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Nadeem F, Singh A, Karim M, Khan A, Mirza S, Kabir SA. The Impact of Obesity on Reflux Recurrence Following Laparoscopic Anti-reflux Surgery: An Evidence-Based Systematic Review and Meta-Analysis. Cureus 2024; 16:e56981. [PMID: 38665763 PMCID: PMC11045245 DOI: 10.7759/cureus.56981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) is frequently seen in the Western population. Laparoscopic anti-reflux surgery (LARS) is effective in managing this condition. Obesity is strongly associated with GERD, and with the rising rate of obesity, there is, therefore, a concurrently increasing frequency of LARS performed. We aim to review the outcomes of LARS in patients with obesity, including the recurrence of GERD symptoms and peri-operative complications. A systematic review and meta-analysis were performed for articles from June 1992 to June 2022. The literature was reviewed for outcomes of LARS in patients with obesity (BMI≥30). Eligibility criteria included specific BMI, study design, type of surgery, and outcomes. The recurrence of symptoms and peri-operative complications were assessed. Thirty-one studies were thoroughly reviewed. Nine studies (five retrospective and four prospective) were selected for meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow, which included 1,499 patients with obesity and 5,521 without. Laparoscopic Nissen fundoplication was the most common procedure performed. The recurrence of symptoms was significantly lower in patients without obesity (p=0.0001). There was no statistically significant difference between patients with and without obesity in peri-operative complications, re-intervention, and early return to theatres. A higher recurrence rate of GERD symptoms post-LARS was reported in patients with obesity. Further research is required to decrease such risks and propose different methods, such as weight loss prior to surgery or Roux-en-Y (R&Y) gastric bypass. Risks and benefits should be considered by clinicians prior to offering LARS to patients with obesity.
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Affiliation(s)
- Faisal Nadeem
- General Surgery/Bariatric Surgery, Walsall Manor Hospital, Walsall, GBR
- Laparoscopic Surgery, Maroof International Hospital, Islamabad, PAK
| | - Ananya Singh
- General Surgery, Walsall Manor Hospital, Walsall, GBR
| | | | - Amir Khan
- General Surgery/Bariatric Surgery, Walsall Manor Hospital, Walsall, GBR
| | - Salman Mirza
- Bariatric Surgery, Walsall Manor Hospital, Walsall, GBR
| | - Syed A Kabir
- General Surgery/Bariatric Surgery, Walsall Manor Hospital, Walsall, GBR
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Huynh P, Konda V, Sanguansataya S, Ward MA, Leeds SG. Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication. Surg Laparosc Endosc Percutan Tech 2020; 31:264-276. [PMID: 33347088 PMCID: PMC8154178 DOI: 10.1097/sle.0000000000000888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation. MATERIALS AND METHODS A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control. RESULTS Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH. CONCLUSIONS Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.
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Affiliation(s)
- Phuong Huynh
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
| | - Vani Konda
- Center for Esophageal Diseases, Baylor University Medical Center, Dallas
| | | | - Marc A. Ward
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
| | - Steven G. Leeds
- Division of Minimally Invasive Surgery, Baylor University Medical Center
- Center for Advanced Surgery, Baylor Scott & White Health
- Texas A&M College of Medicine, Bryan, TX
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PECULIARITIES OF STATE OF PROTECTION AND AGGRESSION FACTORS IN PATIENTS WITH DIABETES MELLITUS TYPE II AND GASTROESOPHAGEAL REFLUX DISEASE. EUREKA: HEALTH SCIENCES 2020. [DOI: 10.21303/2504-5679.2020.001080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Diabetes mellitus is one of the most serious problems of the clinical medicine. This is determined by the fact that it is followed by multisystemic affects, as well as complications on the side of other organs and systems, among which a special place is occupied by gastroesophageal reflux disease. As for the combination and mutual influence of diabetes mellitus and gastroesophageal reflux disease, this issue has not been studied yet, the data of modern literature are not complete and quite contradictory.
The aim of the study: to investigate the state of the factors of aggression and protection of the oesophageal mucosa in patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease without associated pathology.
Method. There were two groups of patients under observation. The first group included 45 patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease (26 men and 19 women). The second group included 38 patients with gastroesophageal reflux disease without associated pathology – 20 men and 18 women. By sex, age, body weight, Helicobacter pylori infection, smoking and alcohol consumption, both groups were comparable. The surveillance program included determining the compensation ratio of carbohydrate metabolism and the state of the factor. The antioxidant protection factor was assessed by the level of catalase activity in the blood serum, as well as by the diameter of the celiac trunk and the blood flow velocity in it. Statistical processing of the obtained data was carried out with the aid of the program WINDOWS STATISTIKA 6.0. For all types of analysis, differences were considered statistically significant with p<0.05.
