At median follow-up of 53 months (19-110 mo) we studied the effects on symptoms, esophageal acid exposure, and medication use and we analyzed the data to determine predictors of successful resolution of airway symptoms. RESULTS Cough, hoarseness, wheezing, sore throat, and dyspnea improved in 65-75% of patients. Heartburn improved in 91% (105/116) of patients and regurgitation in 92% (90/98). The response rate for airway symptoms was the same in patients with and without heartburn. Almost every patient took proton pump inhibitors (PPIs) preoperatively (99%, 127/128) and 61% (n = 78) were taking double or triple dose. Postoperatively, 33% (n = 45) of patients were using daily antiacid therapy but no one was on double dose. The only factor that predicted a successful surgical outcome was the presence of abnormal reflux in the pharynx as determined by 24-hour pharyngeal pH monitoring. One hundred eleven (87%) patients rated their results as excellent (n = 78, 57%) or good (n = 33, 24%). CONCLUSION LARS provides an effective and durable barrier to reflux, and in so doing improves GERD-related airway symptoms in approximately 70% of patients and improves typical GERD symptoms in approximately 90% of patients. Pharyngeal pH monitoring identifies those patients more likely to benefit from LARS, but better diagnostic tools are needed to improve the response of airway symptoms to that of typical esophageal symptoms.
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Affiliation(s)
- J A Kaufman
- Department of Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195-6410, USA
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Symptom-focused results after laparoscopic fundoplication for refractory gastroesophageal reflux disease—a prospective study. Langenbecks Arch Surg 2008; 393:979-84. [DOI: 10.1007/s00423-008-0294-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 01/24/2008] [Indexed: 12/23/2022]
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Gurski RR, da Rosa ARP, do Valle E, de Borba MA, Valiati AA. Extraesophageal manifestations of gastroesophageal reflux disease. J Bras Pneumol 2007; 32:150-60. [PMID: 17273585 DOI: 10.1590/s1806-37132006000200011] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Accepted: 07/07/2005] [Indexed: 02/07/2023] Open
Abstract
Gastroesophageal reflux disease often presents as heartburn and acid reflux, the so-called "typical" symptoms. However, a subgroup of patients presents a collection of signs and symptoms that are not directly related to esophageal damage. These are known collectively as the extraesophageal manifestations of gastroesophageal reflux disease. Principal among such manifestations are bronchospasm, chronic cough and laryngitis, which are classified as atypical symptoms. These manifestations comprise a heterogeneous group. However, some generalizations can be made regarding all of the subgroups. First, although the correlation between gastroesophageal reflux disease and the extraesophageal manifestations has been well established, a cause-and-effect relationship has yet to be definitively elucidated. In addition, the main proposed pathogenic mechanisms of extraesophageal reflux are direct injury of the extraesophageal tissue (caused by contact with gastric acid) and the esophagobronchial reflex, which is mediated by the vagus nerve. Furthermore, gastroesophageal reflux disease might not be considered in the differential diagnosis of patients presenting only the atypical symptoms. In this article, we review the extraesophageal manifestations of gastroesophageal reflux disease, discussing its epidemiology, pathogenesis, diagnosis and treatment. We focus on the most extensively studied and well-established presentations.
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Mjönes AB, Borch K, Tibbling L, Ledin T, Hultcrantz E. Hoarseness and misdirected swallowing in patients with hiatal hernia. Eur Arch Otorhinolaryngol 2007; 264:1437-9. [PMID: 17643255 DOI: 10.1007/s00405-007-0396-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Accepted: 06/28/2007] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to elucidate whether misdirected swallowing is an extra-laryngeal cause of hoarseness and investigate whether the prevalence of misdirected swallowing and hoarseness in patients with hiatal hernias differ from those with and without pathological gastroesophageal reflux (GER). One hundred and ninety eight patients with hiatal hernias diagnosed via esophageal manometry and pH-reflux test and 262 subjects in the general population who did not have a hiatal hernia at endoscopy, filled in a questionnaire about symptoms on hoarseness, misdirected swallowing, and heartburn. Hoarseness (35%), misdirected swallowing to the larynx (MSL; 35%), misdirected swallowing to the nose (MSN; 22%) and heartburn (85%) were significantly more common in patients with hiatal hernia than in controls (13, 5, 1, and 6%, respectively, P<0.001). MSL and MSN in the patient group were significantly interrelated (P<0.0001). Hoarseness and MSL were not significantly associated (P<0.076). Hoarseness and MSL were as common in the hernia group with normal GER, as in the group with pathological GER. There is a predisposition for hoarseness and MSL in patients with hiatal hernias, but the cause-and-effect relationship is unclear. Hoarseness does not seem to be caused by pathological GER.
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Affiliation(s)
- Anna-Britta Mjönes
- Department of Otorhinolaryngology, University Hospital, Linköping, Sweden
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Orr WC, Craddock A, Goodrich S. Acidic and Non-Acidic Reflux During Sleep Under Conditions of Powerful Acid Suppression. Chest 2007; 131:460-5. [PMID: 17296648 DOI: 10.1378/chest.06-1312] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND During sleep, individuals are uniquely vulnerable to acid reflux. Acid reflux during sleep has been studied by a number of investigators, but non-acid reflux is largely unexplored. METHODS In this study, 15 individuals with significant subjective complaints of heartburn were treated with esomeprazole, 40 mg bid, and with placebo, in random order, for 1 week each. After 1 week of treatment, participants underwent combined impedence/pH monitoring and polysomnography. In both drug and placebo conditions, these procedures were done after participants consumed a meal designed to increase the likelihood of reflux events. RESULTS Total reflux events and acid reflux events were significantly decreased with proton-pump inhibitor (PPI) treatment as compared to placebo. Nonacid reflux events were more common with PPI treatment as compared to placebo, but this result was not statistically significant. The ratio of non-acidic to acidic events was significantly greater with PPI treatment, however. Similar results were found for reflux events that occurred only during sleep. Proximal migration of acidic vs non-acidic reflux events was found to be similar. There was no difference in sleep architecture between placebo and drug conditions. CONCLUSION PPI treatment reduced overall reflux events, but non-acidic reflux events were relatively more likely to occur with PPI treatment. The occurrence of these non-acidic reflux events on PPI might conceivably explain why some individuals continue to have symptoms after PPI treatment.
