Impact of ineffective oesophageal motility and wrap type on dysphagia after laparoscopic fundoplication

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.

Is barium esophagram enough? Comparison of esophageal motility found on barium esophagram to high resolution manometry

BACKGROUND

The aim of the study is to determine if barium esophagram (BE) alone is sufficient to diagnose esophageal dysmotility when compared to the gold standard, high-resolution manometry (HRM).

METHODS

This is a retrospective review of patients that underwent laparoscopic fundoplication by two surgeons at a single institution from 10/1/2015-6/29/2019. Patients with large paraesophageal hernias and patients without both BE and HRM were excluded.

RESULTS

Forty-six patients met the inclusion criteria. BE was found to be concordant with HRM for esophageal motility in only 21 patients (46%). Setting HRM as the gold standard, BE had a sensitivity of 14% (95% CI: 5%-35%), specificity of 72% (95% CI: 52%-86%), PPV of 30% (95% CI: 11%-60%), and NPV of 50% (95% CI: 35%-66%). The accuracy was 46%, while a McNemar test showed p = 0.028.

CONCLUSION

Traditional BE should not be used in place of HRM for assessing pre-operative motility in patients undergoing anti-reflux surgery.

Patients with ineffective esophageal motility benefit from laparoscopic antireflux surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common chronic disorder of the gastrointestinal tract, affecting more than 50% of Americans. The development of GERD may be associated with ineffective esophageal motility (IEM). The impact of esophageal motility on outcomes post laparoscopic antireflux surgery (LARS), including quality of life (QOL), remains to be defined. The purpose of this study is to analyze and compare QOL outcomes following LARS among patients with and without ineffective esophageal motility (IEM).

METHODS

This is a single-institution, retrospective review of a prospectively maintained database of patients who underwent LARS, from January 2012 to July 2019, for treatment of GERD at our institution. Patients undergoing revisional surgery were excluded. Patients with normal peristalsis (non-IEM) were distinguished from those with IEM, defined using the Chicago classification, on manometric studies. Four validated QOL surveys were used to assess outcomes: Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL), Laryngopharyngeal Reflux Health-Related QOL (LPR-HRQL), and Swallowing Disorders (SWAL) survey.

RESULTS

203 patients with complete manometric data were identified (75.4% female) and divided into two groups, IEM (n = 44) and non-IEM (n = 159). IEM and Non-IEM groups were parallel in age (58.1 ± 15.3 vs. 62.2 ± 12 years, p = 0.062), body mass index (27.4 ± 4.1 vs. 28.2 ± 4.9 kg/m², p = 0.288), distribution of comorbid disease, sex, and ASA scores. The groups differed in manometry findings and Johnson-DeMeester score (IEM: 38.6 vs. Non-IEM: 24.0, p = 0.023). Patients in both groups underwent similar rates of Nissen fundoplication (IEM: 84.1% vs. Non-IEM: 93.7%, p = 0.061) with greater improvements in dysphagia (IEM: 27.4% vs. 44.2%) in Non-IEM group but comparable benefit in reflux reduction (IEM: 80.6% vs. 72.4%) in both groups at follow-up. There were no differences in postoperative outcomes. Satisfaction rates with LARS were similar between groups (IEM: 80% vs. non-IEM: 77.9%, p > 0.05).

CONCLUSION

Patients with ineffective esophageal motility derive significant benefits in perioperative and QOL outcomes after LARS. Nevertheless, as anticipated, their baseline dysmotility may reduce the degree of improvement in dysphagia rates post-surgery compared to patients with normal motility. Furthermore, the presence of preoperative IEM should not be a contraindication for complete fundoplication. Key to optimal outcomes after LARS is careful patient selection based on objective perioperative data, including manometry evaluation, with the purpose of tailoring surgery to provide effective reflux control and improved esophageal clearance.

Long-term patient satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort: study protocol for a retrospective cohort study with development of a novel scoring system for patient selection

INTRODUCTION

Laparoscopic anti-reflux surgery is standard of care in surgical treatment of gastro-oesophageal reflux disease and is not without risks of adverse effects, including disruption of the fundoplication and postfundoplication dysphagia, in some cases leading to reoperation. Non-surgical factors such as pre-existing anxiety or depression influence postoperative satisfaction and symptom relief. Previous studies have focused on a short-term follow-up or only certain aspects of disease, such as reoperation or postoperative quality of life. The aim of this study is to evaluate long-term patient-satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort using a comprehensive multimodal follow-up, and to develop a clinically applicable scoring system usable in selecting patients for anti-reflux surgery.

