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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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Authors, Collaborators. S2k guideline Gastroesophageal reflux disease and eosinophilic esophagitis of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1786-1852. [PMID: 39389106 DOI: 10.1055/a-2344-6282] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
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Vaiciunaite D, Eriksson SE, Sarici IS, Zheng P, Zaidi AH, Jobe B, Ayazi S. The Utility of Symptom Association Probability (SAP) in Predicting Outcome After Laparoscopic Fundoplication in Patients with Abnormal Esophageal Acid Exposure. J Gastrointest Surg 2023; 27:2014-2022. [PMID: 37407903 PMCID: PMC10511574 DOI: 10.1007/s11605-023-05753-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/10/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION Abnormal DeMeester score on pH monitoring is a well-established predictor of favorable outcome after antireflux surgery (ARS). Esophageal pH monitoring also facilitates analysis of the temporal association between symptoms and reflux episodes. This association can be expressed with several symptom-reflux association indices with symptom association probability (SAP) being the most reliable. SAP is often used as an adjunct to DeMeester score during preoperative assessment of patients seeking ARS. However, data on the utility of SAP in predicting ARS outcome is limited. The aim of this study was to determine the utility of SAP as an adjunct to DeMeester score in predicting outcomes after fundoplication. METHODS Records of patients who underwent primary fundoplication from 2015 to 2021 were reviewed. Patients with a preoperative DeMeester score >14.7 on Bravo pH monitoring were included. A SAP >95% was considered SAP-positive. Favorable outcome was defined as freedom from proton pump inhibitors (PPIs) and patient satisfaction at 1 year postoperatively. Outcomes were compared based on the presence and number of SAP-positive symptoms, individual typical and atypical SAP-positive symptoms, and within demographic, clinical, and reflux severity subgroups. RESULTS The final study population consisted of 597 patients (71.4% female) with a median (IQR) age of 59.0 (49-67). At a mean (SD) follow-up of 10.5 (8) months, 82.0% patients achieved favorable outcome (satisfaction and freedom from PPI), freedom from PPI was 91.7%, and satisfaction was 87.4%. SAP was positive in 430 (72.0%) patients, of which 221 (37.0%) had one SAP-positive symptom, 164 (27.5%) had two SAP-positive symptoms, and 45 (7.5%) had all three SAP-positive symptoms. There was no association between having at least one SAP-positive symptom and favorable outcome (p=0.767). There was no difference in favorable outcome between patients with one, two, or all SAP-positive symptoms (0.785). Outcomes were comparable for SAP-positive typical (p=0.873) and atypical symptoms (p=1.000) and all individual symptoms (p>0.05). Outcomes were also comparable within all subgroups (p>0.05). CONCLUSION Symptom association probability with an abnormal DeMeester score did not enhance the prediction of antireflux surgery outcome. These findings suggest that SAP should not be used in surgical decision-making in patients with objective evidence of reflux.
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Affiliation(s)
- Donata Vaiciunaite
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Sven E Eriksson
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Inanc S Sarici
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Ping Zheng
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Ali H Zaidi
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Blair Jobe
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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Autorinnen/Autoren, Collaborators:. S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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Horton A, Gyawali CP, Patel A. Non-acid Reflux: What to Do When You Don't Feel the Burn. Dig Dis Sci 2021; 66:929-931. [PMID: 32556966 DOI: 10.1007/s10620-020-06400-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Anthony Horton
- Division of Gastroenterology, Duke University School of Medicine, DUMC Box 3913, Durham, NC, 27710, USA.,Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine, DUMC Box 3913, Durham, NC, 27710, USA. .,Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, NC, USA.