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Affiliation(s)
- William C Orr
- Lynn Health Science Institute, 5300 N Independence, Suite 130, Oklahoma City, OK 73112, USA
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14
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Goessler A, Huber-Zeyringer A, Hoellwarth ME. Recurrent gastroesophageal reflux in neurologically impaired patients after fundoplication. Acta Paediatr 2007; 96:87-93. [PMID: 17187611 DOI: 10.1111/j.1651-2227.2006.00005.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIM To evaluate the outcome and analyse the main causes of complications and failures of antireflux surgery for gastroesophageal reflux disease (GERD) in neurologically impaired patients (NIP). METHODS From 1985 to 1999 44 NIP (mean age 12 years) underwent surgery for GERD. Type of surgery, complications and recurrent reflux were analysed. RESULTS Twenty-seven patients (61%) showed preoperatively severe failure to thrive. All patients showed pathologic results in 24-h pH monitoring. Surgical treatment consisted of ventral (n = 25, Thal) or dorsal (n = 4, Toupet) semifundoplication or a Nissen fundoplication (n = 15). Postoperatively, all patients showed an impressive growth, regress of symptoms and improvement of results of diagnostic investigations. Late complications and recurrence of reflux were significantly related to preoperative extreme dystrophy (p < 0.0025). In six patients (15%) severity of symptoms related to recurrent reflux required a reoperation 17.8 month postoperatively (range 8-35 month). Recurrent reflux was found in 40% after ventral semifundoplication and in 46% after Nissen fundoplication (8 and 47 months postoperatively, respectively). CONCLUSION Symptoms improved impressively after fundoplication in mentally retarded children. The incidence of recurrent reflux is not related to the type of surgery, however, it occurs significantly earlier with ventral semifundoplication when compared with Nissen fundoplication. Both late complications as well as recurrent reflux are related significantly to preoperative dystrophy.
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Affiliation(s)
- A Goessler
- Department of Pediatric Surgery, University of Graz, Medical School, Auenbruggerplatz, Graz, Austria.
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15
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Wykypiel H, Bonatti H, Hinder RA, Glaser K, Wetscher GJ. The laparoscopic fundoplications: Nissen and partial posterior (Toupet) fundoplication. Eur Surg 2006. [DOI: 10.1007/s10353-006-0259-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Ciovica R, Gadenstätter M, Klingler A, Neumayer C, Schwab GP. Laparoscopic antireflux surgery provides excellent results and quality of life in gastroesophageal reflux disease patients with respiratory symptoms. J Gastrointest Surg 2005; 9:633-7. [PMID: 15862256 DOI: 10.1016/j.gassur.2005.02.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2004] [Revised: 02/10/2005] [Accepted: 02/14/2005] [Indexed: 01/31/2023]
Abstract
Medical and surgical treatment are able to improve symptoms in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the outcome following laparoscopic antireflux surgery in GERD patients with primary respiratory-related symptoms and to investigate the quality of life index before and after therapy. Three hundred thirty-eight consecutive patients underwent surgical treatment for GERD-induced symptoms. Of this group 126 patients had primary respiratory symptoms related to GERD. All patients were studied by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, the quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI). All patients had medical therapy with proton pump inhibitors preoperatively. A laparoscopic fundoplication was performed in all patients. The outcome was assessed 3 and 12 months postoperatively. Following surgery, all respiratory symptoms were significantly improved. While GIQLI was highly impaired before surgical therapy, a significant improvement of quality of life was obtained. Because medical treatment is likely to fail in GERD patients with respiratory symptoms, the need for surgery arises and may be the only successful treatment in the long term. Quality of life was significantly improved by surgical treatment.
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Affiliation(s)
- Ruxandra Ciovica
- Department of Surgery, Austria, General Hospital of Krems, Krems, Austria.
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18
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Triponez F, Dumonceau JM, Azagury D, Volonte F, Slim K, Mermillod B, Huber O, Morel P. Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group. Surgery 2005; 137:235-42. [PMID: 15674207 DOI: 10.1016/j.surg.2004.07.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic fundoplication effectively controls reflux symptoms in patients with gastroesophageal reflux disease (GERD). However, symptom relapse and side effects, including dysphagia and gas bloat, may develop after surgery. The aim of the study was to assess these symptoms in patients who underwent laparoscopic fundoplication, as well as in control subjects and patients with hiatal hernia. METHODS A standardized, validated questionnaire on reflux, dysphagia, and gas bloat was filled out by 115 patients with a follow-up of 1 to 7 years after laparoscopic fundoplication, as well as by 105 subjects with an incidentally discovered hiatal hernia and 238 control subjects. RESULTS Patients who underwent fundoplication had better reflux scores than patients with hiatal hernia ( P = .0001) and similar scores to control subjects ( P = .11). They also had significantly more dysphagia and gas bloat than patients with hiatal hernia and controls ( P < .005 for all comparisons). Gas bloat and dysphagia were more severe in hiatal hernia patients than in controls ( P < 0.005). After fundoplication, the 25% of the patients with the shortest follow-up (1.5 +/- 0.2 years) and the 25% patients with the longest follow-up (5.8 +/- 0.6 years) had similar reflux, dysphagia, and gas bloat scores ( P = .43, .82, and .85, respectively). CONCLUSION In patients with severe GERD, laparoscopic fundoplication decreases reflux symptoms to levels found in control subjects. These results appear to be stable over time. However, patients who underwent fundoplication experience more dysphagia and gas bloat than controls and patients with hiatal hernia-symptoms that should be seen as a side effect of the procedure and of GERD itself.