METHODS AND ANALYSIS

The study is a retrospective cohort study utilising data from patient records and follow-up with patient-reported quality of life as well as registry-based data. The study population consists of all adult patients having undergone laparoscopic anti-reflux surgery at The Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital Denmark in an 11-year period. From electronic records; patient characteristics, preoperative endoscopic findings, reflux disease characteristics and details on type of surgery, will be identified. Disease-specific quality of life and dysphagia will be collected from a patient-reported follow-up. From Danish national registries, data on comorbidity, reoperative surgery, use of pharmacological anti-reflux treatment, mortality and socioeconomic factors will be included. Primary outcome of this study is treatment success at follow-up.

ETHICS AND DISSEMINATION

Study approval has been obtained from The Danish Patient Safety Agency, The Danish Health Data Authority and Statistics Denmark, complying to Danish and EU legislation. Inclusion in the study will require informed consent from participating subjects. The results of the study will be published in peer-reviewed medical journals regardless of whether these are positive, negative or inconclusive.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03959020).

Minor esophageal functional disorders: are they relevant?

PURPOSE OF REVIEW

High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear.

RECENT FINDINGS

Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility.

SUMMARY

Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.

Large paraesophageal hernia in elderly patients: Two case reports of laparoscopic posterior cruroplasty and anterior gastropexy

BACKGROUND

Paraesophageal hernia (PEH) is a rare form of hiatal hernia, which commonly occurs in elderly people. Although asymptomatic, it can be associated with severe life-threatening complications, such as gastric volvulus. Surgical treatment is reserved for symptomatic patients. Herein, we present two cases of complicated PEH that were treated with laparoscopic posterior cruroplasty and anterior gastropexy.

CASE SUMMARY

An 88-year old woman presented with epigastric pain, hematemesis and food intolerance for the last two days. Physical exam revealed mild abdominal distention. Chest X-ray showed a left thoracic opacity, and barium swallow images showed a mixed type III PEH. Abdominal CT-scan images confirmed the diagnosis of incomplete gastric volvulus. The patient underwent a laparoscopic hernia reduction with sac excision, posterior cruroplasty and anterior gastropexy with continuous barbed suturing. The postoperative course was uneventful, and follow-up showed complete resolution of her symptoms. A 91-year old patient was admitted for dyspnea and fever, with vomiting and food intolerance for the last 7 days. Physical exam revealed absent sounds on both lungs. Chest X-ray showed a large left opacity. CT-scan images revealed a giant PEH with complete gastric volvulus. The patient underwent emergency laparoscopic hernia reduction and sac excision, with re-inforced posterior cruroplasty, and anterior gastropexy with continuous barbed suturing. There were no surgical complications, but the patient died on the 4^th day postoperatively due to respiratory failure.

CONCLUSION

Early laparoscopic posterior cruroplasty and anterior gastropexy is a safe and effective surgical alternative for elderly patients with comorbidities, presenting with symptomatic PEH.

Esophageal Motor Dysfunctions in Gastroesophageal Reflux Disease and Therapeutic Perspectives

Gastroesophageal reflux disease (GERD) is a very common disease, and the prevalence in the general population has recently increased. GERD is a chronic relapsing disease associated with motility disorders of the upper gastrointestinal tract. Several factors are implicated in GERD, including hypotensive lower esophageal sphincter, frequent transient lower esophageal sphincter relaxation, esophageal hypersensitivity, reduced resistance of the esophageal mucosa against the refluxed contents, ineffective esophageal motility, abnormal bolus transport, deficits initiating secondary peristalsis, abnormal response to multiple rapid swallowing, and hiatal hernia. One or more of these mechanisms result in the reflux of stomach contents into the esophagus, delayed clearance of the refluxate, and the development of symptoms and/or complications. New techniques, such as 24-hour pH and multichannel intraluminal impedance monitoring, multichannel intraluminal impedance and esophageal manometry, high-resolution manometry, 3-dimensional high-resolution manometry, enoscopic functional luminal imaging probe, and 24-hour dynamic esophageal manometry, provide more information on esophageal motility and have clarified the pathophysiology of GERD. Proton pump inhibitors remain the preferred pharmaceutical option to treat GERD. The ideal target of GERD treatment is to restore esophageal motility and reconstruct the anti-reflux mechanism. This review focuses on current advances in esophageal motor dysfunction in patients with GERD and the influence of these developments on GERD treatment.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

BACKGROUND

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals.