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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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Hillman L, Yadlapati R, Whitsett M, Thuluvath AJ, Berendsen MA, Pandolfino JE. Review of antireflux procedures for proton pump inhibitor nonresponsive gastroesophageal reflux disease. Dis Esophagus 2017; 30:1-14. [PMID: 28859357 PMCID: PMC5789775 DOI: 10.1093/dote/dox054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/20/2017] [Indexed: 12/11/2022]
Abstract
Up to 40% of patients with gastroesophageal reflux disease (GERD) report persistent symptoms despite proton pump inhibitor (PPI) therapy. This review outlines the evidence for surgical and endoscopic therapies for the treatment of PPI nonresponsive GERD. A literature search for GERD therapies from 2005 to 2015 in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 2928 unique citations. Of those, 45 unique articles specific to surgical and endoscopic therapies for PPI nonresponsive GERD were reviewed. Laparoscopic fundoplication (n = 19) provides symptomatic and physiologic relief out to 10 years, though efficacy wanes with time. Magnetic sphincter augmentation (n = 6) and transoral incisionless fundoplication (n = 9) improve symptoms in PPI nonresponders and may offer fewer side effects than fundoplication, though long-term follow-up is lacking. Radiofrequency energy delivery (n = 8) has insufficient evidence for routine use in treating PPI nonresponsive GERD. Electrical stimulator implantation (n = 1) and endoscopic mucosal surgery (n = 2) are newer therapies under evaluation for the treatment of GERD. Laparoscopic fundoplication remains the most proven therapeutic approach. Newer antireflux procedures such as magnetic sphincter augmentation and transoral incisionless fundoplication offer alternatives with varying degrees of success, durability, and side effect profiles that may better suit individual patients. Larger head-to-head comparison trials are needed to better characterize the difference in symptom response and side effect profiles.
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Affiliation(s)
- L. Hillman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - R. Yadlapati
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - M. Whitsett
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - A. J. Thuluvath
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - M. A. Berendsen
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J. E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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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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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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Singendonk MMJ, Benninga MA, van Wijk MP. Reflux monitoring in children. Neurogastroenterol Motil 2016; 28:1452-9. [PMID: 27682990 DOI: 10.1111/nmo.12922] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/18/2016] [Indexed: 12/23/2022]
Abstract
Recently, multichannel intraluminal impedance (MII) monitoring was added to the repertoire of tests to evaluate the (patho)physiology of gastroesophageal reflux (GER) in children. Its advantage above the sole monitoring of the esophageal pH lies in the ability of the detection of both acid and nonacid GER and to discern between liquid and gas GER. Currently, combined 24 h pH-MII monitoring is recommended for evaluation of gastro-esophageal reflux disease (GERD) and its relation to symptoms in infants and children, despite the lack of reference values in these age groups. There is new evidence in the current issue of this Journal supporting the role of pH-MII monitoring for the evaluation of children presenting with gastrointestinal symptoms suggestive of GERD and the prediction of the presence of reflux esophagitis. However, several issues should be taken into account when performing pH-MII clinically.
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Affiliation(s)
- M M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands.
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - M P van Wijk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands.,Department of Pediatric Gastroenterology, VU University Medical Centre, Amsterdam, The Netherlands
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11
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Testoni PA, Mazzoleni G, Testoni SGG. Transoral incisionless fundoplication for gastro-esophageal reflux disease: Techniques and outcomes. World J Gastrointest Pharmacol Ther 2016; 7:179-89. [PMID: 27158533 PMCID: PMC4848240 DOI: 10.4292/wjgpt.v7.i2.179] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 12/24/2015] [Accepted: 02/23/2016] [Indexed: 02/06/2023] Open
Abstract
Gastro-esophageal reflux disease (GERD) is a very common disorder that results primarily from the loss of an effective antireflux barrier, which forms a mechanical obstacle to the retrograde movement of gastric content. GERD can be currently treated by medical therapy, surgical or endoscopic transoral intervention. Medical therapy is the most common approach, though concerns have been increasingly raised in recent years about the potential side effects of continuous long-term medication, drug intolerance or unresponsiveness, and the need for high dosages for long periods to treat symptoms or prevent recurrences. Surgery too may in some cases have consequences such as long-lasting dysphagia, flatulence, inability to belch or vomit, diarrhea, or functional dyspepsia related to delayed gastric emptying. In the last few years, transoral incisionless fundoplication (TIF) has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy. This review describes the steps of the TIF technique, using the EsophyX(®) device and the MUSE(TM) system. Complications and their management are described in detail, and the recent literature regarding the outcomes is reviewed. TIF reconfigures the tissue to obtain a full-thickness gastro-esophageal valve from inside the stomach, by serosa-to-serosa plications which include the muscle layers. To date the procedure has achieved lasting improvement of GERD symptoms (up to six years), cessation or reduction of proton pump inhibitor medication in about 75% of patients, and improvement of functional findings, measured by either pH or impedance monitoring.