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Affiliation(s)
- Frederic Triponez
- Clinic and Policlinic of Digestive Surgery, Department of Surgery, University Hospital of Geneva, Geneva, Switzerland.
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19
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Wykypiel H, Wetscher GJ. Präoperative Diagnostik bei der gastroösophagealen Refluxkrankheit – was ist notwendig, was ist verzichtbar? Visc Med 2005. [DOI: 10.1159/000083353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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20
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Wykypiel H, Wetscher GJ, Klingler P, Glaser K. The Nissen fundoplication: indication, technical aspects and postoperative outcome. Langenbecks Arch Surg 2004; 390:495-502. [PMID: 15351884 DOI: 10.1007/s00423-004-0494-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2004] [Accepted: 03/11/2004] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is the most common foregut disease, with a great impact on quality of life and with intestinal, respiratory and cardiac symptoms and implications of carcinogenesis of the oesophagus. Medical therapy often fails, due to the complex pathophysiology of GERD. Surgery can cure the disease, since it is able to restore the anti-reflux barrier. It improves quality of life and prevents carcinogenesis. METHODS Review of the literature and presentation of our own experience and data in a series of more than 4,000 evaluated patients referred for suspected reflux disease, of whom 382 have been operated on. CONCLUSION The laparoscopic Nissen fundoplication is the most commonly used operation technique. It provides good long-term results in the majority of patients. However, due to an increase of outflow resistance of the oesophagus this operation is associated with some postoperative side effects. Therefore, alternative anti-reflux procedures may be indicated in selected patients.
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Affiliation(s)
- H Wykypiel
- Department of General and Transplantation Surgery, University Hospital of Innsbruck, Innsbruck, Austria
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21
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Kauer WKH, Stein HJ, Möbius C, Siewert JR. Assessment of respiratory symptoms with dual pH monitoring in patients with gastro-oesophageal reflux disease. Br J Surg 2004; 91:867-71. [PMID: 15227693 DOI: 10.1002/bjs.4551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Gastro-oesophageal reflux disease (GORD) is a commonly underestimated aetiological factor in patients with respiratory symptoms. In this study, acid reflux in healthy volunteers and patients with GORD with and without respiratory symptoms was investigated by dual pH monitoring. METHODS Thirty healthy volunteers and 43 patients with GORD underwent oesophageal manometry and dual pH monitoring with one probe in the proximal and one in the distal oesophagus. Nineteen of the 43 patients complained of respiratory symptoms. RESULTS There were no differences in proximal probe measurements between volunteers and patients without respiratory symptoms. Patients with GORD and respiratory symptoms had a higher prevalence of abnormally high exposure to gastric juice and more reflux episodes in the proximal oesophagus compared with patients with GORD and no respiratory symptoms. Some 17 of 19 patients with GORD and respiratory symptoms showed deteriorated oesophageal body motility. CONCLUSION Dual pH monitoring is feasible and well tolerated, and provides an objective means of evaluating patients with GORD and respiratory symptoms. Prolonged exposure of the proximal oesophagus to gastric juice and disorders of oesophageal body motility seem to be responsible for the development of respiratory symptoms.
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Affiliation(s)
- W K H Kauer
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
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22
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Allen CJ, Anvari M. Does laparoscopic fundoplication provide long-term control of gastroesophageal reflux related cough? Surg Endosc 2004; 18:633-7. [PMID: 15026893 DOI: 10.1007/s00464-003-8821-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2003] [Accepted: 09/17/2003] [Indexed: 01/25/2023]
Abstract
BACKGROUND Of patients with chronic cough, 21% have GERD. Up to half of these patients may not respond adequately to medical, but the long-term results of antireflux surgery for cough is unknown. METHODS A total of 905 patients (209 with respiratory symptoms, mainly cough) underwent laparoscopic Nissen fundoplication. Preoperatively patients underwent esophageal motility studies, 24-h pH monitoring, and symptom evaluation using a validated scale. Of eligible patients, 81% were followed at 6 months, 73% at 2 years, and 60% at 5 years. RESULTS Before surgery, 83% of respiratory patients (RP) and 51% of nonrespiratory patients (NRP) had cough. RP had higher cough scores ( p < 0.0001), but improvement in cough compared to baseline was similar in the RP and NRP ( p = 0.1105 at 6 months, 0.4206 at 2 years, and 0.1348 at 5 years). Cough improved in 83% at 6 months, 74% at 2 years, and 71% at 5 years. CONCLUSIONS Laparoscopic Nissen fundoplication is successful in the long-term control of GERD-related cough, even in patients who fail medical therapy.