PURPOSE

A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

Laparoscopic antireflux surgery: how I do it?

Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the US, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) are effective in the majority of patients. However, some patients will become candidates for surgical intervention, because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI. In these patients, a properly executed laparoscopic antireflux surgery controls esophageal and extra-esophageal symptoms and avoids life-long medical therapy. Important technical elements should be taken into account during the operation to avoid troublesome side effects and obtain optimal postoperative outcomes.

In ineffective esophageal motility, failed swallows are more functionally relevant than weak swallows

BACKGROUND

Esophageal pressure topography (EPT) diagnosis of ineffective esophageal motility (IEM) can be non-specific with unclear clinical significance.

AIMS

To determine whether peristaltic vigor or lower esophageal sphincter (LES) integrity is associated with poor clearance and acid reflux in IEM.

METHODS

Bolus clearance on high-resolution impedance manometry (HRIM) and available reflux studies in patients with IEM were retrospectively reviewed. Bolus clearance was assessed using both line tracing and colored contour methods on HRIM. EPT parameters, bolus clearance, and acid reflux variables were explored.

KEY RESULTS

Eighty-eight patients with IEM were included. Bolus clearance occurred in 71% of all swallows, and 55.7% of patients had complete bolus transit (CBT, bolus clearance in ≥80% of swallows). Bolus clearance was impaired in swallows with distal contractile integral (DCI) <100 mmHg•cm•s compared to DCI 100-450 (0.43 vs 0.79, P < .0001). A cutoff at DCI 100 mmHg•cm•s was associated with clearance with an accuracy of 76% compared to 49% at DCI 450 (P = .0001 for both). A median DCI <100 was associated with a higher Eckardt score (9 vs 3, P = .03), and on reflux testing available in 47 patients, with abnormal acid exposure time (P = .002). Peristaltic reserve (PR) defined as (DCI of multiple rapid swallow/median DCI of wet swallows), integrated relaxation pressure, and resting lower esophageal sphincter pressure were not associated with clearance or acid exposure.

CONCLUSIONS & INFERENCES

Failed peristalsis, as defined by DCI <100 mmHg•cm•s, is associated with impaired bolus clearance and more severe dysphagia in IEM, and likely abnormal acid exposure.

Before and after Esophageal Surgery: Which Information Is Needed from the Functional Laboratory?

BACKGROUND

Indications for benign esophageal surgery and postoperative follow-up need to be highly elaborated with differentiated and structured algorithms, based on objective functional workup in the esophageal laboratory. Functional outcome is of utmost interest and has to be driven by the need for comprehensive but purposeful diagnostic methods.

METHODS

Preoperative diagnostic workup procedures by the functional laboratory include 24-h pH-monitoring, impedance testing, and high-resolution manometry (HRM) - in addition to upper gastrointestinal endoscopy and barium swallow/timed barium esophagogram.

RESULTS

The most frequent indications for benign esophageal surgery are gastroesophageal reflux disease and achalasia; quite rare indications are esophageal diverticula and benign tumors. Esophageal motility testing in addition to 24-h pH-monitoring is crucial before antireflux surgery (ARS) in order to rule out ineffective esophageal motility and to tailor the wrap. With respect to achalasia surgery, the exact type of achalasia (I-III) has to be labeled according to the Chicago classification, and other motility disorders have to be excluded. The postoperative functional evaluation in the early phase (6 months) after either ARS or Heller's myotomy serves as the new baseline motility testing in case of later occurring disturbances in the follow-up.

CONCLUSION

A complete and proper preoperative esophageal function assessment is crucial in order to rule out a primary motility disorder and to avoid postoperative functional complications.

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.

Laparoscopic anterior gastropexy for type III/IV hiatal hernia in elderly patients

Introduction

Large esophageal hiatal hernias occur most commonly in elderly patients with comorbidities, in whom even an elective surgery cannot be performed without high risks. Although fundoplication is recommended for esophageal hiatal hernia repair, we prefer not to limit our options to fundoplication, as obstruction is a frequent main complaint. We favor an anterior gastropexy approach instead to perform anti-reflux surgery and prevent recurrent protrusion and torsion of the incarcerated organ with minimal risk. The aim was to evaluate the safety and effectiveness of anterior gastropexy for large hiatal hernia in elderly patients with comorbidities.