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12
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Scarpellini E, Ang D, Pauwels A, De Santis A, Vanuytsel T, Tack J. Management of refractory typical GERD symptoms. Nat Rev Gastroenterol Hepatol 2016; 13:281-94. [PMID: 27075264 DOI: 10.1038/nrgastro.2016.50] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of patients with refractory GERD (rGERD) is a major clinical challenge for gastroenterologists. In up to 30% of patients with typical GERD symptoms (heartburn and/or regurgitation), acid-suppressive therapy does not provide clinical benefit. In this Review, we discuss the current management algorithm for GERD and the features and management of patients who do not respond to treatment (such as those individuals with an incorrect diagnosis of GERD, inadequate PPI intake, persisting acid reflux and persisting weakly acidic reflux). Symptom response to existing surgical techniques, novel antireflux procedures, and the value of add-on medical therapies (including prokinetics and reflux inhibitors) for rGERD symptoms are discussed. Pharmaceutical agents targeting oesophageal sensitivity, a condition that can contribute to symptom generation in rGERD, are also discussed. Finally, on the basis of available published data and our expert opinion, we present an outline of a current, usable algorithm for management of patients with rGERD that considers the timing and diagnostic use of pH-impedance monitoring on or off PPI, additional diagnostic tests, the clinical use of baclofen and the use of add-on neuromodulators (tricyclic agents and selective serotonin reuptake inhibitors).
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Affiliation(s)
- Emidio Scarpellini
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Division Gastroenterology, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Daphne Ang
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Ans Pauwels
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Adriano De Santis
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Tim Vanuytsel
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jan Tack
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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Desjardin M, Luc G, Collet D, Zerbib F. 24-hour pH-impedance monitoring on therapy to select patients with refractory reflux symptoms for antireflux surgery. A single center retrospective study. Neurogastroenterol Motil 2016; 28:146-52. [PMID: 26526815 DOI: 10.1111/nmo.12715] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 10/01/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Treatment of gastro-esophageal reflux refractory symptoms is challenging. This monocenter retrospective study assessed the value of preoperative pH-impedance monitoring 'on' therapy to predict functional outcome after laparoscopic fundoplication in patients with refractory reflux symptoms. METHODS Patients with a preoperative pH-impedance monitoring 'on' proton pump inhibitors (PPIs) twice daily were assessed at least 6 months after a laparoscopic fundoplication for refractory reflux symptoms. Failure of fundoplication was defined by a Visick score > 2. Postoperative symptoms were assessed by the reflux disease questionnaire (RDQ). The pH-impedance parameters analyzed were the number of reflux events (total, acid, non-acid), esophageal acid exposure time, esophageal bolus exposure time, and symptom-reflux association defined by symptom index (SI) >50% and symptom association probability (SAP) >95%. KEY RESULTS Thirty-three patients (18 female patients, median age 46 years) were assessed after a mean follow-up of 41.3 (range 7-102.2) months. Seven (21.2%) patients were considered as failures. Compared to patients with favorable outcome, these patients were more often 'on' PPI therapy (86% vs 23%, p < 0.05) and had higher RDQ scores in each domain: heartburn (p < 0.05), regurgitation (p < 0.05) and dyspepsia (p < 0.05). A positive SAP was the only pH-impedance parameter statistically associated with successful postoperative outcome (p = 0.004). CONCLUSIONS & INFERENCES On therapy, a preoperative positive symptom association probability is the only pH-impedance parameter associated with favorable outcome after laparoscopic fundoplication for refractory reflux symptoms. These results should be confirmed by prospective studies.
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Affiliation(s)
- M Desjardin
- Gastroenterology and Hepatology Department, Hôpital Saint André, Centre Hospitalier Universitaire de Bordeaux and Université de Bordeaux, Bordeaux, France
| | - G Luc
- Digestive Surgery Department, Hôpital Haut Lévêque, Centre Hospitalier Universitaire de Bordeaux and Université de Bordeaux, Bordeaux, France
| | - D Collet
- Digestive Surgery Department, Hôpital Haut Lévêque, Centre Hospitalier Universitaire de Bordeaux and Université de Bordeaux, Bordeaux, France
| | - F Zerbib
- Gastroenterology and Hepatology Department, Hôpital Saint André, Centre Hospitalier Universitaire de Bordeaux and Université de Bordeaux, Bordeaux, France
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Luna RA, Bronson NW, Hunter JG. Indications for Antireflux Surgery. ANTIREFLUX SURGERY 2015:45-51. [DOI: 10.1007/978-1-4939-1749-5_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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15
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Levy S, Plymale M, Davenport DL, Ponte OIM, Roth JS. Patient Symptoms Correlate Poorly with Objective Measures among Patients with Gastroesophageal Reflux Disease. Am Surg 2014. [DOI: 10.1177/000313481408000925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Presentation of gastroesophageal reflux disease (GERD) varies among patients. To attempt to understand the patient's perception of the severity of their reflux symptoms, we developed a questionnaire on which patients rated symptom severity at each office visit. After receiving Institutional Review Board approval, we retrospectively reviewed patient charts of all patients seen by one surgeon for GERD symptoms and/or presence of hiatal hernia (HH) from September 2012 to April 2013. Data from patient questionnaires combined with objective findings from subsequent or prior workup and eventual operative information were recorded. A total of 144 questionnaires were reviewed from 108 patients. Frequencies were calculated for categorical variables. Patients were divided into four categories based on size of the HH on the endoscopic report; 10 patients had no HH, 15 had small HH, 20 had medium HH, and 31 patients had large HH. Size of HH was not available for three patients. Pre- and postoperative questionnaire responses were obtained for 15 patients. A combined reflux score was calculated using the median for each symptom. Patient perception of severity of symptoms does not necessarily predict presence of pathological reflux or HH nor is there a perfect combination of symptoms to predict the presence of pathological reflux or HH based on our sample. The workup of this pathology must be comprehensive, and the confirmation of reflux is imperative when the diagnosis is unclear.
