Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis

What Factors Are Associated with Clinical Trial Discontinuation in Orthopaedic Surgery: An Analysis of Clinical Trials Between 2007 and 2022

BACKGROUND

Clinical trials play a crucial role in advancing medical knowledge and have the potential to change standards of care. The present study evaluated the prevalence of discontinued clinical trials in orthopaedic surgery. Additionally, we sought to identify the study characteristics associated with and the rationale behind trial discontinuation.

METHODS

A cross-sectional survey of orthopaedic clinical trials using the ClinicalTrials.gov registry and results database was performed for trials between October 1, 2007, and October 7, 2022. Interventional trials listed as "completed," "terminated," "withdrawn," or "suspended" were included. Study characteristics were collected and clinical trial abstracts were reviewed in order to assign the appropriate subspecialty category. A univariate linear regression analysis was performed to determine whether the percentage of discontinued trials changed between 2008 and 2021. Univariate and multivariable hazard ratios (HRs) were calculated to identify factors associated with trial discontinuation.

RESULTS

A total of 8,603 clinical trials were included in the final analysis, of which 1,369 (16%) were discontinued, with the highest rates of discontinuation found in oncology (25%) and trauma (23%). The most common rationales for discontinuation were insufficient patient accrual (29%), technical or logistical issues (9%), business decision (9%), and lack of funding or resources (9%). Industry-funded studies were more likely than government-funded studies to be discontinued (HR: 1.81; p < 0.001). There was no change in the percentage of discontinued trials for each orthopaedic subspecialty between 2008 and 2021 (p = 0.21). As shown on multivariable regression analysis, trials for devices (HR: 1.63 [95% confidence interval, 1.20 to 2.21]; p = 0.002) and drugs (HR: 1.48 [1.10 to 2.02]; p = 0.013) as well as Phase-2 trials (HR: 1.35 [1.09 to 1.69]; p = 0.010), Phase-3 trials (HR: 1.39 [1.09 to 1.78]; p = 0.010), and Phase-4 trials (HR: 1.44 [1.14 to 1.81]; p = 0.010) had a higher likelihood of early discontinuation. However, pediatric trials were less likely to be discontinued (HR: 0.58 [0.40 to 0.86]; p = 0.007).

CONCLUSIONS

The results of the present study suggest the need for continued efforts to ensure the completion of orthopaedic clinical trials in order to limit publication bias and to employ resources and patient contributions more efficiently for research.

CLINICAL RELEVANCE

Discontinued trials contribute to publication bias, which limits the comprehensiveness of the literature available to support evidence-based patient care interventions. Therefore, identifying the factors associated with and the prevalence of orthopaedic trial discontinuation encourages orthopaedic surgeons to design future trials to be more resistant to early discontinuation.

5-Year Collis-Nissen Gastroplasty Outcomes for Type III-IV Hiatal Hernia with Short Esophagus: A Prospective Observational Study

BACKGROUND

To assess the 5-year outcomes of patients undergoing Collis-Nissen gastroplasty for type III-IV hiatal hernia with short esophagus.

STUDY DESIGN

From a prospective observational cohort of patients who underwent antireflux surgery for type III-IV hiatal hernia between 2009 and 2020, those with short esophagus (abdominal length <2.5 cm) in whom a Collis-Nissen procedure was performed and reached at least 5 years of follow-up were identified. Hernia recurrence, patients' symptoms, and quality of life were assessed annually by barium meal x-ray, upper endoscopy, and validated symptoms and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires.

RESULTS

Of the 114 patients with Collis-Nissen gastroplasty, 80 patients who completed a 5-year follow-up were included (mean age 71 years). There were no postoperative leaks or deaths. Recurrent hiatal hernia (any size) was identified in 7 patients (8.8%). Heartburn, regurgitation, chest pain, and cough were significantly improved at each follow-up interval (p < 0.05). Preoperative dysphagia disappeared or improved in 26 of 30 patients, while new-onset dysphagia occurred in 6. Mean postoperative QOLRAD scores significantly improved at all dimensions (p < 0.05).

CONCLUSIONS

Collis gastroplasty combined with Nissen fundoplication provides low hernia recurrence, good control of symptoms, and improved quality of life in patients with large hiatal hernia and short esophagus.

Successful Lifetime/Long-Term Medical Treatment of Acid Hypersecretion in Zollinger-Ellison Syndrome (ZES): Myth or Fact? Insights from an Analysis of Results of NIH Long-Term Prospective Studies of ZES

Analysis of the efficacy/pharmacology of long-term/lifetime medical treatment of acid hypersecretion in a large cohort of ZES patients in a prospective study. This study includes the results from all 303 patients with established ZES who were prospectively followed and received acid antisecretory treatment with either H2Rs or PPIs, with antisecretory doses individually titrated by the results of regular gastric acid testing. The study includes patients treated for short-term periods (<5 yrs), patients treated long-term (>5 yrs), and patients with lifetime treatment (30%) followed for up to 48 years (mean 14 yrs). Long-term/lifelong acid antisecretory treatment with H2Rs/PPIs can be successfully carried out in all patients with both uncomplicated and complicated ZES (i.e., with MEN1/ZES, previous Billroth 2, severe GERD). This is only possible if drug doses are individually set by assessing acid secretory control to establish proven criteria, with regular reassessments and readjustments. Frequent dose changes both upward and downward are needed, as well as regulation of the dosing frequency, and there is a primary reliance on the use of PPIs. Prognostic factors predicting patients with PPI dose changes are identified, which need to be studied prospectively to develop a useful predictive algorithm that could be clinically useful for tailored long-term/lifetime therapy in these patients.