Case presentation

We retrospectively evaluated 8 patients who underwent laparoscopic anterior gastropexy for large hiatal hernia (type III or IV) since 2006. All patients were women with a median age of 82 years (range, 74–87 years). The major complaint was obstruction in all patients, with relatively mild reflux symptoms. They underwent successful laparoscopic surgery with no conversion to laparotomy.

Fundoplication was performed in 4 cases. No perioperative complications occurred, and the main complaint resumed rapidly in all patients, without recurrence during postoperative follow-up of median 48 months (range, 5–77 months).

Conclusion

Laparoscopic anterior gastropexy is safe and effective and can be considered as one of the practical surgical options for large hiatal hernias in elderly patients, whom surgical intervention should be minimized due to their comorbidities.

High-resolution Manometry in Patients with Gastroesophageal Reflux Disease Before and After Fundoplication

Background/Aims

The study aimed to determine pre- and post-fundoplication esophagogastric junction (EGJ) pressure and esophageal peristalsis by high-resolution manometry (HRM) in patients with gastroesophageal reflux disease (GERD).

Methods

Pre-operative and post-operative HRM data from 25 patients with GERD were analyzed using ManoView version 2.0.1. with updated software for Chicago classification and pressure topography. The study involved swallowing water boluses of 10 mL in the upright position.

Results

Significant increase of mean basal EGJ pressure and minimal basal EGJ pressure was found in post-operative as compared with pre-operative patients (P < 0.05 and P < 0.001, respectively). Integrated relaxation pressure (IRP) reached higher values in post-operative patients than in pre-operative patients (P < 0.001). Intra-bolus pressure (IBP) was significantly higher (P < 0.05) and contractile front velocity (CFV) was slower (P < 0.01) in post-operative patients than in pre-operative patients. Moreover significant increase of distal contractile integral (DCI) was found in post-operative patients (P < 0.05). Hiatal hernia was detected by HRM in 11 pre-operative patients. Fifteen out of 25 post-operative patients complained of dysphagia.

Conclusions

Fundoplication restores the antireflux barrier by reinforcing EGJ basal pressures, repairing hiatal hernias, and enhances peristaltic function of the esophagus by increasing DCI. However slight IRP elevation found in post-fundoplication patients may result in bolus pressurization and motility disorders.

POSTFUNDOPLICATION DYSPHAGIA CAUSES SIMILAR WATER INGESTION DYNAMICS AS ACHALASIA

BACKGROUND

- After surgical treatment of gastroesophageal reflux disease dysphagia is a symptom in the majority of patients, with decrease in intensity over time. However, some patients may have persistent dysphagia.

OBJECTIVE

- The objective of this investigation was to evaluate the dynamics of water ingestion in patients with postfundoplication dysphagia compared with patients with dysphagia caused by achalasia, idiopathic or consequent to Chagas' disease, and controls.

METHODS

- Thirty-three patients with postfundoplication dysphagia, assessed more than one year after surgery, together with 50 patients with Chagas' disease, 27 patients with idiopathic achalasia and 88 controls were all evaluated by the water swallow test. They drunk, in triplicate, 50 mL of water without breaks while being precisely timed and the number of swallows counted. Also measured was: (a) inter-swallows interval - the time to complete the task, divided by the number of swallows during the task; (b) swallowing flow - volume drunk divided by the time taken; (c) volume of each swallow - volume drunk divided by the number of swallows.

RESULTS

- Patients with postfundoplication dysphagia, Chagas' disease and idiopathic achalasia took longer to ingest all the volume, had an increased number of swallows, an increase in interval between swallows, a decrease in swallowing flow and a decrease in water volume of each swallow compared with the controls. There was no difference between the three groups of patients. There was no correlation between postfundoplication time and the results.

CONCLUSION

- It was concluded that patients with postfundoplication dysphagia have similar water ingestion dynamics as patients with achalasia.

Effect of Vagus Nerve Integrity on Short and Long-Term Efficacy of Antireflux Surgery

OBJECTIVES

Vagus nerve injury is a feared complication of antireflux surgery (ARS) that may negatively affect reflux control. The aim of the present prospective study was to evaluate short-term and long-term impact of vagus nerve injury, evaluated by pancreatic polypeptide response to insulin-induced hypoglycemia (PP-IH), on the outcome of ARS.