Results. During the study, we found that in patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease, as well as in patients with gastroesophageal reflux disease without associated pathology, the level of pH-metry was reduced, but with varying measures of confidence. At the same time, we found that patients with GERD without associated pathology had a decrease in the blood flow velocity in the celiac trunk. Concurrently, we ascertained that the decrease in the blood flow velocity in patients of both groups reduced the diameter of the celiac trunk.
Conclusions. In patients with diabetes mellitus type II, concomitant gastroesophageal reflux disease has a subtle clinical presentation that is affected by a significant decline in mucosal sealing protection factors. In patients with GERD without associated pathology, typical clinical manifestations, accompanied by inflammation, acid regurgitation and dyspepsia, are more vivid.
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Bashir Y, Chonchubhair HN, Duggan SN, Memba R, Ain QU, Murphy A, McMahon J, Ridgway PF, Conlon KC. Systematic review and meta-analysis on the effect of obesity on recurrence after laparoscopic anti-reflux surgery. Surgeon 2019; 17:107-118. [DOI: 10.1016/j.surge.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/31/2018] [Accepted: 05/04/2018] [Indexed: 01/11/2023]
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Yadlapati R, Dakhoul L, Pandolfino JE, Keswani RN. The Quality of Care for Gastroesophageal Reflux Disease. Dig Dis Sci 2017; 62:569-576. [PMID: 28028689 PMCID: PMC5768307 DOI: 10.1007/s10620-016-4409-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/06/2016] [Indexed: 12/14/2022]
Abstract
Improving the quality of healthcare delivery is a cornerstone of modern medical care shared between all stakeholders. However, effectively improving quality requires both an understanding of the tenets of healthcare quality and how they relate to an individual disease process. This is especially important for common diseases, such as gastroesophageal reflux disease (GERD), where wide variations in practice exist. The high prevalence of GERD coupled with wide variation in clinical approach results in significant economic burden and poor quality of care. Thus, GERD serves as a useful framework to highlight the opportunities and current challenges of delivering high-quality care. In this article, we identify quality metrics in GERD and the areas in need of research to improve the quality of the management of GERD. Additionally, we suggest strategies for improvement as it relates to the proper diagnostic testing utilization and the decision-making process.
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Affiliation(s)
- Rena Yadlapati
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lara Dakhoul
- University of Illinois, Chicago/Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - John E. Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rajesh N. Keswani
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Nam Y, Lee JM, Wang Y, Ha HS, Sohn UD. The effect of Flos Lonicerae Japonicae extract on gastro-intestinal motility function. JOURNAL OF ETHNOPHARMACOLOGY 2016; 179:280-290. [PMID: 26743226 DOI: 10.1016/j.jep.2015.12.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 06/05/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Flos Lonicerae Japonicae is a well-known herb of traditional Chinese medicine that has been used for heat-clearing, detoxification, anti-inflammation, throat pain and gastro-intestinal (GI) disorder. In order to verify the effect of Flos Lonicerae Japonicae on GI disorder, we investigated the prokinetic effect of GC-7101 on GI motility function. MATERIALS AND METHODS GC-7101 is the standardized extract of Flos Lonicerae Japonicae. The contractile action of GC-7101 on feline esophageal smooth muscle cell (ESMC) was evaluated by measuring dispersed cell length. The isometric tension study was performed to investigate the effect of GC-7101 on feline lower esophageal sphincther (LES). The prokinetic effect of GC-7101 was investigated by gastric emptying (GE) and gastro-intestinal transit (GIT) in rats. RESULTS GC-7101 produced concentration-dependent contractions in ESMCs. Pretreatment with 5-HT3 and 5-HT4 receptor blocker (ondansetron and GR113808) inhibited the contractile responses of the GC-7101-induced ESMCs. In isometric tension study, GC-7101 recovered the HCl-induced decreased tone of LES muscle strips. The treatment of GC-7101 enhanced the carbachol-induced contractile responses and the electric field stimulation (EFS)-induced on-contraction. The oral administration of GC-7101 not only significantly accelerated GE and GIT in normal rats but also recovered the delayed GE and GIT, and its effect was more potent than that of conventional prokinetics (e.g., domperidone, a dopamine-receptor antagonist, and mosapride, a 5-HT4-receptor agonist). CONCLUSION GC-7101 revealed a prokinetic effect through enhancing the contractile responses of ESMCs, tone increases, enhancing the carbarchol- or EFS-induced contractile responses of LES muscle strips, and the acceleration of GE and GIT. We have identified the significant potential of GC-7101 for the development of new prokinetic drugs through this study.