Hiatal hernia repair with transoral incisionless fundoplication versus Nissen fundoplication for gastroesophageal reflux disease: A retrospective study

Background and study aims  Concomitant hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) is a therapeutic option for patients with HH > 2 cm and gastroesophageal reflux disease (GERD). Data comparing this approach with laparoscopic Nissen fundoplication (LNF) are lacking. We performed an exploratory analysis to compare these two approaches' adverse events (AEs) and clinical outcomes. Patients and methods  This was a multicenter retrospective cohort study of HH repair followed by LNF versus HH repair followed by TIF in patients with GERD and moderate HH (2-5 cm). AEs were assessed using the Clavien-Dindo classification. Symptoms (heartburn/regurgitation, bloating, and dysphagia) were compared at 6 and 12 months. Results  A total of 125 patients with HH repair with TIF and 70 with HH repair with LNF were compared. There was no difference in rates of discontinuing or decreasing proton pump inhibitor use, dysphagia, esophagitis, disrupted wrap, and HH recurrence between the two groups ( P  > 0.05). The length of hospital stay (1 day vs. 2 days), 30-day readmission rate (0 vs. 4.3 %), early AE rate (0 vs. 18.6 %), and early serious AE rate (0 vs. 4.3 %) favored TIF (all P  < 0.05). The rate of new or worse than baseline bloating was lower in the TIF group at 6 months (13.8 % vs. 30.0 %, P  = 0.009). Conclusions  Concomitant HH repair with TIF is feasible and associated with lower early and serious AEs compared to LNF. Further comparative efficacy studies are warranted.

Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up

Aims

Numerous reports have addressed the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). Long-term follow-up after direct comparison of these two minimally invasive approaches is scarce. The aim of the present study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomized ROLAF trial.

Methods

In the ROLAF trial 40 patients with GERD were randomized to RALF (n = 20) or CLF (n = 20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score.

Results

The GSRS score was similar for RALF (n = 15) and CLF (n = 15) at 12 years´ follow-up (2.1 ± 0.7 vs. 2.2 ± 1.3, p = 0.740). There was no difference in QOLRAD score (RALF 6.4 ± 1.2; CLF 6.4 ± 1.5, p = 0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF [46% (6/13) vs. 33% (4/12), p = 0.806].

Conclusion

In accordance with previous short-term outcome studies, the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term. Registration number: DRKS00014690 (https://www.drks.de).

Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter?

BACKGROUND

Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia.

METHODS

A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected.

RESULTS

The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit.

CONCLUSION

One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis.

Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Fundoplication versus oral proton pump inhibitors for gastroesophageal reflux disease: a systematic review and meta-analysis of randomized clinical trials

Gastroesophageal reflux disease (GERD) is a widely studied and highly prevalent condition. However, few are reported about the exact efficacy and safety of fundoplication (FPT) compared to oral intake proton-pump inhibitors (PPI). This systematic review and meta-analysis of randomized clinical trials (RCT) aims to compare PPI and FPT in relation to the efficacy, as well as the adverse events associated with these therapies. Search carried out in June 2020 was conducted on Medline, Cochrane, EMBASE and LILACS. Selection was restricted to RCT comparing PPI and FPT (open or laparoscopic) in GERD patients. Certainty of evidence and risk of bias were assessed with GRADE Pro and with Review Manager Version 5.4 bias assessment tool. Ten RCT were included. Meta-analysis showed that heartburn (RD =  - 0.19; 95% CI =  - 0.29, - 0.09) was less frequently reported by patients that underwent FPT. Furthermore, patients undergoing surgery had greater pressure on the lower esophageal sphincter than those who used PPI (MD = 7.81; 95% CI 4.79, 10.83). Finally, FPT did not increase significantly the risk for adverse events such as postoperative dysphagia and impaired belching. FPT is a more effective therapy than PPI treatment for GERD, without significantly increasing the risk for adverse events. However, before indicating a possible surgical approach, it is extremely important to correctly assess and select the patients who would benefit from FPT to ensure better results.

Surgical treatment of GERD: systematic review and meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.

METHODS

PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.

RESULTS

From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference =  - 0.51, 95%CI  - 0.63, - 0.40, I² = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I² = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I² = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I² = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I² = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).

CONCLUSIONS

The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.

Complete Fundus Mobilization Reduces Dysphagia After Nissen Procedure

Background. Anti-reflux surgery is an effective treatment for gastroesophageal reflux disease (GERD). Nevertheless, surgery is still indicated with great caution in relation to the risk of complications, and in particular to postoperative dysphagia (PD). Objective. To compare the clinical outcomes, with particular focus on the incidence and severity of PD, of laparoscopic Nissen-Rossetti fundoplication (NRF) and floppy Nissen fundoplication (FNF) with complete fundus mobilization, in the surgical treatment of GERD. Methods. Ninety patients with GERD were enrolled. Forty-four patients (21[47.7%] men, 23[52.2%] women; mean age 42.4 ± 14.3 years) underwent NRF (Group A), and 46 patients (23[50%] men, 23[50%] women; mean age 43.3 ± 15.4 years) received laparoscopic FNF with complete fundus mobilization (Group B). Clinical assessment was performed using a structured questionnaire and SF-36 quality of life (QoL) score. PD was assessed using a validated classification, and an overall outcome was also determined by asking the patient to score it. Results. At 24-month follow-up, 38 (88.3%) patients in Group A vs 39 (86.6%) in Group B reported to be completely satisfied with reflux relief and free of protonic pump inhibitors (PPIs), while 3 (6.9%) in Group A vs 2(4.4%) in Group B reported occasional PPI intake and 2(4.6%) in Group A vs 4(8.8%) in Group B needed regular PPI use. Persistent PD was observed in 8(18.6%) patients in Group A and in 2(4.4%) in Group B (P = .03). No significant differences were found in the QoL score and in the overall outcome perceived by the patients. Conclusion. FNF, with complete fundus mobilization, appears to be associated with a lower rate of postoperative persistent dysphagia.

Tobacco use is not associated with increased risk of recurrent reflux 5 years after laparoscopic anti-reflux surgery

INTRODUCTION

Tobacco use worsens gastrointestinal reflux disease (GERD). Smoking cessation improves GERD symptoms, but its impact on the efficacy of laparoscopic anti-reflux surgery (LARS) is unclear. In this retrospective cohort study, we hypothesized that non-smokers would demonstrate greater long-term improvements in disease-specific quality of life than active smokers.

METHODS

Data were maintained in an IRB-approved prospective database, and patients were stratified according to tobacco use. Postoperative follow-up occurred in clinic and long-term follow-up via telephone interview. Outcomes measured were gastroesophageal health-related quality of life (GERD-HRQL) and GERD symptom scale (GERSS) scores, proton pump inhibitor (PPI) cessation, and satisfaction with surgery.