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Affiliation(s)
- C J Allen
- Department of Medicine, St Joseph's Healthcare-McMaster University, 50, Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada
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Abstract
The association between gastroesophageal reflux disease (GERD) and extraesophageal disease is often referred to as extraesophageal reflux (EER). This article reviews EER, discussing epidemiology, pathogenesis, diagnosis, and treatment with a focus on the most studied and convincing EER disorders-asthma, cough, and laryngitis. Although EER comprises a heterogeneous group of disorders, some general characterizations can be made, as follows. First, although GERD's association with extraesophageal diseases is well-established, definitive evidence of causation has been more elusive, rendering epidemiological data scarce. Secondly, regarding the pathogenesis of EER, 2 basic models have been proposed: direct injury to extraesophageal tissue by acid and pepsin exposure or injury mediated through an esophageal reflex mechanism. Third, because heartburn and regurgitation are often absent in patients with EER, GERD may not be suspected. Even when GERD is suspected, the diagnosis may be difficult to confirm. Although endoscopy and barium esophagram remain important tools for detecting esophageal complications, they may fail to establish the presence of GERD. Even when GERD is diagnosed by endoscopy or barium esophagram, causation between GERD and extraesophageal symptoms cannot be determined. Esophageal pH is the most sensitive tool for detecting GERD, and it plays an important role in EER. However, even pH testing cannot establish GERD's causative relationship to extraesophageal symptoms. In this regard, effective treatment of GERD resulting in significant improvement or remission of the extraesophageal symptoms provides the best evidence for GERD's pathogenic role. Finally, EER generally requires more prolonged and aggressive antisecretory therapy than typical GERD requires.
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Affiliation(s)
- John Napierkowski
- Department of Medicine, Uniformed University of the Health Sciences, Washington, DC, USA
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24
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Abstract
Since the early 1960s, many studies have been published that consider the possible relationship between gastro-oesophageal (acid) reflux (GORD) and various other complaints, including dental erosions, ear, nose and throat problems, chronic cough and asthma. Although a high coincidence of GORD and these supra-oesophageal complaints have been noted, there is no consensus on the pathophysiology and management of such complications. In this article we review the literature published between 1966 and 2000 on this subject. We also analyse the available information on the incidence, pathophysiological mechanisms, diagnostic approach and therapeutic options in the various subgroups of disorders.
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Affiliation(s)
- John N Groen
- Department of Internal Medicine and Gastroenterology, Hospital 'St Jansdal', Harderwijk, The Netherlands.
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25
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Oelschlager BK, Pellegrini CA. Surgical treatment of respiratory complications associated with gastroesophageal reflux disease. Am J Med 2003; 115 Suppl 3A:72S-77S. [PMID: 12928079 DOI: 10.1016/s0002-9343(03)00197-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although the association between gastroesophageal reflux (GER) and typical esophageal symptoms, such as heartburn and regurgitation, is straightforward, this is not the case for the relation between GER and respiratory symptoms. The strongest link is the finding of abnormal reflux in the proximal esophagus or pharynx. This finding, in conjunction with evidence of airway injury such as seen on laryngoscopy, strongly supports the relation between GER and airway disease. Medical therapy provides relief to some patients, but with less consistency than for those with typical symptoms of GER disease. This is likely due to persistent aspiration or injury from supraesophageal reflux. Laparoscopic antireflux surgery is extremely safe and effective for reducing reflux as well as aspiration, and appears to be more effective than medical treatment for treating GER-related respiratory symptoms.
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Abstract
BACKGROUND People with proven gastroesophageal reflux disease may also experience symptoms such as voice loss, chronic cough, globus, and sore throat. These laryngopharyngeal reflux symptoms have been reported to respond to prolonged proton pump inhibitor therapy, but the Hill approach to resolving these specific individual symptoms has not been widely reported in surgical literature. METHODS This clinical outcome study is an analysis of symptom improvement in 145 patients who underwent laparoscopic Hill hiatal hernia repair. A standardized questionnaire was used to score eight gastroesophageal reflux disease symptoms and four laryngopharyngeal reflux symptoms. Also, each patient's primary chief complaints were analyzed. RESULTS Gastroesophageal reflux and laryngopharyngeal reflux symptoms significantly improved (P < 0.01) compared with preoperative symptoms. Each patient's primary chief complaints improved as well. CONCLUSIONS This clinical outcome analysis documents symptomatic improvement of laryngopharyngeal reflux and gastroesophageal reflux. Likewise, when these laryngopharyngeal reflux symptoms are chief complaints, with proven gastroesophageal reflux disease, the Hill approach to symptom resolution is likely to be successful.
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Affiliation(s)
- Robert C Wright
- Meridian Surgical Services, Inc., Good Samaritan Hospital, Puyallup, WA 98371, USA.
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27
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Abstract
BACKGROUND Laparoscopic fundoplication has become the standard of care for the management of symptomatic gastro-oesophageal reflux disease (GORD). Although atypical and respiratory symptoms are frequently described in standard texts in association with reflux, the response of respiratory symptoms to management of GORD has not been extensively studied. METHODS Herein is reported a prospective series of 29 patients who presented with predominantly respiratory symptoms. Typical and respiratory symptoms were graded according to a standard scale. All patients had preoperative investigations confirming GORD. These patients were treated by a laparoscopic Nissen fundoplication and followed up for a minimum of 14 months (range: 14-48 months). Patients were contacted and interviewed by an independent observer. RESULTS Conversion to open surgery was necessary in three patients. There were four significant complications. Ultimately control of typical reflux symptoms was achieved in 88%. Cough was completely relieved in 81% and improved in a further 13%. Wheeze and nocturnal bronchospasm was completely relieved in 50% and improved in the balance. Dysphagia remains a significant problem, with only 42% of patients completely free of trouble. CONCLUSIONS Overall the respiratory symptoms were improved in the majority of patients, with cough responding somewhat better than wheeze. Appropriate patient selection remains the greatest challenge when a patient with cough or wheeze that is considered to be due to GORD is referred for surgery.