METHODS

In the period from 1990 until 2000, 125 patients with gastroesophageal reflux disease (GERD) underwent ARS at a single center. Before and 6 months after surgery, vagus nerve integrity testing (PP-IH), 24-h pH-monitoring, gastric emptying, and reflux-associated symptoms were evaluated. In 2014, 14-25 years after surgery, 110 patients were contacted again for evaluation of long-term symptomatic outcome using two validated questionnaires (Gastrointestinal Symptom Rating Scale (GSRS) and GERD-Health Related Quality of Life (HRQL)).

RESULTS

Short-term follow-up: vagus nerve injury (PP peak ≤47 pmol/l) was observed in 23 patients (18%) 6 months after fundoplication. In both groups, a comparable decrease in reflux parameters and symptoms was observed at 6-month follow-up. Postoperative gastric emptying was significantly delayed in the vagus nerve injury group compared with the vagus nerve intact group. Long-term follow-up: patients with vagus nerve injury showed significantly less effective reflux control and a higher re-operation rate.

CONCLUSIONS

Vagus nerve injury occurs in up to 20% of patients after ARS. Reflux control 6 months after surgery was not affected by vagus nerve injury. However, long-term follow-up showed a negative effect on reflux symptom control and re-operation rate in patients with vagus nerve injury.

Effect of Vagus Nerve Injury on the Outcome of Antireflux Surgery: An Extensive Literature Review

BACKGROUND

Vagus nerve injury (VNI) is a feared complication of antireflux surgery (ARS). The impact of VNI on the functional outcomes of ARS has not yet been evaluated systematically. The aim of this review was to evaluate the impact of VNI on functional and clinical outcome of ARS.

METHODS

A systematic search was performed until March 2015, using the following online databases: MEDLINE, Embase and the Cochrane Register of Controlled Clinical Trials. Eight studies remained available for assessment. Articles were divided into 2 groups: (a) one with unintended, accidental VNI and (b) one group comparing ARS with and without intended vagotomy.

RESULTS

The prevalence of unintended, accidental VNI ranged from 10 to 42% after ARS. No clear differences were seen in outcome for reflux control between the VNI and vagus nerve intact group. A higher prevalence of diarrhea, nausea and vomiting was observed in the VNI group.

CONCLUSION

VNI is a feared but neglected complication of ARS. Larger prospective studies that objectively assess vagus nerve integrity before and after ARS are needed.

Advances in the evaluation and management of esophageal disease of systemic sclerosis

Symptoms of heartburn and dysphagia as well as objective findings of abnormal esophageal acid exposure and esophageal dysmotility are common in patients with systemic sclerosis (SSc). Treatments for SSc esophageal disease are generally limited to gastroesophageal reflux disease (GERD) treatment with proton pump inhibitors. Progresses made in esophageal diagnostic testing offer the potential for improved clinical characterization of esophageal disease in SSc that may help direct management decisions. In addition to reviewing GERD management in patients with SSc, present and potential uses of endoscopy, reflux monitoring, manometry, impedance planimetry, and endoscopic ultrasound are discussed.

Can different subsets of ineffective esophageal motility influence the outcome of nissen fundoplication?

BACKGROUND

Ineffective esophageal motility (IEM) in patients with gastroesophageal reflux disease includes three different subsets that may affect symptom profiles. Our aim was to assess symptoms and functional outcome in patients with erosive esophagitis according to different subsets of IEM, before and after Nissen fundoplication (NF).

METHODOLOGY

A retrospective study with prospective follow-up of 72 patients with reflux esophagitis and IEM in whom open NF was performed. Based on principal manometric esophageal body motility disorder, patients were divided in three groups: predominantly low-amplitude (LAC, N = 38), non-propulsive (NPC, N = 18), and simultaneous low-amplitude esophageal contractions (SC, N = 16). Patients underwent symptomatic questionnaire and stationary esophageal manometry before and 6 months, 1 year, and 3 years after surgery.