RESULTS

Two hundred and thirty-five patients underwent primary LARS, and 31 (13%) were active smokers with 18 median pack-years [10-30]. Baseline PPI use (96% vs. 94%, p = 0.64), presence of a hiatal hernia (79% vs. 68%, p = 0.13), esophagitis (28% vs. 45%, p = 0.13), and DeMeester score (41.9 vs. 33.6, p = 0.47) were similar. Baseline GERD-HRQL and GERSS scores and their post-surgical decreases were also similar between groups. PPI cessation was achieved in 92% of non-smokers and 94% of smokers (p = 0.79), and GERD-HRQL scores decreased to 4 [1-7] and 5 [0-12], respectively (p = 0.53). After 59 [25-74] months, GERD-HRQL scores were 5 [2-11] and 2 [0-13] (p = 0.61) and PPI cessation was maintained in 69% and 79% of patients (p = 0.59). Satisfaction with surgery was similar between smokers and non-smokers (88% vs. 87%, p = 0.85). Female gender was significantly associated with increased improvements in GERD-HRQL (p < 0.01) and GERSS scores (p = 0.04) postoperatively but not at long-term follow-up. Patients without a hiatal hernia were less likely to achieve long-term PPI cessation compared to those with a hernia (OR 0.23, p < 0.01).

CONCLUSIONS

After 5 years, smokers demonstrate similar symptom resolution, PPI cessation rates, and satisfaction with surgery as non-smokers. Active smoking does not appear to negatively impact long-term symptomatic outcomes of LARS.

Laparoscopic Hernia Repair and Fundoplication for Gastroesophageal Reflux Disease

Antireflux surgery is challenging, and has become even more challenging with the introduction of alternative endoscopic and laparoscopic options for patients with gastroesophageal reflux disease (GERD). The Nissen fundoplication remains the gold standard for the durable relief of GERD symptoms and esophagitis. All antireflux procedures have a failure rate, and it is important to minimize factors that are associated with failure. The selection of patients for antireflux surgery as well as the choice of the procedure requires a thorough understanding of esophageal physiology and the pros and cons of various options.

Radiofrequency ablation is safe and effective in the treatment of Chinese patients with gastroesophageal reflux disease: A single-center prospective study

OBJECTIVE

This study aimed to evaluate the safety and efficiency of radiofrequency ablation (RFA) in Chinese patients with gastroesophageal reflux disease (GERD).

METHODS

This was a single-center, prospective study including 27 Chinese patients with GERD. The outcomes in all patients were evaluated before and at 3, 6, and 12 months after RFA, including their GERD health-related quality of life (GERD-HRQL) score, esophageal acid exposure, DeMeester score, lower esophageal sphincter (LES) resting pressure, and patient's satisfaction with symptom control. Furthermore, rabeprazole sodium (RS) administration, reflux esophagitis (RE), and intraoperative and postoperative complications were also evaluated.

RESULTS

RFA treatment significantly reduced the GERD-HRQL score, the percentage of time that esophageal pH < 4, and the DeMeester score, and significantly increased the LES resting pressure in GERD patients. A need for RS administration was reduced and RE symptoms were relieved. Satisfaction rate of 92.6% and 96.3% was reported by these patients at 6 and 12 months post-treatment, respectively. Mild bleeding (<20 mL) occurred in one patient during RFA, and no serious intraoperative and postoperative complications were observed.

CONCLUSION

RFA is safe and effective in the treatment of GERD in Chinese patients.

Evidence-Based Practice Guideline for Surgical Treatment of Gastroesophageal Reflux Disease 2018

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea, and physicians, including surgeons, have been focusing on its treatment. Indeed, in Korea, medical treatment using a proton pump inhibitor is the mainstream treatment for GERD, while awareness of surgical treatment is limited. Accordingly, to promote the understanding of surgical treatment for GERD, the Korean Anti-Reflux Surgery Study Group published the Evidence-Based Practice Guideline for the Surgical Treatment of GERD. The guideline consists of 2 sections: fundamental information such as the definition, symptoms, and diagnostic tools of GERD and a recommendation statement about its surgical treatment. The recommendations presented 5 debates regarding fundoplication: 1) comparison of the effectiveness of medical and surgical treatments, 2) effectiveness of surgical treatment in cases of refractory GERD, 3) effectiveness of surgical treatment of extraesophageal symptoms, 4) comparison of effectiveness between total and partial fundoplication, and 5) effectiveness of fundoplication in cases of hiatal hernia. The present guideline is the first to demonstrate the efficacy of the surgical treatment GERD in Korea.

Surgical outcomes and over one-year follow-up results of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: Single-center experiences

BACKGROUND

Laparoscopic antireflux surgery is a standard surgical treatment method for gastroesophageal reflux disease (GERD) in Western countries. However, the procedure has not been actively carried out in Korea because of concerns regarding surgical complications. Here, we conducted this study to evaluate short-term surgical outcomes of laparoscopic Nissen fundoplication (LNF) performed at a single institution.

METHODS

From January 2010 to August 2016, totally 29 patients underwent LNF for GERD performed by three surgeons at Asan Medical Center, Korea. All patients participated in a telephonic survey including the presence of symptoms and the status of quality of life (QOL).

RESULTS

The median age at operation and BMI were 54 years and 23.8 kg/m², respectively. Preoperatively, 27 patients (93.1%) underwent PPI therapy. All patients had typical or atypical GERD symptoms. One patient (3.4%) required reoperation because of total gastroesophageal junction obstruction. 24 patients (82.8%) reported complete or partial resolution of symptoms, whereas 21 (72.4%) reported partial or complete improvement in quality of life. In patients with reflux esophagitis, GERD symptoms were significantly relieved after LNF (P = 0.005). LNF responders tended to perceive an improvement in quality of life post operation (P < 0.001).

CONCLUSION

LNF is a feasible, safe, and effective treatment option for controlling GERD symptoms as well as improving the quality of life. Presence of reflux esophagitis was a predictor of successful outcomes.