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Affiliation(s)
- Richard Brouwer
- Department of Clinical and Biomedical Science, University of Melbourne, Victoria, Australia
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28
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Affiliation(s)
- Marco G Patti
- Department of Surgery, University of California, San Francisco 94143-0788, USA.
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Bammer T, Freeman M, Shahriari A, Hinder RA, DeVault KR, Achem SR. Outcome of laparoscopic antireflux surgery in patients with nonerosive reflux disease. J Gastrointest Surg 2002; 6:730-7. [PMID: 12399063 DOI: 10.1016/s1091-255x(02)00042-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa.
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Affiliation(s)
- Tanja Bammer
- Department of Surgery, Mayo Clinic, Jacksonville, Florida 32224, USA
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Bammer T, Kamloz T, Pasiut M, Wetscher G, Pointner R. Austrian experiences of antireflux surgery. Surg Endosc 2002; 16:1350-3. [PMID: 11984661 DOI: 10.1007/s00464-001-0076-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2000] [Accepted: 11/29/2001] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antireflux surgery (ARS) is a well established treatment for GERD (gastroesophageal reflux disease). The present study gives an overview of experience in Austria regarding the frequency of open and laparoscopic ARS and how Austrian departments meet the requirements for surgery. METHODS A questionnaire was sent to 115 surgical departments in Austria to evaluate in how many institutions antireflux surgery (open and/or laparoscopically) was performed since 1990, and which pre- and postoperative tests were obligatory, optional, or not performed. Units were divided into specialized and nonspecialized. RESULTS The laparoscopic approach has gained in importance by about 300% in the past 5 years in the few hospitals performing this procedure. Esophageal manometry and 24-h pH monitoring were rarely done in nonspecialized units, despite the fact that GERD is mainly a functional disorder of the esophagus and stomach. In contrast to the nonspecialized units, the specialized unit performed upper endoscopy, esophageal manometry and 24-h esophageal pH monitoring as obligatory tests. CONCLUSIONS ARS, both open and laparoscopic, is not commonly performed in surgical departments in Austria but the frequency has significantly increased in recent years. Laparoscopic ARS is a safe procedure in hospitals performing this frequently. Laparoscopic ARS should only be performed in specialized units with significant experience in gastroesophageal diseases, where functional testing of the esophagus can be done.
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Affiliation(s)
- T Bammer
- Department of General Surgery, A.O. Krankenhaus Zell am See, Paracelsusstrasse 8, A-5700 Zell am See, Austria
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Novitsky YW, Zawacki JK, Irwin RS, French CT, Hussey VM, Callery MP. Chronic cough due to gastroesophageal reflux disease: efficacy of antireflux surgery. Surg Endosc 2002; 16:567-71. [PMID: 11972189 DOI: 10.1007/s00464-001-8328-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2001] [Accepted: 09/24/2001] [Indexed: 01/17/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) can be overlooked as the cause of chronic cough (CC) when typical gastrointestinal symptoms are absent or minimal. We analyzed the outcomes of Nissen fundoplication (NF) for patients who failed medical therapy for CC attributable only to GERD (G-CC). We performed a prospective outcome evaluation of 21 consecutive patients with G-CC undergoing NF from 1997 to 2000 at a tertiary care university hospital. MATERIALS AND METHODS Twenty-one patients without prior antireflux surgeries had G-CC diagnosed by a clinical profile and 24-h pH monitoring showing a cough-reflux correlation. Respiratory symptoms alone were present in 53% of patients. NF was performed when G-CC persisted despite intensive medical therapy, including an antireflux diet. Preoperatively, all patients underwent 24-h pH monitoring, esophageal manometry, barium swallow, gastric emptying study, bronchoscopy, and upper endoscopy. NF was utilized in all cases, laparoscopically in 18. Before and after surgery, patients graded their cough severity using the Adverse Cough Outcome Survey (ACOS). Quality of life was measured using the Sickness Impact Profile (SIP). RESULTS Postoperatively, 18 patients (86%) reported an improvement of their cough. G-CC considerably improved in 16/21 patients (76%), with complete resolution in 13 patients (62%). Mild to moderate improvement was found in 2 patients (10%). Patient-reported cough severity (ACOS) and quality of life (SIP) both significantly improved early (6-12 weeks) postoperatively and persisted during the long-term (1 year) follow-up. The average hospital length of stay was 1.78 +/- 0.2 (l-4) days for the laparoscopic (n = 18) and 6.3 +/- 1.2 (4-8) days for the open surgery (n = 3) groups. CONCLUSION Twenty-four-hour esophageal pH monitoring is a valuable tool for preoperative cough-reflux correlation. Antireflux surgery is effective in carefully selected patients whose refractory CC is attributable only to GERD. NF controls the severity of cough while improving the quality of life. Outcomes are further enhanced using laparoscopic procedures with shorter hospital stays.