RESULTS

Preoperatively, patients in NPC and SC groups had higher mean scores of dysphagia, without statistical significance as opposed to the LAC group (p = 0.239). Postoperative dysphagia occurred in 36 patients, without statistical significance between groups regarding dysphagia grades (p = 0.390). A longer duration of postoperative dysphagia was noted in the SC group (p < 0.05). Improvement of nadir values of contraction amplitudes in distal esophagus occurred postoperatively in all groups, significantly higher in LAC (p < 0.001).

CONCLUSION

Three years after NF, successful symptomatic and functional outcome was achieved in analyzed groups of patients with erosive esophagitis regardless of IEM subtype.

[Stretch sphincter of the esophagus : Paradoxical sphincter with angiomyoelastic architecture]

The investigations described in this article clearly show that the lower esophageal sphincter (LES) represents a variation of circular muscular occlusive mechanisms found elsewhere in the gastrointestinal tract. The LES is a double layer stretch sphincter that operates in an apparently paradoxical manner: it closes when under stretch but opens when the muscle fibers contract. Impedance manometry studies demonstrate that the entire esophagus is involved in the normal functioning of the esophagus as well as in esophageal disorders. The pronounced elasticity of esophageal tissue is a functional feature that has its basis in the singular architecture of elastic fibers located between the muscle layers. All traditional forms of operative treatment of gastroesophageal reflux disease (GERD) impede the natural functioning of the stretch sphincter to a greater or lesser degree by locking it up. The cause of GERD is mainly by contraction of the esophagus brought about by the cephalad transposition of the stretch sphincter segment into the chest. In a sense this is an incipient axial hernia that frequently remains undiagnosed in the early stages. The operative repositioning of the stretch sphincter segment into the abdominal cavity provides sufficient restoration of the natural topographic relationships to achieve a cure of GERD. Whether this straightforward repair restores the function of the entire esophagus remains to be elucidated. The concept of the stretch provides a good explanation of the pathophysiology of achalasia, a condition in which a paralyzed paradoxical ring sphincter remains occluded. Successful myotomy approaches only split the muscularis propria layer of the stretch sphincter while leaving subepithelial muscle fibers intact that remain paralyzed. This limited intervention provides a good relief of symptoms.

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Esophageal manometry in gastroesophageal reflux disease

High-resolution manometry (HRM) allows nuanced evaluation of esophageal motor function, and more accurate evaluation of lower esophageal sphincter (LES) function, in comparison with conventional manometry. Pathophysiologic correlates of gastroesophageal reflux disease (GERD) and esophageal peristaltic performance are well addressed by this technique. HRM may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve and help predict the likelihood of transit symptoms following antireflux surgery. HRM represents a continuously evolving new technology that compliments the evaluation and management of GERD.

Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up

Background

In this prospective non randomized observational cohort study we have evaluated the influence of age on outcome of laparoscopic total fundoplication for GERD.

Methods

Six hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Five hundred and twenty-four patients were younger than 65 years (YG), and 96 patients were 65 years or older (EG). The following parameters were considered in the preoperative and postoperative evaluation: presence, duration, and severity of GERD symptoms, presence of a hiatal hernia, manometric and 24 hour pH-monitoring data, duration of operation, incidence of complications and length of hospital stay.

Results

Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in comparison with younger patients. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 93.0% of young patients and in 88.9% of elderly patients (p = NS).

Conclusions

Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.

Complete versus partial fundoplication in children with gastroesophageal reflux disease: results of a systematic review and meta-analysis

Complete fundoplication (Nissen) has long been accepted as the gold standard surgical procedure in children with therapy-resistant gastroesophageal reflux disease (GERD); however, increasingly more evidence has become available for partial fundoplication as an alternative. The aim of this study was to perform a systematic review and meta-analysis comparing complete versus partial fundoplication in children with therapy-resistant GERD. PubMed (1960 to 2011), EMBASE (from 1980 to 2011), and the Cochrane Library (issue 3, 2011) were systematically searched according to the PRISMA statement. Results were pooled in meta-analyses and expressed as risk ratios (RRs). In total, eight original trials comparing complete to partial fundoplication were identified. Seven of these studies had a retrospective study design. Short-term (RR 0.64; p = 0.28) and long-term (RR 0.85; p = 0.42) postoperative reflux control was similar for complete and partial fundoplication. Complete fundoplication required significantly more endoscopic dilatations for severe dysphagia (RR 7.26; p = 0.007) than partial fundoplication. This systematic review and meta-analysis showed that reflux control is similar after both complete and partial fundoplication, while partial fundoplication significantly reduces the number of dilatations to treat severe dysphagia. However, because of the lack of a well-designed study, we have to be cautious in making definitive conclusions. To decide which type of fundoplication is the best practice in pediatric GERD patients, more randomized controlled trials comparing complete to partial fundoplication in children with GERD are warranted.

Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel

BACKGROUND

Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes.

STUDY DESIGN

A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application.

RESULTS

The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach.

CONCLUSIONS

Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.

Dysphagia postfundoplication: more commonly hiatal outflow resistance than poor esophageal body motility

BACKGROUND

Historically, risk assessment for postfundoplication dysphagia has been focused on esophageal body motility, which has proven to be an unreliable prediction tool. Our aim was to determine factors responsible for persistent postoperative dysphagia.

METHODS

Fourteen postfundoplication patients with primary dysphagia were selected for focused study. Twenty-five asymptomatic post-Nissen patients and 17 unoperated subjects served as controls. Pre- and postoperative clinical and high-resolution manometry parameters were compared.

RESULTS

Thirteen of the 14 symptomatic patients (92.9%) had normal postoperative esophageal body function, determined manometrically. In contrast, 13 of 14 (92.9%) had evidence of esophageal outflow obstruction, 9 of 14 (64.3%) manometrically, and 4 of 14 (28.6%) on endoscopy/esophagram. Median gastroesophageal junction integrated relaxation pressure was significantly greater (16.2 mm Hg) in symptomatic than in asymptomatic post-Nissen patients (11.1 mm Hg, P = .05) or unoperated subjects (10.6 mm Hg, P = .02). Sixty-four percent (9/14) of symptomatic patients had an increased mean relaxation pressure. Dysphagia was present in 9 of 14 (64.3%) preoperatively, and elevated postoperative relaxation pressure was independently associated with dysphagia.

CONCLUSION

These data suggest that postoperative alterations in hiatal functional anatomy are the primary factors responsible for post-Nissen dysphagia. Impaired relaxation of the neo-high pressure zone, recognizable as an abnormal relaxation pressure, best discriminates patients with dysphagia from those without symptoms postfundoplication.

Impaired postoperative EGJ relaxation as a determinant of post laparoscopic fundoplication dysphagia: a study with high-resolution manometry before and after surgery

BACKGROUND

Laparoscopic fundoplication (FP) reduces gastroesophageal reflux (GER) efficiently. Dysphagia is its main complication, but no clear data have been published in literature to evaluate risk factors associated with it. The goal of this retrospective study was to identify factors associated with dysphagia occurring after FP for GER disease, with high-resolution manometry (HRM) performed before and after surgery.

METHODS

Twenty patients (11 women; mean age, 49 (range, 19-68 years) underwent HRM before and 2-3 months after laparoscopic Nissen-Rossetti FP. Analysis was performed with esophageal pressure topography according to the Chicago Classification.

RESULTS

Before FP, ten patients had a manometric hiatal hernia (none after FP). Esophagogastric junction (EGJ) pressures increased after surgery (p < 0.01). Bolus pressurization was present in 2% of all swallows before FP and in 22% after (p = 0.01). Postoperative bolus pressurization percentage was significantly correlated with EGJ relaxation as measured with integrated relaxation pressure (IRP) (r = 0.79, p < 0.01). Eight patients reported dysphagia after FP. The only pre- or post-operative parameter significantly associated with dysphagia was postoperative IRP (5.1 mmHg without vs. 10.3 with dysphagia, p < 0.02).

CONCLUSIONS

FP establishes an efficient antireflux mechanism by correcting hiatal hernia and increasing EGJ pressures. EGJ relaxation as measured by IRP is significantly altered after surgery, leading to more frequent motility disorders, and bolus pressurization. Postoperative dysphagia was associated with higher values of IRP.

Postoperative problems 2011: fundoplication and obesity surgery

Although the surgical treatment of both GERD and obesity is very successful, these procedures have a significant impact on the physiology and function of the proximal GI tract. With the increasing prevalence of both GERD and obesity, more and more patients present at the motility outpatient clinic with symptoms related to surgical interventions for these medical problems. In this review, we describe the main complications following antireflux surgery: dysphagia, gas bloat syndrome, recurrent (persistent) GERD symptoms, and dyspeptic symptoms. The most common motility-related complications of obesity surgery are dumping syndrome and esophageal dysmotility.