A Novel, Dynamic Statistical Model for Predicting Patient Satisfaction with Fundoplication Based on Pre-Operative Symptom Patterns

BACKGROUND

Fundoplication provides excellent control of gastro-oesophageal reflux disease (GORD), but there remain a number of unsatisfied patients who have proven difficult to identify pre-operatively. We hypothesised that pre-operative symptom patterns can predict of the risk of post-operative dissatisfaction.

METHODS

Pre-operative symptoms and post-operative satisfaction were measured using standardised questionnaires along with routine investigations. These data were used to calculate our novel pre-operative risk of dissatisfaction (PROD) score. Potential pre-operative prognostic markers were tested against the post-operative satisfaction data, including the objective investigations and the PROD score. The prognostic utility of the PROD score and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline was tested using receiver operating characteristic analysis to determine the area under the curve (AUC).

RESULTS

An association was found between our PROD score and each of the satisfaction measures (n = 225, p < 0.001) which is likely to be of prognostic utility (AUC = 0.67-0.79). No such association was found between the routine investigations and post-operative satisfaction. The PROD score was found to be of greater prognostic utility than the SAGES guideline (n = 166, p < 0.001).

CONCLUSIONS

The PROD score is a novel, easy-to-use test that can predict individual patient satisfaction with fundoplication.

Management of failure after surgery for gastro-esophageal reflux disease

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.

Tobacco smoking, alcohol consumption and gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) develops when reflux of gastric content causes troublesome symptoms or complications. The main symptoms are heartburn and acid regurgitation and complications include oesophagitis, strictures, Barrett's oesophagus and oesophageal adenocarcinoma. In addition to hereditary influence, GORD is associated with lifestyle factors, mainly obesity. Tobacco smoking is regarded as an aetiological factor of GORD, while alcohol consumption is considered a triggering factor of reflux episodes and not a causal factor. Yet, both tobacco smoking and alcohol consumption can reduce the lower oesophageal sphincter pressure, facilitating reflux. In addition, tobacco smoking reduces the production of saliva rich in bicarbonate, which is important for buffering and clearance of acid in the oesophagus. Alcohol also has a direct noxious effect on the oesophageal mucosa, which predisposes to acidic injury. Tobacco smoking cessation reduces the risk of GORD symptoms and avoidance of alcohol is encouraged in individuals where alcohol consumption triggers reflux.

Factors predicting outcomes of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: experience at a single institution in Korea

Purpose

Laparoscopic fundoplication is considered the standard surgical treatment for gastroesophageal reflux disease (GERD) in Western countries. However, some patients experience poor surgical outcomes with this procedure. The study aimed to identify the predictive factors of the surgical outcomes of laparoscopic Nissen fundoplication for the treatment of Korean GERD patients.

Methods

Sixty-one patients with GERD were treated using laparoscopic Nissen fundoplication between November 2012 and February 2015. Symptom control rates were compared according to clinical and surgical factors to identify predictive factors of successful surgical outcomes.

Results

Thirty-five men and 26 women were enrolled. Preoperatively, typical symptoms were present in 60 patients (98%), while atypical symptoms were present in 40 patients (66%). Postoperatively, typical symptoms were controlled in 51 of 60 patients (85.0%), while atypical symptoms were controlled in 33 of 40 patients (82.5%). Overall, at 6 months postsurgery, 54 (88.5%) reported some resolution of GERD symptoms, with 48 (78.7%) achieving complete control. Patients who exhibited a good response to proton pump inhibitor therapy had a significantly greater rate of complete symptom control (P = 0.035).

Conclusion

Laparoscopic fundoplication is effective for controlling GERD symptoms. Response to preoperative proton pump inhibitor was a predictor of successful outcome.

[Surgical and interventional procedures for reflux therapy : Endoscopic or laparoscopic?]

An optimal functioning of the gastroesophageal antireflux barrier depends on an anatomical overlapping of the lower esophageal sphincter and the crural diaphragm. Restoration of this situation is currently only possible by antireflux interventions combined with hiatoplasty and necessitates a laparoscopic approach. Newer alternative techniques to the generally accepted fundoplication are laparoscopic implantation of the LINX® device or the EndoStim® system and various endoscopic antireflux procedures, such as radiofrequency energy treatment, plication and implantation techniques aimed at augmentation of the gastroesophageal valve. Endoscopic techniques are becoming established more and more between pharmaceutical and surgical therapy instead of replacing them.

Antireflux Surgery in Korea: A Nationwide Study from 2011 to 2014

Background/Aims

Although laparoscopic fundoplication is a well-established therapy for gastroesophageal reflux disease (GERD) in Western countries, the mainstay of GERD treatment in Korea is long-term proton pump inhibitor (PPI) use. The aim of the present study was to evaluate nationwide data regarding antireflux surgery in Korea.

Methods

Data from 2011 to 2014 were collected from the Korean Antireflux Surgery Study Group and then analyzed.

Results

A total of 87 patients underwent laparoscopic fundoplication for the treatment of GERD. Preoperatively, typical symptoms were present in 81 patients (93%) and atypical symptoms were present in 51 patients (59%). Twenty-seven patients (31%) had poor PPI responses. The average surgical time and postoperative hospital stay were 116.3±42.3 minutes and 4.3±3.1 days, respectively. At 3 months after surgery, typical symptoms were completely controlled in 86.3% of patients and partially controlled in 11.7%, whereas atypical symptoms were completely controlled in 63.3% of patients and partially controlled in 23.3%.

Conclusions

This study showed that although atypical symptoms and PPI nonresponders are common, the complete control rates of typical and atypical symptoms were 86.3% and 63.3%, respectively. Laparoscopic fundoplication is an efficacious method of controlling the symptoms of GERD and has an acceptable rate of postoperative morbidity and adverse symptoms.

Are proton pump inhibitors really so dangerous?