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Affiliation(s)
- Salomon Levy
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Margaret Plymale
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel L. Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Oscar I. Moreno Ponte
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - J. Scott Roth
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Ates F, Francis DO, Vaezi MF. Refractory gastroesophageal reflux disease: advances and treatment. Expert Rev Gastroenterol Hepatol 2014; 8:657-67. [PMID: 24745809 DOI: 10.1586/17474124.2014.910454] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
'Refractory gastroesophageal reflux disease' is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with 'refractory symptoms.' We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.
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Affiliation(s)
- Fehmi Ates
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN, Nashville, TN, USA
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17
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EAES recommendations for the management of gastroesophageal reflux disease. Surg Endosc 2014; 28:1753-73. [PMID: 24789125 DOI: 10.1007/s00464-014-3431-z] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux. METHODS The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. RESULTS Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD. CONCLUSIONS Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.
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18
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Giral A, Kurt R, Yeğin EG, Yeğin K. Signal detection theory approach to gastroesophageal reflux disease: a new method for symptom analysis of impedance-pH data. Dis Esophagus 2014; 27:206-13. [PMID: 23795569 DOI: 10.1111/dote.12093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
An accurate reflux-symptom relationship analysis method is an unmet need in gastroesophageal reflux disease (GERD) diagnosis. The aim of this study was to adapt signal detection theory (SDT) approach to reflux-symptom relationship analysis to develop a new diagnosis method. Patients with predominant symptoms of heartburn and regurgitation were enrolled. Proton pump inhibitor (PPI)-responsive and PPI-unresponsive groups were created via interview and PPI trial. Patients then underwent stationary esophageal manometry and 24-hour multichannel intraluminal impedance-pH monitoring. SDT measurement parameters (discriminability: d' and criterion: c) were calculated using empirically selected time windows (0.5, 1, 2, 3, 4 and 5 minutes). The time window that provided the highest d' value was selected as the optimal time window. A cut-off d' value that optimally separates two groups was found using receiver operating characteristics analysis. Sixty-three patients completed the study (45 PPI responsive). Optimal time window and cut-off d' value were found as 1 and 0.767 minute, respectively. Symptom association probability (SAP) index values showed good correlation (rS = 0.7182, P < 0.0001) with d' values. SDT approach to reflux-symptom relationship analysis showed sensitivity (89% vs. 78%) and negative predictive values (75% vs. 60%) favorable over SAP index analysis. SDT approach using 1-minute time window and 0.767 cut-off d' value provides us a new and more accurate measure of reflux-symptom relationship than SAP index analysis.
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Affiliation(s)
- A Giral
- Department of Gastroenterology, Medical Faculty of Marmara University, Istanbul, Turkey
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Abstract
OPINION STATEMENT "Refractory GERD" is one the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive, often twice-daily proton pump inhibitor therapy. The term should be replaced with "refractory symptoms." We must acknowledge that in many patients, symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus, and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to esophagogastroduodenoscopy followed by pH or impedance monitoring. In the majority of patients these tests are normal. The role of non-acid reflux measured by impedance pH testing in this group is uncertain at best and the results from this test alone should not be used to refer patients to surgical fundoplication. In patients unresponsive to acid suppressive therapy, reflux is most commonly not causal and a search for non-GERD causes must ensue.