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Affiliation(s)
- Y W Novitsky
- Department of Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
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32
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Granderath FA, Kamolz T, Schweiger UM, Pasiut M, Wykypiel H, Pointner R. Quality of life and symptomatic outcome three to five years after laparoscopic Toupet fundoplication in gastroesophageal reflux disease patients with impaired esophageal motility. Am J Surg 2002; 183:110-6. [PMID: 11918872 DOI: 10.1016/s0002-9610(01)00868-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Many centers practice a tailored approach to laparoscopic antireflux surgery in attempt to prevent postoperative side effects in gastroesophageal reflux disease (GERD) patients with an impaired esophageal motility. As a result of controversial findings reported in literature no worldwide accepted consensus exists regarding the appropriate indication for this tailored approach. The aim of this prospective study was to evaluate quality of life and symptomatic outcome in selected patients for a follow-up of 3 to 5 years. METHODS A total of 155 patients with esophageal dismotility underwent laparoscopic Toupet fundoplication (LTF). Basic requirements for surgery included in all patients a detailed evaluation of symptoms and quality of life (Gastrointestinal Quality of Life Index [GIQLI]), esophagogastroduodenoscopy, 24-hour pH monitoring, and esophageal manometry. Patients were evaluated 6 weeks, 3 months, 1 year, and 3 to 5 years after LTF. RESULTS GERD-related symptoms such as heartburn, regurgitation, dysphagia, or chest pain showed a significant improvement (P <0.05 to 0.001) in all gradings immediately after surgery. During the complete follow-up, a total of 4 patients (2.6%) required laparoscopic redo surgery because of recurrent GERD symptoms. Two patients (1.3%) were adequately maintained on short-term proton pump inhibitor therapy because of mild symptoms. All these patients have shown a pathological DeMeester score within the early period after surgery (3 months or 1 year control). Severe and persistent side effects have been present in 7 patients (4.5%), mild to moderate side effects in 11 patients (7.1%). Other side effects have been temporary and resolved spontaneously. GIQLI improved significantly (P <0.05 to 0.01) in all dimensions and persisted for at least 5 years with mean values comparable with healthy individuals. CONCLUSIONS LTF is effective, well tolerated, and improves quality of life, improving long-term outcome with an acceptable rate of long-term side effects in GERD patients with moderate to severe esophageal dismotility for a follow-up period of 3 to 5 years.
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Greason KL, Miller DL, Deschamps C, Allen MS, Nichols FC, Trastek VF, Pairolero PC. Effects of antireflux procedures on respiratory symptoms. Ann Thorac Surg 2002; 73:381-5. [PMID: 11845846 DOI: 10.1016/s0003-4975(01)03407-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antireflux surgery can reduce respiratory symptoms associated with gastroesophageal reflux. However, there is a paucity of data on the durability of this benefit. To evaluate the long-term effects of antireflux surgery on respiratory complaints associated with gastroesophageal reflux, we reviewed our experience. METHODS Retrospective review of 2,123 antireflux procedures completed between 1986 and 1998 identified 65 patients (3.1%) with associated respiratory symptoms. There were 32 men and 33 women, ranging in age from 20 to 80 years (median 59 years). Respiratory symptoms included wheezing in 43 patients, sputum production in 37, cough in 30, choking episodes in 24, and hoarseness in 17. Preoperative medication use included steroids in 23 patients and bronchodilators in 18. RESULTS Antireflux operations included the uncut Collis-Nissen fundoplication in 29 patients, Belsy Mark IV repair in 13, open Nissen fundoplication in 13, and laparoscopic Nissen fundoplication in 10. Perioperative complications occurred in 19 patients who underwent open procedures and in none who had laparoscopic procedures. There was one death in the open-operation group and none in the laparoscopic group. Median follow-up was 65 months (range 1 to 174 months) and was complete in 62 patients (96.9%). Improvement in respiratory symptoms (83%) and reduction in-respiratory medication use (78%) were significant as compared to a calculated 33% placebo-effect improvement (p < 0.05). CONCLUSIONS Antireflux operations significantly reduce respiratory complaints associated with gastroesophageal reflux. This benefit appears to be long term.
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Affiliation(s)
- Kevin L Greason
- Division of Cardiothoracic Surgery, Naval Medical Center, San Diego, California, USA
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Klaus A, Swain JM, Hinder RA. Laparoscopic antireflux surgery for supraesophageal complications of gastroesophageal reflux disease. Am J Med 2001; 111 Suppl 8A:202S-206S. [PMID: 11749951 DOI: 10.1016/s0002-9343(01)00831-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Gastroesophageal reflux disease can result in such supraesophageal complications as hoarseness, sore throat, cough, bronchitis, asthma, recurrent pneumonia, intermittent choking, chest pain, and ear pain. Appropriate patient care involves careful evaluation to decide on medical or surgical therapy. Preoperative testing must include endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry. Additional evaluations, such as barium swallow, chest x-ray, bronchoscopy, and sinus radiographs, may be required. Medical treatment improves gastroesophageal reflux and supraesophageal symptoms. However, surgical therapy seems to provide better long-term results. A profile that predicts the best response to medical therapy has not been identified, although the best results with surgery are achieved in patients with nocturnal asthma, onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical treatment.
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Affiliation(s)
- A Klaus
- Department of Surgery, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Oelschlager BK, Pellegrini CA. Minimally invasive surgery for gastroesophageal reflux disease. J Laparoendosc Adv Surg Tech A 2001; 11:341-9. [PMID: 11814124 DOI: 10.1089/10926420152761851] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Surgical treatment of gastroesophageal reflux disease (GERD) is indicated for patients with moderate to severe signs and symptoms or a need for increasing doses of antisecretory drugs. Long segment Barrett's metaplasia is another indication, especially in young patients. Preoperative evaluation differs somewhat depending on whether the patient's symptoms are typical or atypical of GERD. Laparoscopic fundoplication is described. Follow-up of as long as 8 years indicates that more than 90% of patients are satisfied with the results, although 14% are using antisecretory drugs regularly. Recurrent symptoms or dysphagia may indicate surgical failure, and medical therapy, esophageal dilatation, or surgery may be appropriate. Laparoscopic surgery in these patients takes longer than the original procedure but has many benefits if performed by an experienced surgeon.