For decades, millions of patients with acid-related disorders have had their acid inhibited effectively and safely first with H2-receptor antagonists (H2RAs) and then with proton pump inhibitors (PPI). As with any pharmacological agent, PPIs have been reported to be associated with some adverse events, but several recent large-scale observational studies have evidenced new and serious abnormalities generally linked to their chronic use. However, these studies have often important limitations for their frequent retrospective design and other methodological drawbacks, such as selection biases of the analyzed populations and the presence of various confounding factors. Overall, although the conclusions of these pharmacovigilant investigations must be taken into account and can generate important hypotheses for future research, they do not have to create panic among patients and alarmism among physicians. On considering the weakness of these studies, we suggest physicians should not refrain from continuing to use PPIs, if these drugs are given for medical indications clearly established in the literature and, more importantly, they should not be induced to shift to H2RAs, a class of antisecretory agents that are much less effective than PPIs. A return to the past is potentially dangerous for the patients, taking into account the well-known success of PPIs in the wide spectrum of all acid-related conditions.

Laparoscopic Mesh-augmented Hiatoplasty With Cardiophrenicopexy Versus Laparoscopic Nissen Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Double-center Randomized Controlled Trial

OBJECTIVE

Laparoscopic mesh-augmented hiatoplasty with cardiophrenicopexy (LMAH-C) might represent an alternative treatment of gastroesophageal reflux disease (GERD) and may provide durable reflux control without fundoplication. The expected benefit is the prevention of fundoplication-related side effects. Aim of the present trial was to compare LMAH-C with laparoscopic Nissen fundoplication (LNF) in patients with GERD.

METHODS

In a double-center randomized controlled trial (RCT) patients with proven GERD were eligible and assigned by central randomization to either LMAH-C (n = 46) or LNF (n = 44). The indigestion subscore of the Gastrointestinal Symptom Rating Scale questionnaire (GSRS) indicating gas-related symptoms as possible side effects of LNF was the primary endpoint. Secondary endpoints comprised pH testing and endoscopy and other symptoms measured by the GSRS, dysphagia, and the Gastrointestinal Quality of Life Index. The follow-up period was 36 months.

RESULTS

Indigestion subscore (LMAH-C 2.9 ± 1.5 vs LNF 3.7 ± 1.6; P = 0.031) but not dysphagia (2.8 ± 1.9 vs 2.3 ± 1.7; P = 0.302) and quality of life (106.9 ± 25.5 vs 105.8 ± 24.9; P = 0.838) differed between the groups at 36 months postoperatively. Although the reflux subscore improved in both groups, it was worse in LMAH-C patients (2.5 ± 1.6 vs 1.6 ± 1.0; P = 0.004) corresponding to a treatment failure of 77.3% in LMAH-C patients and of 34.1% in LNF patients (P < 0.001).

CONCLUSIONS

LNF is more effective in the treatment of GERD than LMAH-C. Procedure-related side effects seem to exist but do not affect the quality of life. Laparoscopic fundoplication therefore remains the standard surgical treatment for GERD.

Laparoscopic fundoplication surgery versus medical management for gastro-oesophageal reflux disease (GORD) in adults

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a common condition with 3% to 33% of people from different parts of the world suffering from GORD. There is considerable uncertainty about whether people with GORD should receive an operation or medical treatment for controlling the condition.

OBJECTIVES

To assess the benefits and harms of laparoscopic fundoplication versus medical treatment for people with gastro-oesophageal reflux disease.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group (UGPD) Trials Register (June 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 6, 2015), Ovid MEDLINE (1966 to June 2015), and EMBASE (1980 to June 2015) to identify randomised controlled trials. We also searched the references of included trials to identify further trials.

SELECTION CRITERIA

We considered only randomised controlled trials (RCT) comparing laparoscopic fundoplication with medical treatment in people with GORD irrespective of language, blinding, or publication status for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR) or standardised mean difference (SMD) with 95% confidence intervals (CI) using both fixed-effect and random-effects models with RevMan 5 based on available case analysis.

MAIN RESULTS

Four studies met the inclusion criteria for the review, and provided information on one or more outcomes for the review. A total of 1160 participants in the four RCTs were either randomly assigned to laparoscopic fundoplication (589 participants) or medical treatment with proton pump inhibitors (571 participants). All the trials included participants who had had reflux symptoms for at least six months and had received long-term acid suppressive therapy. All the trials included only participants who could undergo surgery if randomised to the surgery arm. All of the trials were at high risk of bias. The overall quality of evidence was low or very low. None of the trials reported long-term health-related quality of life (HRQoL) or GORD-specific quality of life (QoL).The difference between laparoscopic fundoplication and medical treatment was imprecise for overall short-term HRQOL (SMD 0.14, 95% CI -0.02 to 0.30; participants = 605; studies = 3), medium-term HRQOL (SMD 0.03, 95% CI -0.19 to 0.24; participants = 323; studies = 2), medium-term GORD-specific QoL (SMD 0.28, 95% CI -0.27 to 0.84; participants = 994; studies = 3), proportion of people with adverse events (surgery: 7/43 (adjusted proportion = 14.0%); medical: 0/40 (0.0%); RR 13.98, 95% CI 0.82 to 237.07; participants = 83; studies = 1), long-term dysphagia (surgery: 27/118 (adjusted proportion = 22.9%); medical: 28/110 (25.5%); RR 0.90, 95% CI 0.57 to 1.42; participants = 228; studies = 1), and long-term reflux symptoms (surgery: 29/118 (adjusted proportion = 24.6%); medical: 41/115 (35.7%); RR 0.69, 95% CI 0.46 to 1.03; participants = 233; studies = 1).The short-term GORD-specific QoL was better in the laparoscopic fundoplication group than in the medical treatment group (SMD 0.58, 95% CI 0.46 to 0.70; participants = 1160; studies = 4).The proportion of people with serious adverse events (surgery: 60/331 (adjusted proportion = 18.1%); medical: 38/306 (12.4%); RR 1.46, 95% CI 1.01 to 2.11; participants = 637; studies = 2), short-term dysphagia (surgery: 44/331 (adjusted proportion = 12.9%); medical: 11/306 (3.6%); RR 3.58, 95% CI 1.91 to 6.71; participants = 637; studies = 2), and medium-term dysphagia (surgery: 29/288 (adjusted proportion = 10.2%); medical: 5/266 (1.9%); RR 5.36, 95% CI 2.1 to 13.64; participants = 554; studies = 1) was higher in the laparoscopic fundoplication group than in the medical treatment group.The proportion of people with heartburn at short term (surgery: 29/288 (adjusted proportion = 10.0%); medical: 59/266 (22.2%); RR 0.45, 95% CI 0.30 to 0.69; participants = 554; studies = 1), medium term (surgery: 12/288 (adjusted proportion = 4.2%); medical: 59/266 (22.2%); RR 0.19, 95% CI 0.10 to 0.34; participants = 554; studies = 1), long term (surgery: 46/111 (adjusted proportion = 41.2%); medical: 78/106 (73.6%); RR 0.56, 95% CI 0.44 to 0.72); participants = 217; studies = 1) and those with reflux symptoms at short-term (surgery: 6/288 (adjusted proportion = 2.0%); medical: 53/266 (19.9%); RR 0.10, 95% CI 0.05 to 0.24; participants = 554; studies = 1) and medium term (surgery: 6/288 (adjusted proportion = 2.1%); medical: 37/266 (13.9%); RR 0.15, 95% CI 0.06 to 0.35; participants = 554; studies = 1) was less in the laparoscopic fundoplication group than in the medical treatment group.