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Affiliation(s)
- Yoonjin Nam
- Department of Pharmacology, College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 156-784, Republic of Korea.
| | - Jong Mi Lee
- Department of Pharmacology, College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 156-784, Republic of Korea.
| | - Yiyi Wang
- Department of Pharmacology, College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 156-784, Republic of Korea.
| | - Hyun Su Ha
- Department of Pharmacology, College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 156-784, Republic of Korea.
| | - Uy Dong Sohn
- Department of Pharmacology, College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 156-784, Republic of Korea.
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Soffer E, Rodríguez L, Rodriguez P, Gómez B, Neto MG, Crowell MD. Effect of electrical stimulation of the lower esophageal sphincter in gastroesophageal reflux disease patients refractory to proton pump inhibitors. World J Gastrointest Pharmacol Ther 2016; 7:145-155. [PMID: 26855821 PMCID: PMC4734948 DOI: 10.4292/wjgpt.v7.i1.145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/09/2015] [Accepted: 12/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of lower esophageal sphincter (LES)-electrical stimulation therapy (EST) in a subgroup of patients that reported only partial response to proton pump inhibitors (PPIs) therapy, compared to a group of patient with complete response.
METHODS: Bipolar stitch electrodes were laparoscopically placed in the LES and connected to an implantable pulse generator (EndoStim BV, the Hague, the Netherlands), placed subcutaneously in the anterior abdominal wall. Stimulation at 20 Hz, 215 μsec, 3-8 mAmp in 30 min sessions was delivered starting on day 1 post-implant. Patients were evaluated using gastroesophageal reflux disease (GERD)-HRQL, symptom diaries; esophageal pH and esophageal manometry before and up to 24 mo after therapy and results were compared between partial and complete responders.
RESULTS: Twenty-three patients with GERD on LES-EST were enrolled and received continuous per-protocol stimulation through 12 mo and 21 patients completed 24 mo of therapy. Of the 23 patients, 16 (8 male, mean age 52.1 ± 12 years) had incomplete response to PPIs prior to LES-EST, while 7 patients (5 male, mean age 52.7 ± 4.7) had complete response to PPIs. In the sub-group with incomplete response to PPIs, median (IQR) composite GERD-HRQL score improved significantly from 9.5 (9.0-10.0) at baseline on-PPI and 24.0 (20.8-26.3) at baseline off-PPI to 2.5 (0.0-4.0) at 12-mo and 0.0 (0.0-2.5) at 24-mo follow-up (P < 0.05 compared to on-and off-PPI at baseline). Median (IQR) % 24-h esophageal pH < 4.0 at baseline in this sub-group improved significantly from 9.8% (7.8-11.5) at baseline to 3.0% (1.9-6.3) at 12 mo (P < 0.001) and 4.6% (2.0-5.8) at 24 mo follow-up (P < 0.01). At their 24-mo follow-up, 9/11 patients in this sub-group were completely free of PPI use. These results were comparable to the sub-group that reported complete response to PPI therapy at baseline. No unanticipated implantation or stimulation-related adverse events, or any untoward sensation due to stimulation were reported in either group and LES-EST was safely tolerated by both groups.
CONCLUSION: LES-EST is safe and effective in controlling symptoms and esophageal acid exposure in GERD patients with incomplete response to PPIs. These results were comparable to those observed PPI responders.
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Bencini L, Moraldi L, Bartolini I, Coratti A. Esophageal surgery in minimally invasive era. World J Gastrointest Surg 2016; 8:52-64. [PMID: 26843913 PMCID: PMC4724588 DOI: 10.4240/wjgs.v8.i1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 11/28/2015] [Accepted: 12/04/2015] [Indexed: 02/06/2023] Open
Abstract
The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.
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Jiang Y, Cui WX, Wang Y, Heng D, Tan JC, Lin L. Antireflux surgery vs medical treatment for gastroesophageal reflux disease: A meta-analysis. World J Meta-Anal 2015; 3:284-294. [DOI: 10.13105/wjma.v3.i6.284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/17/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare the effect of antireflux surgery with medicine in treating gastroesophageal reflux disease (GERD) patients using meta- analysis.