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Affiliation(s)
- B K Oelschlager
- Swallowing Center, Department of Surgery, University of Washington, Seattle 98195-6410, USA.
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Wetscher GJ, Gadenstaetter M, Klingler PJ, Weiss H, Obrist P, Wykypiel H, Klaus A, Profanter C. Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease. Ann Surg 2001; 234:627-32. [PMID: 11685025 PMCID: PMC1422086 DOI: 10.1097/00000658-200111000-00007] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate whether Barrett's metaplasia may develop despite effective medical therapy. SUMMARY BACKGROUND DATA Gastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. METHODS Eighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett's metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. RESULTS Twelve (14.5%) patients developed Barrett's while receiving medical therapy; this was not seen after surgery. Patients developing Barrett's had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. CONCLUSIONS Antireflux surgery is superior to medical therapy in the prevention of Barrett's metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.
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Affiliation(s)
- G J Wetscher
- Department of Surgery, University of Innsbruck, Innsbruck, Austria.
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Eubanks TR, Omelanczuk P, Hillel A, Maronian N, Pope CE, Pellegrini CA. Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy. Am J Surg 2001; 181:466-70. [PMID: 11448445 DOI: 10.1016/s0002-9610(01)00597-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pharyngeal pH monitoring is a diagnostic tool used to identify Gastroesophageal reflux disease (GERD) as an etiology of respiratory symptoms. We performed pharyngeal pH monitoring on 14 patients with respiratory symptoms thought to be induced by GERD. METHODS Symptoms and pH monitoring (esophageal and pharyngeal) were assessed prior to and 3 months after the initiation of double-dose proton pump inhibitor therapy. RESULTS Symptoms included cough, hoarseness, and throat clearing. Ten patients had at least one episode of pharyngeal reflux (PR+) and 4 patients had no pharyngeal reflux (PR-). Pharyngeal reflux episodes in PR+ patients decreased from 3.5 to 0.9 (P <0.05) per day with 8 of 10 (80%) patients having elimination or reduction of such episodes. Eight of 9 PR+ patients (89%) with suppressed pharyngeal reflux on medical therapy had resolution of respiratory symptoms. Three of 4 PR- patients (75%) had persistent symptoms on medical therapy. CONCLUSIONS Proton pump inhibitor therapy improves clinical symptoms and decreases pharyngeal reflux episodes in patients with respiratory symptoms related to GERD. Direct measurement of pharyngeal pH is helpful in the identification of patients likely to respond to antireflux therapy.
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Affiliation(s)
- T R Eubanks
- Department of Surgery, University of Washington Medical Center, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195, USA.
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Weiss HG, Nehoda H, Labeck B, Peer-Kühberger MD, Klingler P, Gadenstätter M, Aigner F, Wetscher GJ. Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility. Am J Surg 2000; 180:479-82. [PMID: 11182402 DOI: 10.1016/s0002-9610(00)00511-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. METHODS Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m(2)). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. RESULTS The median BMI dropped significantly to 33.1 kg/m(2) (P <0.05). Preoperatively 12 patients complained of reflux symptoms. Mild esophagitis was detected in 10 patients. Postoperatively only 1 patient complained of heartburn and mild esophagitis was diagnosed in another patient. None of the patients had dysphagia. Preoperatively a defective LES and pathologic pH-testing were found in 9 and 15 patients, respectively. These parameters were normal in all of the patients postoperatively. Postoperatively there was significant impairment of LES relaxation and deterioration of esophageal peristalsis with dilatation of the esophagus in some of the patients. CONCLUSION Laparoscopic adjustable gastric banding provides a sufficient antireflux barrier and therefore prevents pathologic gastroesophageal reflux. However, it impairs relaxation of the LES, leading to weak esophageal peristalsis.
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Affiliation(s)
- H G Weiss
- Department of Surgery, University of Innsbruck, Innsbruck, Austria
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Hinder RA, Branton SA, Floch NR. Surgical therapy for supraesophageal reflux complications of gastroesophageal reflux disease. Am J Med 2000; 108 Suppl 4a:178S-180S. [PMID: 10718473 DOI: 10.1016/s0002-9343(99)00360-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Supraesophageal complications of gastroesophageal reflux can be successfully treated by antireflux surgery. Careful preoperative testing, including 24-hour esophageal pH, manometry, and endoscopy, will help to identify appropriate patients who will benefit from surgery. The best results are achieved in patients with nocturnal asthma, the onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical therapy. Cough is more responsive to surgical therapy than is asthma. The benefits of minimally-invasive surgery are evident in patients with pulmonary disease, who have a faster recovery with fewer complications than after open surgery.
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Affiliation(s)
- R A Hinder
- Department of Surgery, Mayo Clinic Jacksonville, Florida 32224, USA
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Abstract
GERD and asthma have met the three criteria set out to prove a relationship between the two diseases. Patients with GERD have a higher prevalence of asthma, and there are several pathophysiologic mechanisms by which acid reflux can cause bronchospasm. Furthermore, aggressive antireflux therapy in patients with asthma and GERD results in improvements in asthma outcome in as many as 70% to 80% of patients treated in both medical and surgical series. Nevertheless, there are design flaws in many of the outcome studies performed to date. To further clarify this issue, future studies should be multicentered and placebo controlled using acid-suppressive therapy for at least 3 to 6 months with documentation of asthma outcome, cost analysis, and quality-of-life assessment. As with many things in medicine, all the data are not consistent. However, I strongly believe that the available data support the aggressive search for GERD and treatment in any patient with difficult-to-control asthma.