AUTHORS' CONCLUSIONS

There is considerable uncertainty in the balance of benefits versus harms of laparoscopic fundoplication compared to long-term medical treatment with proton pump inhibitors. Further RCTs of laparoscopic fundoplication versus medical management in patients with GORD should be conducted with outcome-assessor blinding and should include all participants in the analysis. Such trials should include long-term patient-orientated outcomes such as treatment-related adverse events (including severity), quality of life, and also report on the social and economic impact of the adverse events and symptoms.

Use of acid-suppressive therapy before anti-reflux surgery in 2922 patients: a nationwide register-based study in Denmark

BACKGROUND

Guidelines recommend that patients with gastro-oesophageal reflux disease are adequately treated with acid-suppressive therapy before undergoing anti-reflux surgery. Little is known of the use of acid-suppressive drugs before anti-reflux surgery.

AIM

To determine the use of proton pump inhibitors and H2 -receptor antagonists in the year before anti-reflux surgery.

METHODS

A nationwide retrospective study of all patients aged ≥18 undergoing first-time anti-reflux surgery in Denmark during 2000-2012 using data from three different sources: the Danish National Register of Patients, the Danish National Prescription Register, and the Danish Person Register.

RESULTS

The study population thus included 2922 patients (median age: 48 years, 55.7% male). The annual proportion of patients redeeming ≥180 DDD of acid-suppressive therapy increased from 17.0% 5 years before anti-reflux surgery to 64.9% 1 year before. The probability for inadequate dosing 1 year before surgery (<180 DDD) was significantly increased for younger patients, patients operated in the period 2000-2003, patients who had not undergone pre-surgical manometry, pH- or impedance monitoring, and patients who had not redeemed prescriptions on NSAID or anti-platelet drugs.

CONCLUSION

Compliance with medical therapy should be evaluated thoroughly before planning anti-reflux surgery, as a high proportion of patients receive inadequate dosing of acid-suppressive therapy prior to the operation.

Paraesophageal Hernia Repair With Partial Longitudinal Gastrectomy in Obese Patients

BACKGROUND AND OBJECTIVES

Treatment of gastroesophageal reflux disease (GERD) with hiatal hernia in obese patients has proven difficult, as studies demonstrate poor symptom control and high failure rates in this patient population. Recent data have shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes.

METHODS

We retrospectively reviewed 28 obese and morbidly obese patients who presented from December 2007 through July 2013 with large or recurrent type 3 or 4 paraesophageal hernia. All of the patients underwent combined paraesophageal hernia repair and partial longitudinal gastrectomy. Charts were retrospectively reviewed, and the patients were contacted to determine symptomatic relief.

RESULTS

Mean preoperative body mass index was 38.1 ± 4.9 kg/m(2). Anatomic failure of prior fundoplication occurred in 7 patients (25%). The remaining 21 had primary paraesophageal hernia, 3 of which were type 4. Postoperative complications included pulmonary embolism (n = 1), pulmonary decompensation (n = 2), and wound infection (n = 1). Mean hospital stay was 5 ± 3 days. Upper gastrointestinal esophagogram was performed in 21 patients with no immediate recurrence or staple line dehiscence. Mean excess weight loss was 44 ± 25%. All of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month. At 1 year, symptom scores decreased significantly. At 27 months, however, there was a mild increase in the scores. Return of severe symptoms occurred in 2 patients, both of whom underwent conversion to gastric bypass.

CONCLUSIONS

Combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe, feasible approach to the management of large or recurrent paraesophageal hernia in well-selected obese and morbidly obese patients. Short-term results were promising; however, intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass.

Feasibility, safety, and short-term efficacy of the laparoscopic Nissen-Hill hybrid repair

BACKGROUND

A novel antireflux procedure combining laparoscopic Nissen fundoplication and Hill repair components was tested in 50 patients with paraesophageal hernia (PEH) and/or Barrett's esophagus (BE) because these two groups have been found to have a high rate of recurrence with conventional repairs.

METHODS

Patients with symptomatic PEH and/or non-dysplastic BE underwent repair. Quality of life (QOL) metrics, manometry, EGD, and pH testing were administered pre- and postoperatively.

RESULTS

Fifty patients underwent repair. There was no mortality and four major complications. At 13-month follow-up, there was one (2%) clinical recurrence, and two (4%) asymptomatic fundus herniations. Mean DeMeester scores improved from 57.2 to 7.7 (p < 0.0001). Control of preoperative symptoms was achieved in 90% with 6% resumption of antisecretory medication. All QOL metrics improved significantly.

CONCLUSIONS

The hybrid Nissen-Hill repair for patients with PEH and BE appears safe and clinically effective at short-term follow-up. It is hoped that the combined structural components may reduce the rate of recurrence compared to existing repairs.

Does Measurement of Esophagogastric Junction Distensibility by EndoFLIP Predict Therapy- responsiveness to Endoluminal Fundoplication in Patients With Gastroesophageal Reflux Disease?