METHODS: MEDLINE, Embase and the Cochrane Library were searched. We only included randomized controlled trials (RCTs) comparing the effect of surgical intervention with medical therapy for GERD. Statistical analyses were performed using RevMan 5.2 and STATA 12.0 software. RevMan 5.2 was used to assess the risk of bias and calculate the pooled effect size, while Stata 12.0 was used to evaluate publication bias and for sensitivity analysis. We evaluated the primary outcomes with GERD-/health-related quality of life in short (one to three years) and long (three to twelve years) periods of follow-up. Secondary outcomes evaluated were DeMeester scores and the percentage of time that pH < 4 to evaluate the degree of acid exposure.
RESULTS: This meta-analysis included 7 studies with 1972 patients. It showed a positive effect of antireflux surgery compared with medical treatment in terms of health-related quality of life [standardized mean difference (SMD) = 0.18; 95%CI: 0.01 to 0.34] and GERD-related quality of life (SMD = 0.35; 95%CI: 0.11 to 0.59). We also conducted the subgroup analyses based on follow-up periods and found that surgery remained more effective than medicine over the short to medium follow-up time, but the advantage of antireflux surgery probably not maintained for long time. GERD-related quality of life in the surgical group was significantly higher than medical group for the < 3 years follow-up (SMD = 0.45; 95%CI: 0.23 to 0.66); the difference was not statistically significant when the follow-up time was ≥ 3 years (SMD = 0.30; 95%CI: -0.10 to 0.69). Meta-analysis showed a statistically significant difference between the surgical group and medical group in the percentage of time that pH < 4 (SMD = 0.38; 95%CI: 0.14 to 0.61). Meta-analysis indicated a positive effect of antireflux surgery compared with medical treatment concerning DeMeester scores (SMD = 0.32; 95%CI: 0.00 to 0.65).
CONCLUSION: Although both were effective, in some respects surgical intervention was more effective than medical therapy to treat GERD when follow-up time was up to three years.
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Chaves RCDM, Navarro-Rodriguez T. Respiratory physiotherapy in gastroesophageal reflux disease: A review article. World J Respirol 2015; 5:28-33. [DOI: 10.5320/wjr.v5.i1.28] [Citation(s) in RCA: 2] [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: 09/29/2014] [Revised: 01/05/2015] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a frequent disorder which is expensive to diagnose and treat. Initiating therapy with empiric trial of proton-pump inhibitor is a well established strategy; however, symptoms of GERD do often persist regardless of effective medication. Nowadays, increasing interest concerning the efficacy and safety of chronic acid suppression with proton-pump inhibitors (PPIs), prompts a consideration for GERD treatment strategies related to the basic physiology of the lower esophageal sphincter, including modulation of its tone and ending of spontaneous transient lower esophageal sphincter relaxation, which contributes to reflux. Together, the lower esophageal sphincter and the crural diaphragm represent the major antireflux barrier, protecting the esophagus from reflux of gastric content. In order to prevent the need for enduring PPIs therapy or surgical procedures, substitute therapeutics approaches are being researched. Recently, studies have focused on the response of the respiratory muscles to inspiratory muscle training. As a result, inspiratory muscle training has emerged as a potential alternative for treatment of gastroesophageal reflux. The present report reviews the physiologic factors contributing to GERD, and presents the newly developed therapies that can be applied either alone or in association with available efficient GERD therapy.
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Subramanian CR, Triadafilopoulos G. Refractory gastroesophageal reflux disease. Gastroenterol Rep (Oxf) 2015; 3:41-53. [PMID: 25274499 PMCID: PMC4324866 DOI: 10.1093/gastro/gou061] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 07/26/2014] [Accepted: 07/31/2014] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents into the esophagus causes troublesome symptoms, esophageal injury, and/or complications. Use of proton pump inhibitors (PPI) remains the standard therapy for GERD and is effective in most patients. Those whose symptoms are refractory to PPIs should be evaluated further and other treatment options should be considered, according to individual patient characteristics. Response to PPIs could be total (no symptoms), partial (residual breakthrough symptoms), or absent (no change in symptoms). Patients experiencing complete response do not usually need further management. Patients with partial response can be treated surgically or by using emerging endoscopic therapies. Patients who exhibit no response to PPI need further evaluation to rule out other causes.
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Affiliation(s)
- Charumathi Raghu Subramanian
- Internal Medicine, Guthrie Clinic, Sayre, PA, USA and Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - George Triadafilopoulos
- Internal Medicine, Guthrie Clinic, Sayre, PA, USA and Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
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