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20
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Evaluation of short-term and long-term results after laparoscopic antireflux surgery: esophageal manometry and 24-h pH monitoring versus quality of life index. Langenbecks Arch Surg 2013; 398:1107-14. [DOI: 10.1007/s00423-013-1118-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 09/06/2013] [Indexed: 12/15/2022]
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Rosemurgy A, Paul H, Madison L, Luberice K, Donn N, Vice M, Hernandez J, Ross SB. A Single Institution's Experience and Journey with over 1000 Laparoscopic Fundoplications for Gastroesophageal Reflux Disease. Am Surg 2012. [DOI: 10.1177/000313481207800928] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There have been great advances in laparoscopic surgery for gastroesophageal reflux disease (GERD), including laparoendoscopic single-site (LESS) surgery. This study details our experience with over 1000 patients undergoing fundoplication for GERD and the journey therein. A total of 1078 patients have been prospectively followed after fundoplication. Patients scored the frequency/severity of symptoms using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). We compared the outcomes of the first and last 100 patients. Median data are reported. Of 1078 patients, 943 underwent conventional laparoscopic fundoplication and 135, most recently, underwent LESS fundoplication. Before fundoplication, patients noted frequent/severe symptoms (e.g., heartburn: frequency = 8, severity = 8). Fundoplication ameliorated frequency/severity of symptoms (e.g., heartburn: frequency = 2, severity = 0; less than preoperatively, P < 0.05). Relative to our first 100 patients, patients after LESS surgery had similar symptom control (e.g., heartburn: frequency = eight to two vs eight to zero, severity = eight to one vs six to one) but had shorter hospital stays (2 vs 1 day, P < 0.05) and had no apparent scars. Laparoscopic fundoplication provides durable and efficacious treatment for GERD; long-term symptom resolution and patient satisfaction support its continued application. The advent of LESS surgery advances surgeons’ abilities to provide safe and salutary care while promoting cosmesis.
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Affiliation(s)
| | - Harold Paul
- Department of Surgery, Tampa General Hospital, Tampa, Florida
| | - Lauren Madison
- Department of Surgery, Tampa General Hospital, Tampa, Florida
| | | | - Natalie Donn
- Department of Surgery, Tampa General Hospital, Tampa, Florida
| | - Michelle Vice
- Department of Surgery, Tampa General Hospital, Tampa, Florida
| | | | - Sharona B. Ross
- University of South Florida College of Medicine, Tampa, Florida
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Zerbib F, Bruley des Varannes S, Simon M, Galmiche JP. Functional heartburn: definition and management strategies. Curr Gastroenterol Rep 2012; 14:181-8. [PMID: 22451252 DOI: 10.1007/s11894-012-0255-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Functional heartburn (FH) is a functional gastro-intestinal disorder characterized by symptoms of heartburn not related to gastro-esophageal reflux. The absence of evidence of reflux-related symptoms relies on absence of esophagitis at endoscopy (including biopsies to exclude eosinophilic esophagitis), a normal esophageal acid exposure during esophageal pH-monitoring together with a negative symptom-reflux association analysis and an unsatisfactory response to proton pump inhibitor therapy. Addition of impedance measurement to pH-monitoring is likely to increase the number of patients with recognized reflux-related symptoms. The pathophysiology of functional heartburn remains largely unknown but involves disturbed esophageal perception and psychological factors such as depression, anxiety and somatization. The treatment of FH remains largely empirical and an individual approach is therefore recommended. The clinician should provide reassurance and refrain from performing too many invasive tests or therapeutic procedures. The use of pain modulators is recommended by most experts despite the lack of appropriate clinical trials to support it.
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Affiliation(s)
- Frank Zerbib
- Gastroenterology and Hepatology Department, Saint André Hospital, Centre Hospitalier Universitaire de Bordeaux.
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Abstract
Esophageal impedance monitoring and high-resolution manometry (HRM) are useful tools in the diagnostic work-up of patients with upper gastrointestinal complaints. Impedance monitoring increases the diagnostic yield for gastroesophageal reflux disease in adults and children and has become the gold standard in the diagnostic work-up of reflux symptoms. Its role in the work-up for belching disorders and rumination seems promising. HRM is superior to other diagnostic tools for the evaluation of achalasia and contributes to a more specific classification of esophageal disorders in patients with non-obstructive dysphagia. The role of HRM in patients with dysphagia after laparoscopic placement of an adjustable gastric band seems promising. Future studies will further determine the clinical implications of the new insights which have been acquired with these techniques. This review aims to describe the clinical applications of impedance monitoring and HRM.
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