Background/Aims

In patients with gastroesophageal reflux disease (GERD), an increased esophagogastric junction (EGJ) distensibility has been described. Assessment of EGJ distensibility with the endoscopic functional luminal imaging probe (EndoFLIP) technique might identify patients responsive to transoral incisionless fundoplication (TIF), whereas postoperative measurement of EGJ distensibility might provide insight into the antireflux mechanism of TIF. Therefore, we investigated the value of the EndoFLIP technique in GERD patients treated by TIF.

Methods

Forty-two GERD patients underwent EGJ distensibility measurement before TIF using the EndoFLIP technique. In a subgroup of 25 patients, EndoFLIP measurement was repeated both postoperative and at 6 months follow-up. Treatment outcome was assessed according to esophageal acid exposure time (AET; objective outcome) and symptom scores (clinical outcome) 6 months after TIF.

Results

Multiple logistic regression analysis showed that preoperative EGJ distensibility (OR, 0.16; 95% CI, 0.03–0.78; P = 0.023) and preoperative AET (OR, 0.62; 95% CI, 0.42–0.90; P = 0.013) were independent predictors for objective treatment outcome but not for clinical outcome after TIF. The best cut-off value for objective outcome was 2.3 mm²/mmHg for preoperative EGJ distensibility and 11% for preoperative AET. EGJ distensibility decreased direct postoperative from 2.0 (1.2–3.3) to 1.4 (1.0–2.2) mm²/mmHg (P = 0.014), but increased to 2.2 (1.5–3.0) at 6 months follow-up (P = 0.925, compared to preoperative).

Conclusions

Preoperative EGJ distensibility and preoperative AET were independent predictors for objective treatment outcome but not for clinical outcome after TIF. According to our data, the EndoFLIP technique has no added value either in the preoperative diagnostic work-up or in the post-procedure evaluation of endoluminal antireflux therapy.

Randomized controlled trial of transoral incisionless fundoplication vs. proton pump inhibitors for treatment of gastroesophageal reflux disease

OBJECTIVES

Transoral incisionless fundoplication (TIF) was developed in an attempt to create a minimally invasive endoscopic procedure that mimics antireflux surgery. The objective of this trial was to evaluate effectiveness of TIF compared with proton pump inhibition in a population consisting of gastroesophageal reflux disease (GERD) patients controlled with proton pump inhibitors (PPIs) who opted for an endoscopic intervention over lifelong drug dependence.

METHODS

Patients with chronic GERD were randomized (2:1) for TIF or continuation of PPI therapy. American Society of Anesthesiologists >2, body mass index >35 kg/m(2), hiatal hernia >2 cm, and esophageal motility disorders were exclusion criteria. Primary outcome measure was GERD-related quality of life. Secondary outcome measures were esophageal acid exposure, number of reflux episodes, PPI usage, appearance of the gastroesophageal valve, and healing of reflux esophagitis. Crossover for the PPI group was allowed after 6 months.

RESULTS

A total of 60 patients (TIF n=40, PPI n=20, mean body mass index 26 kg/m(2), 37 male) were included. At 6 months, GERD symptoms were more improved in the TIF group compared with the PPI group (P<0.001), with a similar improvement of distal esophageal acid exposure (P=0.228) compared with baseline. The pH normalization for TIF group and PPI group was 50% and 63%, respectively. All patients allocated for PPI treatment opted for crossover. At 12 months, quality of life remained improved after TIF compared with baseline (P<0.05), but no improvement in esophageal acid exposure compared with baseline was found (P=0.171) and normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%.

CONCLUSION

Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved.

Surgical treatment of gastroesophageal reflux disease

Operative treatment of GERD has become more common since the introduction of LARS. Careful patient selection based on symptoms, response to medical therapy, and preoperative testing will optimize the chances for effective and durable postoperative control of symptoms. Complications of the LARS are rare and generally can be managed without reoperation. When reoperation is necessary for failed antireflux surgery, it should be performed by high-volume gastroesophageal surgeons.

Repair of Paraesophageal Hiatal Hernias—Is a Fundoplication Needed? A Randomized Controlled Pilot Trial

BACKGROUND

The need for a fundoplication during repair of paraesophageal hiatal hernias (PEH) remains unclear. Prevention of gastroesophageal reflux represents a trade-off against the risk of fundoplication-related side effects. The aim of this trial was to compare laparoscopic mesh-augmented hiatoplasty with simple cardiophrenicopexy (LMAH-C) with laparoscopic mesh-augmented hiatoplasty with fundoplication (LMAH-F) in patients with PEH.

STUDY DESIGN

The study was designed as a patient- and assessor-blinded randomized controlled pilot trial, registration number: DRKS00004492 (www.germanctr.de/). Patients with symptomatic PEH were eligible and assigned by central randomization to LMAH-C or LMAH-F. Endpoints were postoperative gastroesophageal reflux, complications, and quality of life 12 months postoperatively.

RESULTS

Forty patients (9 male, 31 female) were randomized. Patients were well matched for baseline characteristics. At 3 months, the DeMeester score was higher after LMAH-C compared with LMAH-F (40.9 ± 39.9 vs. 9.6 ± 17; p = 0.048). At 12 months, the reflux syndrome score was higher after LMAH-C compared with LMAH-F (1.9 ± 1.2 vs. 1.1 ± 0.4; p = 0.020). In 53% of LMAH-C patients and 17% of LMAH-F patients, postoperative esophagitis was present (p = 0.026). Values of dysphagia (2.1 ± 1.6 vs 1.9 ± 1.4; p = 0.737), gas bloating (2.6 ± 1.4 vs 2.8 ± 1.4; p = 0.782), and quality of life (116.0 ± 16.2 vs 115.9 ± 15.8; p = 0.992) were similar. Relevant postoperative complications occurred in 4 (10%) patients and did not differ between the groups.

CONCLUSIONS

Laparoscopic repair of PEH should be combined with a fundoplication to avoid postoperative gastroesophageal reflux and resulting esophagitis. Fundoplication-related side effects do not appear to be clinically relevant. Multicenter randomized trials are required to confirm these findings.

Refractory gastroesophageal reflux disease

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.