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Affiliation(s)
- J E Richter
- Department of Gastroenterology, The Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
Supraesophageal complications of GERD have become more commonly recognized or suspected by physicians. However, the direct association between these complications and GERD has often been difficult, if not impossible, to establish. Furthermore, the majority of patients with suspected supraesophageal complications of GERD do not have either the characteristic symptoms of heartburn and regurgitation or the definitive findings of esophageal inflammation, which would help reinforce the suspicion of a connection between the supraesophageal complications and GERD. Frequent acid reflux has been shown in patients with various bron-chopulmonary, laryngopharyngeal, or oral cavity disorders. GERD is one of the most common gastrointestinal complaints in the population. It is possible that the supraesophageal problems and acid reflux are mutually independent disorders that occur in the same person. The suspected mechanisms of GERD-related supraesophageal complications appear to be directed through two pathways: by a vagal reflex between the esophagus and tracheobronchial tree triggered by acid reflux or by microaspiration that causes contact damage to mucosal surfaces. The most useful diagnostic modality available to the clinician to aid in the diagnosis of supraesophageal GERD complications is the ambulatory pH recording technique. However, the sensitivity and specificity of this test for recording esophageal or pharyngeal acid reflux events has been critically challenged. Despite the many clinical studies that support the theory that GER has a role in suspected supraesophageal complications, only 1 long-term prospective controlled study of a large group of patients with asthma has shown the positive effects of the elimination of acid reflux. With the focus now on "outcomes medicine," there is a serious need for appropriately designed, controlled studies to answer the many questions surrounding a cause-and-effect association between acid reflux and supraesophageal disorders. Because of the lack of convincing proof between acid reflux and suspected supraesophageal complications, the physician must resort to an intent-to-treat strategy as both a primary therapy and a diagnostic trial. High-dose PPI therapy for prolonged periods is the recognized conservative therapy. Operative therapy (i.e., fundoplication operation) is the procedure of choice when overt regurgitation occurs or when medical therapy, although successful, is not practical for long periods. Controlled, well-designed clinical trials and more sophisticated techniques to measure and quantify acid reflux are crucial in the future to help determine which patients with suspected supraesophageal complications actually have acid reflux as a primary cause. The medical community needs to be alerted to the possibility of an association between GERD and supra-esophageal complications so that patients with a GERD-related complication will be recognized and effectively treated.
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Affiliation(s)
- W J Hogan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, USA
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Patti MG, Arcerito M, Tamburini A, Diener U, Feo CV, Safadi B, Fisichella P, Way LW. Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms. J Gastrointest Surg 2000; 4:143-9. [PMID: 10675237 DOI: 10.1016/s1091-255x(00)80050-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11%). These 39 patients had been symptomatic for an average of 134 months. They were all taking H2-blocking agents (21%) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisone (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antireflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%.
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Affiliation(s)
- M G Patti
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143-0788, USA.
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Wetscher GJ, Glaser K, Gadenstaetter M, Profanter C, Hinder RA. The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture. Am J Surg 1999; 177:189-92. [PMID: 10219852 DOI: 10.1016/s0002-9610(99)00011-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.
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Affiliation(s)
- G J Wetscher
- Department of Surgery, University of Innsbruck, Austria
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Klingler PJ, Hinder RA, Cina RA, DeVault KR, Floch NR, Branton SA, Seelig MH. Laparoscopic antireflux surgery for the treatment of esophageal strictures refractory to medical therapy. Am J Gastroenterol 1999; 94:632-6. [PMID: 10086643 DOI: 10.1111/j.1572-0241.1999.00926.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The response of esophageal strictures to laparoscopic antireflux surgery remains controversial. The aim of this study was to examine the outcome of patients with medically refractory esophageal strictures caused by severe gastroesophageal reflux disease and treated surgically. METHODS A prospective follow-up analysis was completed using data obtained from detailed specific questioning by an independent observer. Responses were rated for symptoms, dysphagia (range 1-19), satisfaction with treatment, well-being (1 = best, 10 = worst), and need for further therapy. RESULTS Of 102 patients, 74 (72.5%) responded to follow-up. There were 31 women, mean age 59.6 yr, and 43 men, mean age 55.2 yr. Mean follow-up was 25 months (range 4-68 months). A total of 252 dilations before surgery decreased to 29 after surgery (p < 0.0001) in the mean observation period of 26 months before and 25 months after surgery (mean/patient 5.3 and 1.8, respectively, p < 0.001). The mean dysphagia score was 6.8 +/- 3.6 preoperatively and 3.7 +/- 1.4 postoperatively (p < 0.0001). Nine (12%) patients required continuous postoperative H2-blockers or proton pump inhibitors. Seven of these had gastritis or peptic ulcer disease. Before antireflux surgery, 10 (13.5%) had frequent pneumonia. No pneumonia was observed after surgery. Sixty-eight (91.9%) patients were satisfied with their decision to have surgery. Among these, the well-being score was 1.8 +/- 0.4 postoperatively vs 5.5 +/- 1.2 (p < 0.001) preoperatively. CONCLUSIONS Laparoscopic surgery in patients with medically refractory esophageal strictures results in a good clinical outcome with minimal complications. Patients are very satisfied with relief of dysphagia, and there is a diminished need for further dilation, with good quality of life.
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Affiliation(s)
- P J Klingler
- Department of Surgery, Mayo Clinic Jacksonville, Florida 32224, USA
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Thompson JS. 50 years of abdominal surgery at the Southwestern Surgical Congress: common problems and uncommon surgeons. Am J Surg 1998; 175:62S-74S. [PMID: 9558054 DOI: 10.1016/s0002-9610(98)00062-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha 68198-3280, USA
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