Transoral incisionless fundoplication for the treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common and costly chronic medical condition affecting millions of patients. It is associated with substantial morbidity and negatively impacts quality of life. Reflux of gastric contents into the esophagus damages the esophageal mucosa and is associated with conditions including esophagitis and esophageal stricture. While GERD is most commonly seen in Western populations, changes in dietary patterns and the global increase in obesity have led to a pronounced increase in its prevalence worldwide. Medical and surgical GERD therapies are costly and pose considerable side effects, leading many to pursue effective endoscopic treatment options. Transoral incisionless fundoplication is an endoluminal procedure that offers patients a minimally invasive treatment option with the potential to eliminate the need for medical acid suppression with a low risk of side effects.

Long-term cost-effectiveness of medical, endoscopic and surgical management of gastroesophageal reflux disease

BACKGROUND

The long-term cost effectiveness of medical, endoscopic, and operative treatments for adults with gastroesophageal reflux disease (GERD) remains unclear. We sought to estimate the cost effectiveness of medical, endoscopic, and operative treatments for adults with GERD who require daily proton pump inhibitor (PPI) therapy.

METHODS

A Markov model was generated from the payer's perspective using a 6-month cycle and 30-year time horizon. The base-case patient was a 45-year-old man with symptomatic GERD taking 20 mg of omeprazole twice daily. Four treatment strategies were analyzed: PPI therapy, transoral incisionless fundoplication (EsophyX), radiofrequency energy application to the lower esophageal sphincter (Stretta) and laparoscopic Nissen fundoplication. The model parameters were selected using the published literature and institutional billing data. The main outcome measure was the incremental cost-effectiveness ratio (cost per quality-adjusted life-year gained) for each therapy.

RESULTS

In the base case analysis, which assumed a PPI cost of $234 over 6 months ($39 per month), Stretta and laparoscopic Nissen fundoplication were the most cost-effective options over a 30-year time period ($2,470.66 and $5,579.28 per QALY gained, respectively). If the cost of PPI therapy exceeded $90.63 per month over 30 years, laparoscopic Nissen fundoplication became the dominant treatment option. EsophyX was dominated by laparoscopic Nissen fundoplication at all points in time.

CONCLUSION

Low-cost PPIs, Stretta, and laparoscopic Nissen fundoplication all represent cost-effective treatment strategies. In this model, when PPIs exceed $90 per month, medical therapy is no longer cost effective. Procedural GERD therapy should be considered for patients who require high-dose or expensive PPIs.

[The Mexican consensus on gastroesophageal reflux disease. Part II]

OBJECTIVE

To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002.

METHODS

Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher.

RESULTS

Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%.

CONCLUSION

Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.

Stretta Radiofrequency Treatment for GERD: A Safe and Effective Modality

Gastroesophageal reflux disease is one of the leading gastrointestinal disorders. Current treatments include lifestyle modifications, pharmacological therapies, surgical fundoplications, and, more recently, endoscopic procedures. The rising concern of long-term side effects of the popular proton-pump inhibitors and the more recent evidence raising doubts about the durability of fundoplication have spurred reinterest in endoscopic procedures to treat reflux disorders. In the aftermath of several innovative antireflux procedures that were introduced and failed clinically or financially over the past decade, there is lingering confusion regarding the merits of the presently available interventions. This paper focuses on one endoscopic procedure, Stretta, which now enjoys the longest experience, a recent meta-analysis, and robust data supporting its safety, efficacy, and durability. Stretta reduces esophageal acid exposure, decreases the frequency of transient lower esophageal relaxation, increases patient satisfaction, decreases medication use, and improves quality of life. As such, this procedure remains a valuable nonsurgical treatment option in the management of gastroesophageal reflux disease.

Laparoscopic mesh-augmented hiatoplasty without fundoplication as a method to treat large hiatal hernias

Purpose

Laparoscopic hiatal hernia repair with additional fundoplication is a commonly recommended standard surgical treatment for symptomatic large hiatal hernias with paraesophageal involvement (PEH). However, due to the risk of persistent side effects, this method remains controversial. Laparoscopic mesh-augmented hiatoplasty without fundoplication (LMAH), which combines hiatal repair and mesh reinforcement, might therefore be an alternative.

Methods

In this retrospective study of 55 (25 male, 30 female) consecutive PEH patients, the perioperative course and symptomatic outcomes were analyzed after a mean follow-up of 72 months.

Results

The mean DeMeester symptom score decreased from 5.1 to 1.8 (P < 0.001) and the gas bloating value decreased from 1.2 to 0.5 (P = 0.001). The dysphagia value was 0.7 before surgery and 0.6 (P = 0.379) after surgery. The majority of the patients were able to belch and vomit (96 and 92 %, respectively). Acid-suppressive therapy on a regular basis was discontinued in 68 % of patients. In 4 % of patients, reoperation was necessary due to recurrent or persistent reflux. A mesh-related stenosis that required endoscopic dilatation occurred in 2 % of patients.

Conclusions

LMAH is feasible, safe and provides an anti-reflux effect, even without fundoplication. As operation-related side effects seem to be rare, LMAH is a potential treatment option for large hiatal hernias with paraesophageal involvement.

Surgical management of gastroesophageal reflux disease

Antireflux surgery has become a well-established therapy for gastroesophageal reflux disease (GERD) and its complications. The popularization of minimally invasive surgical techniques has brought about a revolution in the use of fundoplication for the long-term management of GERD. A reliable and objective understanding of the outcomes following fundoplication is important for all physicians treating GERD, so that informed decisions can be made regarding the optimal treatment strategy for a given patient. With ongoing study, the appropriate indications for surgical intervention among the array of potential antireflux therapies will continue to be elucidated.

Endolumenal therapies for gastroesophageal reflux disease

TIF Stretta and Endocinch all seem technically safe in well-selected patients including those with prior esophageal and gastric surgeries. Long-term effectiveness is being evaluated. Given the current enthusiasm for increasingly less invasive surgical techniques, the inertia for endolumenal therapies continues to grow. Other endolumenal therapies for Gastroesophageal reflux disease (GERD) have initiated trials. These pursue similar fundoplication or lower esophageal sphincter reconstruction using simpler techniques with fewer steps. Because all endolumenal approaches to GERD evolve, objective evaluation for symptom resolution and reduced esophageal acid exposure with improved esophagogastric physiology will remain a constant.